The most appropriate cervical vertebra for the measurement of occipitocervical inclination parameter: a validation study of C3, C4, and C5 levels using multi-positional magnetic resonance imaging

  • Permsak Paholpak
  • Blake Formanek
  • Andrew Vega
  • Koji Tamai
  • Zorica BuserEmail author
  • Jeffrey C. Wang
Original Article



To evaluate which cervical level is the most appropriate level to measure occipitocervical inclination (OCI).


Sixty-two patients with multi-positional MRI: 24 males and 38 females, who had cervical lordosis and had a disk degeneration grade of 3 or less were included. We measured patient’s OCI at C3, C4, and C5, occipitocervical angle (OCA), occipitocervical distance (OCD), C2–7 angle, and cervical sagittal vertical axis (cSVA) in neutral, flexion, and extension position. The correlation between OCI and OCA, OCD, C2–7 angle, and cSVA on each cervical level in all three positions was tested using Pearson’s correlation coefficient test. The difference between OCIs at each cervical level was tested by Wilcoxon signed-rank test. p value of less than 0.05 was set as a statistically significant level.


C5 OCI showed statistically significant correlation with OCA, OCD, C2–7 angle, and cSVA in all three positions (p < 0.05, r = 0.214–0.525). C3 OCI in flexion (p = 0.393, r = 0.081) and C4 OCI in neutral and flexion (neutral p = 0.275, r 0.104; flexion p = 0.987, r = 0.002) did not show significant correlation with C2–7 angle. There was a statistically significant difference between C3, C4, and C5 OCIs in neutral and extension position (p < 0.05). At the same time, OCI showed statistically strong correlation between adjacent cervical levels (p < 0.001, r = 0.627–0.822).


C5 cervical level is the most appropriate level for OCI measurement. OCI should be measured at the same cervical level at all time. C4 OCI can reliably substitute C5 OCI in case C5 which is invisible on radiographic image.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.


Occipitocervical Occipitocervical alignment Occipitocervical parameters Occipitocervical inclination Occipitocervical angle 


Compliance with ethical standards

Conflict of interest

No conflicts of interest for the current study.


Disclosures outside of submitted work: ZB- consultancy: Xenco Medical, AO Spine (past); Research Support: SeaSpine (paid directly to institution); JCW - Royalties – Biomet, Seaspine, Amedica, DePuy Synthes; Investments/Options – Bone Biologics, Pearldiver, Electrocore, Surgitech; Board of Directors - North American Spine Society, AO Foundation (20,000 honorariums for board position, plus travel for board meetings), Cervical Spine Research Society; Editorial Boards - Spine, The Spine Journal, Clinical Spine Surgery, Global Spine Journal; Fellowship Funding (paid directly to institution): AO Foundation.

Supplementary material

586_2019_6028_MOESM1_ESM.pptx (2.8 mb)
Supplementary material 1 (PPTX 2842 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Orthopaedic Surgery, Keck School of MedicineUniversity of Southern CaliforniaLos AngelesUSA
  2. 2.Department of Orthopaedics, Faculty of MedicineKhon Kaen UniversityKhon KaenThailand
  3. 3.Department of Orthopaedics, Faculty of MedicineOsaka City UniversityOsakaJapan

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