Morphological Changes of the Cervical Spine in Adolescent Idiopathic Scoliosis and Correlation Analysis

Morphological Changes of the Cervical Spine in Adolescent Idiopathic Scoliosis and Correlation Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Morphological Changes of the Cervical Spine in Adolescent Idiopathic Scoliosis and Correlation Analysis Feipeng Qin, Jiajun Ma, Yi Shen, Hapulile Ndalyolusha Tileinge, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9137144/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background To investigate the morphological changes of the cervical spine in patients with adolescent idiopathic scoliosis (AIS) and to analyze their correlation with other coronal and sagittal plane parameters of the spine. Methods A retrospective collection of full-length spinal radiographs was conducted for 199 patients with AIS who were treated at and 77 adolescents without scoliosis (control group) the Third Affiliated Hospital of Zhejiang Chinese Medical University between January 2019 and February 2025. Patients with AIS were classified into two groups based on the physiological curvature of their cervical spine: a non-kyphotic group and a cervical kyphosis (CK) group. The following radiographic parameters were measured: coronal main curve Cobb angle, C2-C7 angle, T1 slope (T1S), T1 coronal tilt, apical vertebra translation (AVT), thoracic kyphosis (TK), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), cervical sagittal vertical axis (cSVA), and sagittal vertical axis (SVA). Intergroup comparisons and correlation analyses of these parameters were subsequently performed. Results The incidence of CK among patients with AIS was 60.3%, which was significantly higher than the 46.8% observed in the control group. Compared to patients with mild scoliosis, those with moderate scoliosis exhibited a significant reduction in the C2–C7 angle (P < 0.05), while the CSVA showed a significant increase (P 0.05). In the thoracic main curve group, patients with a left convex curve had a significantly lower rate of CK compared to those with a right convex curve (P = 0.039). Correlation analysis revealed that CK was positively correlated with the Cobb angle (r = 0.282, P < 0.001), PT (r = 0.184, P = 0.009), and PI (r = 0.154, P = 0.029), while it showed a negative correlation with TK (r = -0.459, P < 0.001) and T1S (r = -0.505, P < 0.001). Conclusion Cervical kyphosis is a prevalent morphological change observed in patients with AIS, and it may be associated with the severity of scoliosis. Furthermore, the occurrence of cervical kyphosis is correlated with spinopelvic parameters including the Cobb angle, PT, PI, TK, and T1S. In the context of conservative treatment for AIS, restoring the physiological curvature of the cervical spine may be beneficial for correcting scoliosis, serving as a potential adjunctive therapeutic strategy. Adolescent Idiopathic Scoliosis C2–C7 Angle Cervical Kyphosis Curve Direction Correlation Analysis Figures Figure 1 Figure 2 Introduction Adolescent Idiopathic Scoliosis (AIS) is a three-dimensional spinal deformity of unknown etiology and is one of the major conditions affecting the spinal health of adolescents, with a global prevalence of approximately 2%-3% [1] . Although the coronal Cobb angle has long been relied upon as the gold standard for diagnosis and severity grading in clinical practice, increasing evidence suggests that the pathological changes in AIS cannot be adequately summarized by a single plane; structural alterations in both the sagittal and axial planes are equally significant and should not be overlooked [2-4] . In the field of sagittal plane studies, a core theory is the concept of "spinal-pelvic sagittal balance" [5] , which describes the intricate mechanical compensatory relationships among various segments from the cranial base to the pelvis. The cervical spine, as the apex of this compensatory chain, plays a crucial role in maintaining head positioning and overall balance.In recent years, researchers have begun to focus on the cervical spine of patients with AIS, with preliminary studies revealing significant changes in sagittal plane morphology. However, existing research primarily centers on the associations of parameters within the sagittal plane [6] , and investigations into how coronal plane deformities affect the sagittal alignment of the cervical spine—a cross-plane issue—are still relatively scarce. Understanding this "coronal-sagittal" relationship is crucial for elucidating the three-dimensional compensatory mechanisms underlying AIS. Based on this rationale, the present study employs a retrospective case analysis approach, systematically collecting full-length spinal X-ray data of AIS patients from the Third Affiliated Hospital of Zhejiang Chinese Medical University over the past five years. The aim of this research is to analyze the intrinsic relationships between coronal plane scoliosis characteristics and sagittal parameters of the cervical spine, with the hope of filling the current research gap and providing theoretical support for comprehensive three-dimensional assessments and the development of individualized treatment strategies for AIS. Materials and methods This retrospective case study analyzed patients who underwent full-length standing anteroposterior and lateral spinal radiographs at the Third Affiliated Hospital of Zhejiang Chinese Medical University from January 2019 to February 2025. The study included 199 patients with AIS and 77 adolescents without scoliosis (control group). Radiological parameters of the coronal and sagittal planes were measured on the full-length spinal radiographs. All included subjects were categorized into two groups based on the physiological curvature of their cervical spine: (1)a non-kyphotic group, defined as a C2-C7 angle≥0°; and (2) a CK group, defined as a C2-C7 angle < 0°. All included subjects underwent full-length standing anteroposterior and lateral spinal radiographs. All measurements were performed using Surgimap software. Parameters Measured on Anteroposterior X-rays of the Entire Spine(Fig.1) 1. Cobb Angle: The angle formed between the parallel lines of the superior endplate of the most tilted vertebra above the apex and the inferior endplate of the most tilted vertebra below the apex, used to quantify the main curve. 2. Apical Vertebral Translation (AVT): The horizontal distance measured from the center of the apical vertebra to the midsacral line. 3. T1 Coronal Tilt: The angle formed between the line of the superior endplate of the T1 vertebra and a horizontal reference line. 4. Apical Vertebral Rotation (AVR): The rotation angle of the apical vertebra, calculated by measuring the vertebral body width (D) and the offset distance of the convex-side pedicle (d). The ratio of D/d is then used to determine the rotation angle by referencing the corresponding table. [7] Parameters Measured on Lateral Radiographs(Fig.2) 1. C2-C7 Angle: The sagittal alignment of the cervical spine, measured as the Cobb angle between the inferior endplate of C2 and the inferior endplate of C7. A value is recorded as positive if it opens anteriorly (toward the trachea), negative if it opens posteriorly (toward the nuchal ligament), and zero if the two end plates are parallel. 2. T1 Slope (T1S): The angle between the superior endplate of T1 and the horizontal plane. 3. Thoracic Kyphosis (TK): The Cobb angle between the superior endplate of T1 and the inferior endplate of T12. 4. Lumbar Lordosis (LL): The Cobb angle between the superior endplate of L1 and the superior endplate of S1. 5. Sacral Slope (SS): The angle between the superior endplate of S1 and the horizontal plane. 6. Pelvic Tilt (PT): The angle between a vertical line and a line connecting the midpoint of the sacral plate to the axis of the bicoxofemoral heads. 7. Pelvic Incidence (PI): The angle between a line perpendicular to the superior endplate of S1 at its midpoint and a line connecting this midpoint to the axis of the bicoxofemoral heads. 8. Sagittal Vertical Axis (SVA): The horizontal distance between the C7 plumb line and the superior corner of S1. An SVA greater than 50 mm is defined as sagittal imbalance [8] . The value is positive when the C7 plumb line falls anterior to the posterior superior corner of S1 and negative when it falls posteriorly. 9. Cervical Sagittal Vertical Axis (CSVA): The horizontal distance between the C2 plumb line and the posterior corner of C7. A cSVA greater than 40 mm is generally associated with lower health-related quality of life scores [9] . Statistical Analysis Statistical analyses were performed using SPSS software version 25.0. Continuous variables are presented as mean ± standard deviation (for normally distributed data) or as a median and interquartile range (for non-normally distributed data).Intergroup comparisons were conducted using the independent samples t-test for normally distributed data and the Mann-Whitney U test for non-normally distributed data.. Categorical variables are presented as counts and percentages and were analyzed using the chi-square (χ²) test. The point-biserial correlation coefficient was used to analyze the correlation between binary categorical data and continuous data. The strength of correlation was interpreted as weak (|r| < 0.3), mild (0.3 ≤ |r| < 0.5), moderate (0.5 ≤ |r| 0.95).A two-tailed p-value of < 0.05 was considered statistically significant. Results Baseline Characteristics A total of 276 subjects were included in the study, comprising 199 patients with AIS and 77 adolescents without scoliosis. No significant differences were observed between the two groups in terms of gender, age, height, weight, body mass index (BMI), or Risser sign. The mean Cobb angle in the AIS group was 20.39°± 9.16° (range, 10°to 45°). Detailed baseline characteristics are presented in Table 1. Table 1. Baseline Characteristics of the Study Population AIS Group Non-Scoliosis Group P Number 199 77 Height, cm 162.07±10.92 163.47±9.46 NS Weight, kg 48.04±10.54 50.27±8.93 NS BMI, kg/m² 18.09±2.64 18.73±2.29 NS Age, years 13.92±2.41 13.72±2.84 NS Risser sign 3.11±1.91 3.27±1.75 NS Gender, F:M 142/57 53/24 NS NS, not significant. Comparison of Coronal and Sagittal Parameters Between the AIS and Non-Scoliosis Groups Comparison of coronal and sagittal parameters between the AIS and non-scoliosis groups revealed significant differences in Cobb angle, AVT, and AVR. The T1 coronal tilt angle (P<0.05) and the rate of CK (P=0.042) were significantly higher in the scoliosis group than in the non-scoliosis group, whereas C2–C7 angle (P=0.028) and TK (P=0.001) were significantly lower. No significant differences were observed in the remaining parameters. Detailed data are presented in Tables 2 and 3 Table 2. Comparison of Coronal Parameters Between the AIS and Non-Scoliosis Groups AIS Group Non-Scoliosis Group P COBB angle,° 20.39±9.16 4.82±2.82 <0.05 T1 coronal tilt,° 4.02±3.12 2.46±1.97 <0.05 AVT,mm 18.53±10.63 7.85±5.38 <0.05 AVR,° 8.48±7.09 2.57±1.81 <0.05 Table 3. Comparison of Sagittal Parameters Between the AIS and Non-Scoliosis Groups AIS Group Non-Scoliosis Group P C2-C7 angle,° -1.28±15.97 2.52±14.31 0.028 cSVA,mm 17.11±9.25 17.72±7.81 NS T1S,° 18.41±10.01 18.06±16.32 NS SVA,mm -9.91±33.41 -11.27±34.57 NS TK,° 34.62±13.72 38.57±9.73 0.001 LL,° 50.94±12.08 50.38±11.64 NS SS,° 37.77±9.58 36.01±8.45 NS PT,° 8.33±8.74 9.04±9.35 NS PI,° 46.09±11.27 45.05±11.03 NS CK, *n*(%) 120(60.3%) 36(46.8%) 0.042 CL, *n*(%) 79(39.7%) 41(53.2%) 0.042 NS, not significant. Comparison of Cervical Sagittal Parameters Between Patients with Mild and Moderate Scoliosis Comparison of cervical sagittal parameters between patients with mild and moderate scoliosis demonstrated that the C2–C7 angle was significantly greater in the mild scoliosis group (P = 0.001), while both the CSVA (P = 0.024) and CK rate (P < 0.001) were significantly lower. Detailed data are presented in Table 4. Table 4. Comparison of Cervical Sagittal Parameters Between Patients with Mild and Moderate Scoliosis Mild Scoliosis(Cobb Angle Cobb Angle ≥25°) P Number 140 59 C2-C7 angle,° 1.18±15.69 -7.11±15.24 0.001 cSVA,mm 16.29±9.05 19.06±9.51 0.024 CK, *n*(%) 73(52.1%) 47(79.7%) <0.001 Comparison of Cervical Sagittal Parameters According to Curve Level and Direction Comparison of cervical sagittal parameters across different curve patterns revealed no significant differences in C2–C7 angle, cSVA, or rate of CK among the main thoracic, main lumbar, and thoracolumbar groups. In patients with main thoracic AIS, subgroup analysis based on curve direction showed that the rate of CK was significantly lower in those with left-convex curves than in those with right-convex curves (P = 0.039), while no significant differences were observed in the remaining parameters. Detailed data are presented in Tables 5 and 6. Table 5.Comparison of Cervical Sagittal Parameters According to Curve Level Main Thoracic Group Main Lumbar Group Thoracolumbar Group P Number 107 50 42 C2-C7 angle,° -3.55±16.21 0.29±14.24 2.63±16.69 NS CSVA,mm 17.15±9.06 17.74±9.81 16.24±9.22 NS CK, *n*(%) 69(64.5%) 29(58.0%) 22(52.4%) NS Table 6. Comparison of Cervical Sagittal Parameters in the Main Thoracic Curve Group by Curve Direction main thoracic group Direction Left-Convex Right-Convex P Number 37 70 C2-C7 angle,° -0.07±16.05 -5.38±16.10 NS CSVA,mm 17.99±9.49 16.71±8.86 NS CK, *n*(%) 19(51.4%) 50(71.4%) 0.039 NS, not significant. Comparison of Coronal and Sagittal Parameters Between Scoliosis Patients With and Without Cervical Kyphosis Comparison of coronal and sagittal parameters between the CK group and the non-kyphosis group demonstrated that T1S (P<0.001), SVA (P=0.041), and TK (P<0.001) were significantly lower in the CK group, whereas PT (P=0.012) and Cobb angle (P<0.001) angle were significantly higher. No significant differences were observed in the remaining parameters. Detailed data are presented in Table 7. Table 7. Comparison of Coronal and Sagittal Parameters Between Scoliosis Patients With and Without Cervical Kyphosis Non-Kyphosis Group (n= 79) CK Group (n= 120) P C2-C7 angle,° 14.58±10.86 -11.72±8.40 <0.001 CSVA,mm 15.99±10.12 17.84±8.59 NS T1S,° 24.61±10.22 14.32±7.46 <0.001 SVA,mm -4.04±33.18 -13.81±33.11 0.041 TK,° 42.33±12.19 29.50±12.23 <0.001 LL,° 51.74±11.36 50.40±12.55 NS SS,° 37.60±9.37 37.88±9.76 NS PT,° 6.35±7.88 9.63±9.06 0.012 PI,° 43.95±9.03 47.50±12.36 NS Cobb angle,° 17.14±6.89 22.35±9.91 <0.001 T1 coronal tilt,° 3.79±3.25 4.18±3.03 NS AVT,mm 16.89±9.59 19.61±11.17 NS AVR,° 7.44±6.35 9.16±7.49 NS NS, not significant. Correlation Analysis Between Cervical Kyphosis and Coronal and Sagittal Parameters Correlation analysis between cervical CK and various coronal and sagittal parameters revealed that CK was weakly positively correlated with Cobb angle, PT, and pelvic PI; mildly negatively correlated with TK; and moderately negatively correlated with T1S. No significant correlations were observed with the remaining parameters. Detailed data are presented in Table 8. Table 8. Correlation Analysis Between Cervical Kyphosis and Coronal and Sagittal Parameters r P cSVA,mm 0.098 NS T1S,° -0.505** <0.001 SVA,mm -0.144* NS TK,° -0.459** <0.001 LL,° -0.055 NS SS,° 0.014 NS PT,° 0.184** 0.009 PI,° 0.154* 0.029 Cobb angle,° 0.282** <0.001 T1 coronal tilt,° 0.063 NS AVT,mm 0.134 NS AVR,° 0.119 NS Discussion AIS is a principal spinal disorders affecting adolescent health, characterized by a three-dimensional structural deformity of the spine involving the coronal, sagittal, and axial planes. As an integral component of the spinopelvic complex, the cervical spine plays a key role in maintaining global sagittal balance through its alignment [10] . However, the relationship between cervical sagittal morphology and main coronal curve characteristics in patients with mild to moderate AIS remains insufficiently explored. Abnormal cervical curvature in AIS has been investigated for decades. As early as 1983, Cochran et al [11] reported that approximately 47% of patients with AIS exhibited loss of cervical lordosis or overt cervical kyphosis. Subsequent studies have corroborated this finding: Canavese et al [12] observed a CK incidence of 34.4% in a cohort of 32 patients, while Hiyama et al [13] and Tang et al [14] reported rates of 59.5% and 60.7%, respectively. These studies uniformly adopted a C2–C7 angle < 0° as the radiographic criterion for CK. Applying the same threshold, the present study identified a CK prevalence of 60.3% in the AIS group, which was significantly higher than that in the non-scoliosis control group; the C2–C7 angle was also significantly lower in the AIS group. Furthermore, TK was found to be significantly different between the AIS and control groups, consistent with previous findings reported by Zhang et al [15] and Yong et al [16] . These observations further support the notion that cervical sagittal malalignment constitutes an integral component of the three-dimensional deformity in AIS. Cervical morphological alterations in AIS are generally considered to be associated with global spinal realignment, particularly with changes in sagittal profile such as TK. In the context of nonoperative management of scoliosis, increasing emphasis has been placed on the role of sagittal alignment. Accordingly, we postulate that restoration of cervical lordosis may facilitate the recovery of thoracic and lumbar physiological curvature and thereby contribute to coronal curve correction. From a clinical perspective, therapeutic strategies aimed at restoring cervical lordosis should be considered adjunctive to conventional scoliosis correction approaches. Tang et al [14] reported that the prevalence of CK increased with increasing Cobb angle, with patients demonstrating a Cobb angle > 40° exhibiting a significantly higher rate of CK compared to those with Cobb angle ≤ 40°. However, although the authors stratified Cobb angle into four subgroups and identified overall intergroup differences, no post hoc pairwise comparisons were performed. Consequently, the specific pattern of risk variation across incremental Cobb angle intervals remains unclear, and whether a critical angular threshold exists could not be conclusively determined. Han et al [17] subsequently demonstrated that in patients with a Cobb angle < 45°; Cobb angle was negatively correlated with C2-C7 angle, that is, the C2-C7 angle decreased as the Cobb angle increased. In line with these observations, the present study found that patients with moderate scoliosis exhibited significantly smaller C2-C7 angles and significantly greater cSVA and rates of CK compared to those with mild scoliosis. Collectively, these findings consistently indicate that the severity of cervical sagittal imbalance increases in parallel with the magnitude of the coronal Cobb angle. Comparison of cervical sagittal parameters among the three curve pattern groups (main thoracic, thoracolumbar, and main lumbar) revealed no significant differences in C2-C7 angle, cSVA, or rate of CK. The location of the main curve did not influence the prevalence of CK. These findings suggest that the coronal position of the main curve may not directly dictate cervical sagittal alignment, nor does it independently contribute to the risk of developing CK. Cervical sagittal imbalance appears to be more closely associated with global truncal alignment, spinopelvic relationships, or compensatory mechanisms, rather than being determined solely by the level of the main curve. Subgroup analysis of patients with main thoracic AIS, stratified by curve direction, revealed that the CK rate was significantly lower in those with left-convex curves than in those with right-convex curves. This finding suggests that curve direction may influence the prevalence of CK in patients with main thoracic AIS. The present study demonstrated significant differences between the CK group and the non-kyphosis group in multiple parameters, including C2-C7 angle, T1S, SVA, TK, PT, and Cobb angle. No significant differences were observed in AVT or coronal T1 tilt. Hilibrand et al. [18] ,Akbar et al. [3] , and Hiyama et al. [13] have previously reported a significant association between diminished thoracic kyphosis and the presence of CK. Wang et al. [19] further observed that the T5-T12 Cobb angle was significantly lower in the CK group compared to the CL group. Han et al. [17] also identified a positive correlation between C2-C7 angle and TK, indicating that reduced thoracic kyphosis is accompanied by diminished cervical lordosis. The present findings corroborate this compensatory relationship: TK was significantly lower in the CK group than in the non-kyphosis group, and correlation analysis revealed a significant negative correlation between CK and TK, whereas no significant correlation was found between CK and LL. Jiang et al. [20] reported a positive correlation between cervical tilt and AVT in the main thoracic curve. La Maida et al. [21] demonstrated that apical vertebral derotation-translation techniques aimed at correcting AVT could simultaneously improve sagittal balance and CL. Tang et al. [14] also identified an association between AVT and CK, suggesting that AVT may serve as a predictor of cervical morphological changes. However, the present study did not observe such associations. Among patients with AIS and a Cobb angle < 45°, no significant difference in AVT was found between the CK and non-kyphosis groups, and correlation analysis revealed no significant relationship between CK and AVT. This discrepancy may be attributable to differences in curve severity across study cohorts. The aforementioned studies primarily included patients with severe scoliosis (Cobb angle > 40°), in whom more pronounced structural deformities may elicit stronger and more coordinated compensatory mechanisms involving the thoracic spine, pelvis, and cervical segments to maintain global balance and horizontal gaze. Under such conditions, parameters reflecting coronal imbalance, such as AVT, may exhibit more robust correlations with cervical morphology. In contrast, the present cohort consisted predominantly of patients with mild to moderate AIS, in whom compensatory patterns may not yet be fully developed or may operate through different mechanisms, potentially accounting for the absence of a clear association between AVT and cervical sagittal parameters. Spinopelvic parameters related to the T1 vertebra have been proposed as predictors of global spinal alignment [22-25] . Knott et al. [26] demonstrated a significant correlation between T1S and SVA, suggesting that T1S may serve as a useful parameter for assessing sagittal balance. Pesenti et al. [22] further reported that T1S and sagittal tilt effectively predict postoperative changes in regional parameters such as CL and TK. Moreover, Tang et al. [14] observed that both T1S and coronal T1 tilt were significantly greater in patients with CK compared to those with CL, and identified a positive correlation between coronal T1 tilt and CK, emphasizing that both sagittal and coronal parameters of T1 influence cervical alignment. The present findings, however, differ from those previously reported. In our cohort, T1S was significantly lower in the CK group than in the non-kyphosis group, while no significant difference was observed in coronal T1 tilt between the two groups. Correlation analysis further revealed a significant negative correlation between CK and T1S, whereas no significant association was found between CK and coronal T1 tilt. Collectively, these observations support the utility of T1S in the evaluation of cervical alignment and global sagittal balance. Hu et al. [27] reported a higher prevalence of CK in patients with a coronal thoracic Cobb angle ≥ 20°. Han et al. [17] further demonstrated that when the Cobb angle < 45°, the C2–C7 angle was negatively correlated with the Cobb angle. The present study similarly identified a positive correlation between CK and Cobb angle, supporting the influence of coronal spinal deformity on cervical sagittal morphology. In addition, our findings revealed that CK was negatively correlated with both T1S and TK, suggesting that a diminished T1 slope or thoracic kyphosis may be associated with aggravation of CK. Previous studies have reported a negative correlation between Cobb angle and TK, implying that coronal thoracic curves may indirectly affect cervical alignment via alterations in thoracic kyphosis.Furthermore, CK was positively correlated with both PT and PI, indicating that the pelvis may contribute to the development or progression of CK through a bottom-to-top compensatory mechanism. Limitations The present study has several limitations. First, its retrospective design precludes dynamic observation of disease progression or temporal changes in cervical alignment. Second, the sample size distribution across different AIS curve types was uneven. In the subgroup analysis stratified by curve direction, the number of patients with right-convex thoracolumbar or main lumbar curves was insufficient, thereby limiting the validity of comparative analyses within these subgroups. Future studies with larger and more balanced cohorts are warranted to obtain more robust evidence regarding the influence of curve direction on cervical sagittal parameters. Third, the absence of more granular stratification of coronal curve patterns may have introduced confounding effects related to combined or double-curve configurations. Subsequent investigations should incorporate more precise subcategorization of curve types to better isolate the independent contribution of each curve pattern to cervical alignment. Conclusion Cervical kyphosis was significantly correlated with the Cobb angle, PT, PI, TK, and T1S. In contrast, the location of the main curve was not significantly associated with the prevalence of CK among patients with AIS. However, within the specific subgroup of main thoracic curves, curve direction emerged as an independent factor: patients with left-convex curves demonstrated a significantly lower rate of CK compared to those with right-convex curves. From a clinical perspective, restoration of cervical lordosis may confer beneficial effects on scoliosis correction and can be considered a valuable adjunctive strategy in the conservative management of AIS. Declarations Data availability ： All data included in the study are authentic and available from the corresponding author. Ethics approval and consent to participate This retrospective study obtained approval from the Medical Ethics Committee of the 3rd Affiliated Hospital of Zhejiang Chinese Medical University (Approval No.: ZSYY-KY-2017-045).Informed consent was obtained from all participants. The study was conducted in accordance with the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials All data generated or analysed during this study are included in this published article [and its supplementary information files]. Competing interests The authors declare that they have no competing interests Funding Not applicable. Authors’ contributions Conceptualization: Xiaoming Ying; methodology: Xiaoming Ying; formal analysis and investigation: Feipeng Qin, Jiajun Ma, Yi Shen, Hapulile Ndalyolusha Tileinge; writing—original draft preparation:Feipeng Qin, Jiajun Ma, writing—review and editing: Yi Shen, Hapulile Ndalyolusha Tileinge; funding acquisition: Xiaoming Ying; resources: Xiaoming Ying; supervision: Xiaoming Ying Acknowledgements Not applicable. References Pérez-Machado G ,Berenguer-Pascual E ,Bovea-Marco M , et al. From genetics to epigenetics to unravel the etiology of adolescent idiopathic scoliosis [J]. Bone, 2020, 140 115563-115563. LangC,ZouQ,SuiW,DengY,HuangZ,YangJ.Coronal deformity angular ratio may serveas a valuable parameter to predict in-brace correction in patients with adolescent idiopathic scoliosis [epub ahead of print] .SpineJ.2018. Akbar M, Almansour H, Lafage R, et al. Sagittal alignment of the cervical spine in the setting of adolescent idiopathic scoliosis. 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Apical vertebral derotation and translation (AVDT) for adolescent idiopathic scoliosis using screws and sublaminar bands: a safer concept for deformity correction. Eur Spine J. 2018;27:157-164. Pesenti S, Blondel B, Peltier E, Choufani E, Bollini G, Jouve JL. Interest of T1 parameters for sagittal alignment evaluation of adolescent idiopathic scoliosis patients. Eur Spine J. 2016;25: 424-429. Protopsaltis TS, Lafage R, Smith JS, et al. The lumbar pelvic angle, the lumbar component of the T1 pelvic angle, correlates with HRQOL, PI-LL mismatch, and it predicts global alignment. Spine (Phila Pa 1976). 2018;43:681-687. Protopsaltis T, Terran J, Soroceanu A, et al. T1 slope minus cervical lordosis (TS-CL), the cervical answer to PI-LL, defines cervical sagittal deformity in patients undergoing thoracolumbar osteotomy. Int J Spine Surg. 2018;12:362-370. Tamai K, Romanu J, Grisdela P Jr, et al. Small C7- T1 lordotic angle and muscle degeneration at C7 level were independent radiological characteristics of patients with cervical imbalance: a propensity score-matched analysis. Spine J. 2018;18:1505-1512. Knott PT, Mardjetko SM, Techy F. The use of the T1 sagittal angle in predicting overall sagittal balance of the spine. Spine J. 2010;10:994-998. Xiaobang H U, Lieberman I H. Prevalence and Factors Affecting Cervical Deformity in Adolescent Idiopathic Scoliosis Patients: A Single-Center Retrospective Radiological Study[J]. Int J Spine Surg. 2018 Mar 30;12(1):22-25. Additional Declarations No competing interests reported. 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Although the coronal Cobb angle has long been relied upon as the gold standard for diagnosis and severity grading in clinical practice, increasing evidence suggests that the pathological changes in AIS cannot be adequately summarized by a single plane; structural alterations in both the sagittal and axial planes are equally significant and should not be overlooked \u003csup\u003e[2-4]\u003c/sup\u003e. In the field of sagittal plane studies, a core theory is the concept of \u0026quot;spinal-pelvic sagittal balance\u0026quot; \u003csup\u003e[5]\u003c/sup\u003e, which describes the intricate mechanical compensatory relationships among various segments from the cranial base to the pelvis. The cervical spine, as the apex of this compensatory chain, plays a crucial role in maintaining head positioning and overall balance.In recent years, researchers have begun to focus on the cervical spine of patients with AIS, with preliminary studies revealing significant changes in sagittal plane morphology. However, existing research primarily centers on the associations of parameters within the sagittal plane \u003csup\u003e[6]\u003c/sup\u003e, and investigations into how coronal plane deformities affect the sagittal alignment of the cervical spine\u0026mdash;a cross-plane issue\u0026mdash;are still relatively scarce. Understanding this \u0026quot;coronal-sagittal\u0026quot; relationship is crucial for elucidating the three-dimensional compensatory mechanisms underlying AIS. Based on this rationale, the present study employs a retrospective case analysis approach, systematically collecting full-length spinal X-ray data of AIS patients from the Third Affiliated Hospital of Zhejiang Chinese Medical University over the past five years. The aim of this research is to analyze the intrinsic relationships between coronal plane scoliosis characteristics and sagittal parameters of the cervical spine, with the hope of filling the current research gap and providing theoretical support for comprehensive three-dimensional assessments and the development of individualized treatment strategies for AIS.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThis retrospective case study analyzed patients who underwent full-length standing anteroposterior and lateral spinal radiographs at the Third Affiliated Hospital of Zhejiang Chinese Medical University from January 2019 to February 2025. The study included 199 patients with AIS and 77 adolescents without scoliosis (control group). Radiological parameters of the coronal and sagittal planes were measured on the full-length spinal radiographs. All included subjects were categorized into two groups based on the physiological curvature of their cervical spine: (1)a non-kyphotic group, defined as a C2-C7 angle\u0026ge;0\u0026deg;; and (2) a CK group, defined as a C2-C7 angle \u0026lt; 0\u0026deg;.\u003c/p\u003e\n\u003cp\u003eAll included subjects underwent full-length standing anteroposterior and lateral spinal radiographs. All measurements were performed using Surgimap software.\u003c/p\u003e\n\u003cp\u003eParameters Measured on Anteroposterior X-rays of the Entire Spine(Fig.1)\u003c/p\u003e\n\u003cp\u003e1. Cobb Angle: The angle formed between the parallel lines of the superior endplate of the most tilted vertebra above the apex and the inferior endplate of the most tilted vertebra below the apex, used to quantify the main curve.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2. Apical Vertebral Translation (AVT): The horizontal distance measured from the center of the apical vertebra to the midsacral line. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3. T1 Coronal Tilt: The angle formed between the line of the superior endplate of the T1 vertebra and a horizontal reference line.\u003c/p\u003e\n\u003cp\u003e4. Apical Vertebral Rotation (AVR): The rotation angle of the apical vertebra, calculated by measuring the vertebral body width (D) and the offset distance of the convex-side pedicle (d). The ratio of D/d is then used to determine the rotation angle by referencing the corresponding table.\u003csup\u003e[7]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParameters Measured on Lateral Radiographs(Fig.2)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1. C2-C7 Angle: The sagittal alignment of the cervical spine, measured as the Cobb angle between the inferior endplate of C2 and the inferior endplate of C7. A value is recorded as positive if it opens anteriorly (toward the trachea), negative if it opens posteriorly (toward the nuchal ligament), and zero if the two end plates are parallel.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2. T1 Slope (T1S): The angle between the superior endplate of T1 and the horizontal plane.\u003c/p\u003e\n\u003cp\u003e3. Thoracic Kyphosis (TK): The Cobb angle between the superior endplate of T1 and the inferior endplate of T12.\u003c/p\u003e\n\u003cp\u003e4. Lumbar Lordosis (LL): The Cobb angle between the superior endplate of L1 and the superior endplate of S1.\u003c/p\u003e\n\u003cp\u003e5. Sacral Slope (SS): The angle between the superior endplate of S1 and the horizontal plane.\u003c/p\u003e\n\u003cp\u003e6. Pelvic Tilt (PT): The angle between a vertical line and a line connecting the midpoint of the sacral plate to the axis of the bicoxofemoral heads.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e7. Pelvic Incidence (PI): The angle between a line perpendicular to the superior endplate of S1 at its midpoint and a line connecting this midpoint to the axis of the bicoxofemoral heads. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e8. Sagittal Vertical Axis (SVA): The horizontal distance between the C7 plumb line and the superior corner of S1. An SVA greater than 50 mm is defined as sagittal imbalance \u003csup\u003e[8]\u003c/sup\u003e. The value is positive when the C7 plumb line falls anterior to the posterior superior corner of S1 and negative when it falls posteriorly.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e9. Cervical Sagittal Vertical Axis (CSVA): The horizontal distance between the C2 plumb line and the posterior corner of C7. A cSVA greater than 40 mm is generally associated with lower health-related quality of life scores \u003csup\u003e[9]\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were performed using SPSS software version 25.0. Continuous variables are presented as mean \u0026plusmn; standard deviation (for normally distributed data) or as a median and interquartile range (for non-normally distributed data).Intergroup comparisons were conducted using the independent samples t-test for normally distributed data and the Mann-Whitney U test for non-normally distributed data.. Categorical variables are presented as counts and percentages and were analyzed using the chi-square (\u0026chi;\u0026sup2;) test. The point-biserial correlation coefficient was used to analyze the correlation between binary categorical data and continuous data. The strength of correlation was interpreted as weak (|r| \u0026lt; 0.3), mild (0.3 \u0026le; |r| \u0026lt; 0.5), moderate (0.5 \u0026le; |r| \u0026lt; 0.8), strong (|r| \u0026ge; 0.8), or very strong ( |r| \u0026gt; 0.95).A two-tailed \u0026nbsp;p-value of \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 276 subjects were included in the study, comprising 199 patients with AIS and 77 adolescents without scoliosis. No significant differences were observed between the two groups in terms of gender, age, height, weight, body mass index (BMI), or Risser sign. The mean Cobb angle in the AIS group was 20.39\u0026deg;\u0026plusmn;\u0026nbsp;9.16\u0026deg;\u0026nbsp;(range, 10\u0026deg;to 45\u0026deg;). Detailed baseline characteristics are presented in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Baseline Characteristics of the Study Population\u0026nbsp;\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eAIS Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNon-Scoliosis Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e199\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eHeight, cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e162.07\u0026plusmn;10.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e163.47\u0026plusmn;9.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eWeight, kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e48.04\u0026plusmn;10.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e50.27\u0026plusmn;8.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eBMI, kg/m\u0026sup2;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e18.09\u0026plusmn;2.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e18.73\u0026plusmn;2.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e13.92\u0026plusmn;2.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e13.72\u0026plusmn;2.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eRisser sign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e3.11\u0026plusmn;1.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e3.27\u0026plusmn;1.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eGender, F:M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e142/57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e53/24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNS, not significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of Coronal and Sagittal Parameters Between the AIS and Non-Scoliosis Groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComparison of coronal and sagittal parameters between the AIS and non-scoliosis groups revealed significant differences in Cobb angle, AVT, and AVR. The T1 coronal tilt angle (P\u0026lt;0.05) and the rate of CK (P=0.042) were significantly higher in the scoliosis group than in the non-scoliosis group, whereas C2\u0026ndash;C7 angle (P=0.028) and TK (P=0.001) were significantly lower. No significant differences were observed in the remaining parameters. Detailed data are presented in Tables 2 and 3\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eComparison of Coronal Parameters Between the AIS and Non-Scoliosis Groups\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eAIS Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNon-Scoliosis Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eCOBB angle,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e20.39\u0026plusmn;9.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e4.82\u0026plusmn;2.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eT1 coronal tilt,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e4.02\u0026plusmn;3.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e2.46\u0026plusmn;1.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAVT,mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e18.53\u0026plusmn;10.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e7.85\u0026plusmn;5.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAVR,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e8.48\u0026plusmn;7.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e2.57\u0026plusmn;1.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Comparison of Sagittal Parameters Between the AIS and Non-Scoliosis Groups\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eAIS Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNon-Scoliosis Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eC2-C7 angle,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e-1.28\u0026plusmn;15.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e2.52\u0026plusmn;14.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e0.028\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003ecSVA,mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e17.11\u0026plusmn;9.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e17.72\u0026plusmn;7.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eT1S,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e18.41\u0026plusmn;10.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e18.06\u0026plusmn;16.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eSVA,mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e-9.91\u0026plusmn;33.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e-11.27\u0026plusmn;34.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eTK,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e34.62\u0026plusmn;13.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e38.57\u0026plusmn;9.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eLL,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e50.94\u0026plusmn;12.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e50.38\u0026plusmn;11.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eSS,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e37.77\u0026plusmn;9.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e36.01\u0026plusmn;8.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003ePT,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e8.33\u0026plusmn;8.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e9.04\u0026plusmn;9.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003ePI,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e46.09\u0026plusmn;11.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e45.05\u0026plusmn;11.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eCK, *n*(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e120(60.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e36(46.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e0.042\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eCL, *n*(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e79(39.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e41(53.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e0.042\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNS, not significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of Cervical Sagittal Parameters Between Patients with Mild and Moderate Scoliosis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComparison of cervical sagittal parameters between patients with mild and moderate scoliosis demonstrated that the C2\u0026ndash;C7 angle was significantly greater in the mild scoliosis group (P = 0.001), while both the CSVA (P = 0.024) and CK rate (P \u0026lt; 0.001) were significantly lower. Detailed data are presented in Table 4.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u003c/strong\u003eComparison of Cervical Sagittal Parameters Between Patients with Mild and Moderate Scoliosis\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eMild Scoliosis(Cobb Angle \u0026lt;25\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eModerate Scoliosis(45\u0026deg; \u0026gt;Cobb Angle \u0026ge;25\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eC2-C7 angle,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e1.18\u0026plusmn;15.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e-7.11\u0026plusmn;15.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003ecSVA,mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e16.29\u0026plusmn;9.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e19.06\u0026plusmn;9.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e0.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eCK, *n*(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e73(52.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e47(79.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of Cervical Sagittal Parameters According to Curve Level and Direction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComparison of cervical sagittal parameters across different curve patterns revealed no significant differences in C2\u0026ndash;C7 angle, cSVA, or rate of CK among the main thoracic, main lumbar, and thoracolumbar groups. In patients with main thoracic AIS, subgroup analysis based on curve direction showed that the rate of CK was significantly lower in those with left-convex curves than in those with right-convex curves (P = 0.039), while no significant differences were observed in the remaining parameters. Detailed data are presented in Tables 5 and 6.\u003c/p\u003e\n\u003cp\u003eTable 5.Comparison of Cervical Sagittal Parameters According to Curve Level\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"568\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 106px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003eMain Thoracic Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003eMain Lumbar Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eThoracolumbar Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 106px;\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003e107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 106px;\"\u003e\n \u003cp\u003eC2-C7 angle,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003e-3.55\u0026plusmn;16.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e0.29\u0026plusmn;14.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e2.63\u0026plusmn;16.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 106px;\"\u003e\n \u003cp\u003eCSVA,mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003e17.15\u0026plusmn;9.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e17.74\u0026plusmn;9.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e16.24\u0026plusmn;9.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 106px;\"\u003e\n \u003cp\u003eCK, *n*(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003e69(64.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e29(58.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e22(52.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6.\u003c/strong\u003eComparison of Cervical Sagittal Parameters in the Main Thoracic Curve Group by Curve Direction\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"565\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 425px;\"\u003e\n \u003cp\u003emain thoracic group\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003eDirection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eLeft-Convex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eRight-Convex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003eC2-C7 angle,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e-0.07\u0026plusmn;16.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e-5.38\u0026plusmn;16.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003eCSVA,mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e17.99\u0026plusmn;9.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e16.71\u0026plusmn;8.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003eCK, *n*(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e19(51.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e50(71.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e0.039\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNS, not significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of Coronal and Sagittal Parameters Between Scoliosis Patients With and Without Cervical Kyphosis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComparison of coronal and sagittal parameters between the CK group and the non-kyphosis group demonstrated that T1S (P\u0026lt;0.001), SVA (P=0.041), and TK (P\u0026lt;0.001) were significantly lower in the CK group, whereas PT (P=0.012) and Cobb angle (P\u0026lt;0.001) angle were significantly higher. No significant differences were observed in the remaining parameters. Detailed data are presented in Table 7.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7.\u003c/strong\u003eComparison of Coronal and Sagittal Parameters Between Scoliosis Patients With and Without Cervical Kyphosis\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eNon-Kyphosis Group (n= 79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eCK Group\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n= 120)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eC2-C7 angle,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e14.58\u0026plusmn;10.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e-11.72\u0026plusmn;8.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eCSVA,mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e15.99\u0026plusmn;10.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e17.84\u0026plusmn;8.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eT1S,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e24.61\u0026plusmn;10.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e14.32\u0026plusmn;7.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eSVA,mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e-4.04\u0026plusmn;33.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e-13.81\u0026plusmn;33.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eTK,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e42.33\u0026plusmn;12.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e29.50\u0026plusmn;12.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eLL,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e51.74\u0026plusmn;11.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e50.40\u0026plusmn;12.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eSS,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e37.60\u0026plusmn;9.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e37.88\u0026plusmn;9.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003ePT,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e6.35\u0026plusmn;7.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e9.63\u0026plusmn;9.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003ePI,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e43.95\u0026plusmn;9.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e47.50\u0026plusmn;12.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eCobb angle,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e17.14\u0026plusmn;6.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e22.35\u0026plusmn;9.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eT1 coronal tilt,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e3.79\u0026plusmn;3.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e4.18\u0026plusmn;3.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAVT,mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e16.89\u0026plusmn;9.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e19.61\u0026plusmn;11.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAVR,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e7.44\u0026plusmn;6.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e9.16\u0026plusmn;7.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNS, not significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorrelation Analysis Between Cervical Kyphosis and Coronal and Sagittal Parameters\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrelation analysis between cervical CK and various coronal and sagittal parameters revealed that CK was weakly positively correlated with Cobb angle, PT, and pelvic PI; mildly negatively correlated with TK; and moderately negatively correlated with T1S. No significant correlations were observed with the remaining parameters. Detailed data are presented in Table 8.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 8.\u003c/strong\u003eCorrelation Analysis Between Cervical Kyphosis and Coronal and Sagittal Parameters\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003ecSVA,mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e0.098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eT1S,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e-0.505**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eSVA,mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e-0.144*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eTK,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e-0.459**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eLL,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e-0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eSS,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003ePT,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e0.184**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003ePI,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e0.154*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eCobb angle,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e0.282**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eT1 coronal tilt,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAVT,mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e0.134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAVR,\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e0.119\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAIS is a principal spinal disorders affecting adolescent health, characterized by a three-dimensional structural deformity of the spine involving the coronal, sagittal, and axial planes. As an integral component of the spinopelvic complex, the cervical spine plays a key role in maintaining global sagittal balance through its alignment \u003csup\u003e[10]\u003c/sup\u003e. However, the relationship between cervical sagittal morphology and main coronal curve characteristics in patients with mild to moderate AIS remains insufficiently explored. Abnormal cervical curvature in AIS has been investigated for decades. As early as 1983, Cochran et al \u003csup\u003e[11]\u003c/sup\u003e reported that approximately 47% of patients with AIS exhibited loss of cervical lordosis or overt cervical kyphosis. Subsequent studies have corroborated this finding: Canavese et al \u003csup\u003e[12]\u003c/sup\u003e observed a CK incidence of 34.4% in a cohort of 32 patients, while Hiyama et al \u003csup\u003e[13]\u003c/sup\u003e and Tang et al \u003csup\u003e[14]\u003c/sup\u003e reported rates of 59.5% and 60.7%, respectively. These studies uniformly adopted a C2\u0026ndash;C7 angle \u0026lt; 0\u0026deg;\u0026nbsp;as the radiographic criterion for CK. Applying the same threshold, the present study identified a CK prevalence of 60.3% in the AIS group, which was significantly higher than that in the non-scoliosis control group; the C2\u0026ndash;C7 angle was also significantly lower in the AIS group. Furthermore, TK was found to be significantly different between the AIS and control groups, consistent with previous findings reported by Zhang et al \u003csup\u003e[15]\u003c/sup\u003e and Yong et al\u003csup\u003e\u0026nbsp;[16]\u003c/sup\u003e. These observations further support the notion that cervical sagittal malalignment constitutes an integral component of the three-dimensional deformity in AIS. Cervical morphological alterations in AIS are generally considered to be associated with global spinal realignment, particularly with changes in sagittal profile such as TK. In the context of nonoperative management of scoliosis, increasing emphasis has been placed on the role of sagittal alignment. Accordingly, we postulate that restoration of cervical lordosis may facilitate the recovery of thoracic and lumbar physiological curvature and thereby contribute to coronal curve correction. From a clinical perspective, therapeutic strategies aimed at restoring cervical lordosis should be considered adjunctive to conventional scoliosis correction approaches.\u003c/p\u003e\n\u003cp\u003eTang et al \u003csup\u003e[14]\u003c/sup\u003e reported that the prevalence of CK increased with increasing Cobb angle, with patients demonstrating a Cobb angle \u0026gt; 40\u0026deg;\u0026nbsp;exhibiting a significantly higher rate of CK compared to those with Cobb angle\u0026nbsp;\u0026le;\u0026nbsp;40\u0026deg;. However, although the authors stratified Cobb angle into four subgroups and identified overall intergroup differences, no post hoc pairwise comparisons were performed. Consequently, the specific pattern of risk variation across incremental Cobb angle intervals remains unclear, and whether a critical angular threshold exists could not be conclusively determined. Han et al \u003csup\u003e[17]\u003c/sup\u003e subsequently demonstrated that in patients with a Cobb angle \u0026lt; 45\u0026deg;; Cobb angle was negatively correlated with C2-C7 angle, that is, the C2-C7 angle decreased as the Cobb angle increased. In line with these observations, the present study found that patients with moderate scoliosis exhibited significantly smaller C2-C7 angles and significantly greater cSVA and rates of CK compared to those with mild scoliosis. Collectively, these findings consistently indicate that the severity of cervical sagittal imbalance increases in parallel with the magnitude of the coronal Cobb angle.\u003c/p\u003e\n\u003cp\u003eComparison of cervical sagittal parameters among the three curve pattern groups (main thoracic, thoracolumbar, and main lumbar) revealed no significant differences in C2-C7 angle, cSVA, or rate of CK. The location of the main curve did not influence the prevalence of CK. These findings suggest that the coronal position of the main curve may not directly dictate cervical sagittal alignment, nor does it independently contribute to the risk of developing CK. Cervical sagittal imbalance appears to be more closely associated with global truncal alignment, spinopelvic relationships, or compensatory mechanisms, rather than being determined solely by the level of the main curve.\u003c/p\u003e\n\u003cp\u003eSubgroup analysis of patients with main thoracic AIS, stratified by curve direction, revealed that the CK rate was significantly lower in those with left-convex curves than in those with right-convex curves. This finding suggests that curve direction may influence the prevalence of CK in patients with main thoracic AIS.\u003c/p\u003e\n\u003cp\u003eThe present study demonstrated significant differences between the CK group and the non-kyphosis group in multiple parameters, including C2-C7 angle, T1S, SVA, TK, PT, and Cobb angle. No significant differences were observed in AVT or coronal T1 tilt. Hilibrand et al.\u003csup\u003e\u0026nbsp;[18]\u003c/sup\u003e ,Akbar et al. \u003csup\u003e[3]\u003c/sup\u003e, and Hiyama et al. \u003csup\u003e[13]\u003c/sup\u003e have previously reported a significant association between diminished thoracic kyphosis and the presence of CK. Wang et al. \u003csup\u003e[19]\u003c/sup\u003e further observed that the T5-T12 Cobb angle was significantly lower in the CK group compared to the CL group. Han et al. \u003csup\u003e[17]\u003c/sup\u003e also identified a positive correlation between C2-C7 angle and TK, indicating that reduced thoracic kyphosis is accompanied by diminished cervical lordosis. The present findings corroborate this compensatory relationship: TK was significantly lower in the CK group than in the non-kyphosis group, and correlation analysis revealed a significant negative correlation between CK and TK, whereas no significant correlation was found between CK and LL.\u003c/p\u003e\n\u003cp\u003eJiang et al. \u003csup\u003e[20]\u003c/sup\u003e reported a positive correlation between cervical tilt and AVT in the main thoracic curve. La Maida et al. \u003csup\u003e[21]\u003c/sup\u003e demonstrated that apical vertebral derotation-translation techniques aimed at correcting AVT could simultaneously improve sagittal balance and CL. Tang et al. \u003csup\u003e[14]\u003c/sup\u003e also identified an association between AVT and CK, suggesting that AVT may serve as a predictor of cervical morphological changes. However, the present study did not observe such associations. Among patients with AIS and a Cobb angle \u0026lt; 45\u0026deg;, no significant difference in AVT was found between the CK and non-kyphosis groups, and correlation analysis revealed no significant relationship between CK and AVT. This discrepancy may be attributable to differences in curve severity across study cohorts. The aforementioned studies primarily included patients with severe scoliosis (Cobb angle \u0026gt; 40\u0026deg;), in whom more pronounced structural deformities may elicit stronger and more coordinated compensatory mechanisms involving the thoracic spine, pelvis, and cervical segments to maintain global balance and horizontal gaze. Under such conditions, parameters reflecting coronal imbalance, such as AVT, may exhibit more robust correlations with cervical morphology. In contrast, the present cohort consisted predominantly of patients with mild to moderate AIS, in whom compensatory patterns may not yet be fully developed or may operate through different mechanisms, potentially accounting for the absence of a clear association between AVT and cervical sagittal parameters.\u003c/p\u003e\n\u003cp\u003eSpinopelvic parameters related to the T1 vertebra have been proposed as predictors of global spinal alignment \u003csup\u003e[22-25]\u003c/sup\u003e. Knott et al. \u003csup\u003e[26]\u003c/sup\u003e demonstrated a significant correlation between T1S and SVA, suggesting that T1S may serve as a useful parameter for assessing sagittal balance. Pesenti et al. \u003csup\u003e[22]\u003c/sup\u003e further reported that T1S and sagittal tilt effectively predict postoperative changes in regional parameters such as CL and TK. Moreover, Tang et al. \u003csup\u003e[14]\u003c/sup\u003e observed that both T1S and coronal T1 tilt were significantly greater in patients with CK compared to those with CL, and identified a positive correlation between coronal T1 tilt and CK, emphasizing that both sagittal and coronal parameters of T1 influence cervical alignment. The present findings, however, differ from those previously reported. In our cohort, T1S was significantly lower in the CK group than in the non-kyphosis group, while no significant difference was observed in coronal T1 tilt between the two groups. Correlation analysis further revealed a significant negative correlation between CK and T1S, whereas no significant association was found between CK and coronal T1 tilt. Collectively, these observations support the utility of T1S in the evaluation of cervical alignment and global sagittal balance.\u003c/p\u003e\n\u003cp\u003eHu et al. \u003csup\u003e[27]\u003c/sup\u003e reported a higher prevalence of CK in patients with a coronal thoracic Cobb angle\u0026nbsp;\u0026ge;\u0026nbsp;20\u0026deg;. Han et al. \u003csup\u003e[17]\u003c/sup\u003e further demonstrated that when the Cobb angle \u0026lt; 45\u0026deg;, the C2\u0026ndash;C7 angle was negatively correlated with the Cobb angle. The present study similarly identified a positive correlation between CK and Cobb angle, supporting the influence of coronal spinal deformity on cervical sagittal morphology. In addition, our findings revealed that CK was negatively correlated with both T1S and TK, suggesting that a diminished T1 slope or thoracic kyphosis may be associated with aggravation of CK. Previous studies have reported a negative correlation between Cobb angle and TK, implying that coronal thoracic curves may indirectly affect cervical alignment via alterations in thoracic kyphosis.Furthermore, CK was positively correlated with both PT and PI, indicating that the pelvis may contribute to the development or progression of CK through a bottom-to-top compensatory mechanism.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study has several limitations. First, its retrospective design precludes dynamic observation of disease progression or temporal changes in cervical alignment. Second, the sample size distribution across different AIS curve types was uneven. In the subgroup analysis stratified by curve direction, the number of patients with right-convex thoracolumbar or main lumbar curves was insufficient, thereby limiting the validity of comparative analyses within these subgroups. Future studies with larger and more balanced cohorts are warranted to obtain more robust evidence regarding the influence of curve direction on cervical sagittal parameters. Third, the absence of more granular stratification of coronal curve patterns may have introduced confounding effects related to combined or double-curve configurations. Subsequent investigations should incorporate more precise subcategorization of curve types to better isolate the independent contribution of each curve pattern to cervical alignment.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCervical kyphosis was significantly correlated with the Cobb angle, PT, PI, TK, and T1S. In contrast, the location of the main curve was not significantly associated with the prevalence of CK among patients with AIS. However, within the specific subgroup of main thoracic curves, curve direction emerged as an independent factor: patients with left-convex curves demonstrated a significantly lower rate of CK compared to those with right-convex curves. From a clinical perspective, restoration of cervical lordosis may confer beneficial effects on scoliosis correction and can be considered a valuable adjunctive strategy in the conservative management of AIS.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data included in the study are authentic and available from the corresponding author.\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThis retrospective study obtained approval from the Medical Ethics Committee of the 3rd Affiliated Hospital of Zhejiang Chinese Medical University (Approval No.: ZSYY-KY-2017-045).Informed consent was obtained from all participants. The study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003col start=\"3\"\u003e\n \u003cli\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article [and its supplementary information files].\u003c/p\u003e\n\u003col start=\"4\"\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003col start=\"5\"\u003e\n \u003cli\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003col start=\"6\"\u003e\n \u003cli\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eConceptualization: Xiaoming Ying; methodology: Xiaoming Ying; formal analysis and investigation: Feipeng Qin, Jiajun Ma, Yi Shen, Hapulile Ndalyolusha Tileinge; writing\u0026mdash;original draft preparation:Feipeng Qin, Jiajun Ma, writing\u0026mdash;review and editing: Yi Shen, Hapulile Ndalyolusha Tileinge; funding acquisition: Xiaoming Ying; resources: Xiaoming Ying; supervision: Xiaoming Ying\u003c/p\u003e\n\u003col start=\"7\"\u003e\n \u003cli\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eP\u0026eacute;rez-Machado G ,Berenguer-Pascual E ,Bovea-Marco M , et al. 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[CHANGE AND CLINICAL SIGNIFICANCE OF CERVICAL SPINE SAGITTAL ALIGNMENT OF ADOLESCENT IDIOPATHIC SCOLIOSIS]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2016 Mar;30(3):336-42. Chinese. PMID: 27281880.\u003c/li\u003e\n\u003cli\u003eCochran T, Irstam L, Nachemson A. Long-term anatomic and functional changes in patients with adolescent idiopathic scoliosis treated by Harrington rod fusion. Spine (Phila Pa 1976). 1983 Sep;8(6):576-84\u003c/li\u003e\n\u003cli\u003eCanavese F,Turcot K,De Ｒosa V,et al．Cervical spinesagittal alignment variations following posterior spinal fusion andinstrumentation for adolescent idiopathic scoliosis［J］． Eur Spine J,2011,12 ( 7) : 1141-1148\u003c/li\u003e\n\u003cli\u003eHiyama A, Sakai D, Watanabe M, et al. Sagittal alignment of the cervical spine in adolescent idiopathic scoliosis: a comparative study of 42 adolescents with idiopathic scoliosis and 24 normal adolescents[J]. European Spine Journal, 2016, 25(10): 1-8.\u003c/li\u003e\n\u003cli\u003eTang Y, Xu X, Zhu F, et al. Incidence and Risk Factors of Cervical Kyphosis in Patients with Adolescent Idiopathic Scoliosis[J]. World Neurosurg. 2019 Jul;127:e788-e792.\u003c/li\u003e\n\u003cli\u003eZhang HY, Chen NS, Shi GQ, Ye X, Li SL, Li XM, Fan BH, Pan YS, Ying XM. [Imaging study on thoracic and lumbar physiological curvature in adolescent idiopathic scoliosis]. Zhongguo Gu Shang. 2024 Jan 25;37(1):26-32. Chinese.\u003c/li\u003e\n\u003cli\u003eYong Q, Zhen L, Zezhang Z, Bangping Q, Feng Z, Tao W, Jun J, Xu S, Xusheng Q, Weiwei M, Weijun W. Comparison of sagittal spinopelvic alignment in Chinese adolescents with and without idiopathic thoracic scoliosis. Spine (Phila Pa 1976). 2012 May 20;37(12):E714-20. \u003c/li\u003e\n\u003cli\u003eHan SM, Wen JX, Cao L, Wu HZ, Liu C, Yang C, Yang HH, Gao BL, Wu WJ. Sagittal morphology of the cervical spine in adolescent idiopathic scoliosis: a retrospective case-control study. Quant Imaging Med Surg. 2022 Jun;12(6):3049-3060.\u003c/li\u003e\n\u003cli\u003eHilibrand AS, Tannenbaum DA, Graziano GP, Loder RT, Hensinger RN. The sagittal alignment of the cervical spine in adolescent idiopathic scoliosis. J Pediatr Orthop. 1995;15:627-632.\u003c/li\u003e\n\u003cli\u003eWang W, Zhu Z, Zhu F, Sun C, Wang Z, Sun X, Qiu Y. Different curve pattern and other radiographical characteristics in male and female patients with adolescent idiopathic scoliosis\u003c/li\u003e\n\u003cli\u003eJiang J, Qian BP, Qiu Y, Wang B, Yu Y, Zhu ZZ. Full fusion of proximal thoracic curve helps to prevent postoperative cervical tilt in Lenke type 2 adolescent idiopathic scoliosis patients with right elevated shoulder.BMC Musculoskelet Disord. 2017; 18:362.\u003c/li\u003e\n\u003cli\u003eLa Maida GA, Peroni DR, Ferraro M, Della Valle A, Vitali C, Misaggi B. Apical vertebral derotation and translation (AVDT) for adolescent idiopathic scoliosis using screws and sublaminar bands: a safer concept for deformity correction. Eur Spine J. 2018;27:157-164.\u003c/li\u003e\n\u003cli\u003ePesenti S, Blondel B, Peltier E, Choufani E, Bollini G, Jouve JL. Interest of T1 parameters for sagittal alignment evaluation of adolescent idiopathic scoliosis patients. Eur Spine J. 2016;25: 424-429.\u003c/li\u003e\n\u003cli\u003eProtopsaltis TS, Lafage R, Smith JS, et al. The lumbar pelvic angle, the lumbar component of the T1 pelvic angle, correlates with HRQOL, PI-LL mismatch, and it predicts global alignment. Spine (Phila Pa 1976). 2018;43:681-687.\u003c/li\u003e\n\u003cli\u003eProtopsaltis T, Terran J, Soroceanu A, et al. T1 slope minus cervical lordosis (TS-CL), the cervical answer to PI-LL, defines cervical sagittal deformity in patients undergoing thoracolumbar osteotomy. Int J Spine Surg. 2018;12:362-370.\u003c/li\u003e\n\u003cli\u003eTamai K, Romanu J, Grisdela P Jr, et al. Small C7- T1 lordotic angle and muscle degeneration at C7 level were independent radiological characteristics of patients with cervical imbalance: a propensity score-matched analysis. Spine J. 2018;18:1505-1512.\u003c/li\u003e\n\u003cli\u003eKnott PT, Mardjetko SM, Techy F. The use of the T1 sagittal angle in predicting overall sagittal balance of the spine. Spine J. 2010;10:994-998.\u003c/li\u003e\n\u003cli\u003eXiaobang H U, Lieberman I H. Prevalence and Factors Affecting Cervical Deformity in Adolescent Idiopathic Scoliosis Patients: A Single-Center Retrospective Radiological Study[J]. Int J Spine Surg. 2018 Mar 30;12(1):22-25.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescent Idiopathic Scoliosis, C2–C7 Angle, Cervical Kyphosis, Curve Direction, Correlation Analysis","lastPublishedDoi":"10.21203/rs.3.rs-9137144/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9137144/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003eTo investigate the morphological changes of the cervical spine in patients with adolescent idiopathic scoliosis (AIS) and to analyze their correlation with other coronal and sagittal plane parameters of the spine.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e A retrospective collection of full-length spinal radiographs was conducted for 199 patients with AIS who were treated at and 77 adolescents without scoliosis (control group) the Third Affiliated Hospital of Zhejiang Chinese Medical University between January 2019 and February 2025. Patients with AIS were classified into two groups based on the physiological curvature of their cervical spine: a non-kyphotic group and a cervical kyphosis (CK) group. The following radiographic parameters were measured: coronal main curve Cobb angle, C2-C7 angle, T1 slope (T1S), T1 coronal tilt, apical vertebra translation (AVT), thoracic kyphosis (TK), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), cervical sagittal vertical axis (cSVA), and sagittal vertical axis (SVA). Intergroup comparisons and correlation analyses of these parameters were subsequently performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e The incidence of CK among patients with AIS was 60.3%, which was significantly higher than the 46.8% observed in the control group. Compared to patients with mild scoliosis, those with moderate scoliosis exhibited a significant reduction in the C2–C7 angle (P \u0026lt; 0.05), while the CSVA showed a significant increase (P \u0026lt; 0.05). No significant differences were observed in the C2-C7 angle, cSVA, or CK rates among the lumbar, thoracolumbar, and thoracic main curve groups (P \u0026gt; 0.05). In the thoracic main curve group, patients with a left convex curve had a significantly lower rate of CK compared to those with a right convex curve (P = 0.039). Correlation analysis revealed that CK was positively correlated with the Cobb angle (r = 0.282, P \u0026lt; 0.001), PT (r = 0.184, P = 0.009), and PI (r = 0.154, P = 0.029), while it showed a negative correlation with TK (r = -0.459, P \u0026lt; 0.001) and T1S (r = -0.505, P \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e Cervical kyphosis is a prevalent morphological change observed in patients with AIS, and it may be associated with the severity of scoliosis. Furthermore, the occurrence of cervical kyphosis is correlated with spinopelvic parameters including the Cobb angle, PT, PI, TK, and T1S. In the context of conservative treatment for AIS, restoring the physiological curvature of the cervical spine may be beneficial for correcting scoliosis, serving as a potential adjunctive therapeutic strategy.\u003c/p\u003e","manuscriptTitle":"Morphological Changes of the Cervical Spine in Adolescent Idiopathic Scoliosis and Correlation Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-03 11:18:07","doi":"10.21203/rs.3.rs-9137144/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-12T05:44:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-11T16:54:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"203728391820237387984490050960381346374","date":"2026-04-16T23:03:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-05T02:47:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147385603412630575322412423410390968675","date":"2026-04-03T02:49:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291133078536106642524532766524862352636","date":"2026-04-02T15:50:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-01T12:45:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"251402387886359660105898622790103196917","date":"2026-03-29T05:51:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-28T15:14:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-26T09:08:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-26T05:47:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-25T10:30:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2026-03-25T10:01:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f9f73465-2485-4073-a7ef-5cc7bc600e67","owner":[],"postedDate":"April 3rd, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-12T05:44:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-11T16:54:12+00:00","index":76,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-17T14:53:39+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-03 11:18:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9137144","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9137144","identity":"rs-9137144","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}