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Repeated measurements were made of surface postural angles registering the relative positions of the head and neck in photographs and of angles of the upper cervical vertebrae recorded in lateral cephalometric radiographs in the same subjects. For all registrations, subjects assumed the natural head rest position.To examine the correlation between external measurement of head and neck posture and the anatomic positions of the upper four cervical vertebrae.Interpretation of surface cervical posture measurement is confounded by lack of knowledge about the extent of the underlying compensatory adjustments among the upper cervical vertebrae that may accompany variation in head and neck posture. The correlation between surface measurement and postural characteristics of the upper cervical spine has not been reported to date.The association between a set of angles describing the anatomic position of the four upper cervical vertebrae on lateral cephalometric radiographs and a surface measurement of head and neck posture, the craniovertebral angle, was studied in 34 young adult women aged between 17.2 and 30.5 years, mean age, 24.5 years. Anatomic positions of the upper four cervical vertebrae were expressed by angles relative to the true vertical or horizontal. Surface angles registering head and neck position for each subject were obtained from photographs recorded on two occasions.No strong correlation could be established between the angles taken from the lateral cephalometric radiographs measuring the extent of upper cervical lordosis, orientation of the atlas, vertebral inclination, or odontoid process tilt and surface angles recording head and neck position. This finding was attributed principally to the much greater positional variability demonstrated within the upper cervical spine when compared with the surface measurements of head and neck position.Anatomic alignment of the upper cervical vertebrae cannot be inferred from variation in surface measurement of head and neck posture. This is the case even in those people identified with more extreme head and neck postural tendencies.