Correlation and Reliability of Cervical Sagittal Alignment Parameters between Lateral Cervical Radiograph and Lateral Whole-Body EOS Stereoradiograph

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Study Design

Retrospective analysis.


To evaluate the correlation and reliability of cervical sagittal alignment parameters obtained from lateral cervical radiographs (XRs) compared with lateral whole-body stereoradiographs (SRs).


We evaluated adults with cervical deformity using both lateral XRs and lateral SRs obtained within 1 week of each other between 2010 and 2014. XR and SR images were measured by two independent spine surgeons using the following sagittal alignment parameters: C2-C7 sagittal Cobb angle (SCA), C2-C7 sagittal vertical axis (SVA), C1-C7 translational distance (C1-7), T1 slope (T1-S), neck tilt (NT), and thoracic inlet angle (TIA). Pearson correlation and paired t test were used for statistical analysis, with intra- and interrater reliability analyzed using intraclass correlation coefficient (ICC).


A total of 35 patients were included in the study. We found excellent intrarater reliability for all sagittal alignment parameters in both the XR and SR groups with ICC ranging from 0.799 to 0.994 for XR and 0.791 to 0.995 for SR. Interrater reliability was also excellent for all parameters except NT and TIA, which had fair reliability. We also found excellent correlations between XR and SR measurements for most sagittal alignment parameters; SCA, SVA, and C1-C7 had r > 0.90, and only NT had r < 0.70. There was a significant difference between groups, with SR having lower measurements compared with XR for both SVA (0.68 cm lower, p < 0.001) and C1-C7 (1.02 cm lower, p < 0.001). There were no differences between groups for SCA, T1-S, NT, and TIA.


Whole-body stereoradiography appears to be a viable alternative for measuring cervical sagittal alignment parameters compared with standard radiography. XR and SR demonstrated excellent correlation for most sagittal alignment parameters except NT. However, SR had significantly lower average SVA and C1-C7 measurements than XR. The lower radiation exposure using single SR has to be weighed against its higher cost compared with XR.

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