Sagittal alignment patterns in forward head posture: an EOS-based head-to-pelvis correlation analysis

Retrospective radiographic study.

Forward head posture (FHP) is commonly observed in individuals with prolonged screen exposure and may affect spinal alignment. Because the craniovertebral angle (CVA) alone does not fully capture how sagittal balance is distributed across the spine, this study evaluated head-to-pelvis sagittal alignment patterns in individuals with and without FHP, with particular attention to the upper cervical region.

This study evaluated head-to-pelvis sagittal balance (SB) patterns in individuals with and without FHP using standing whole-body EOS radiographs. A total of 201 adults were referred for evaluation of low back pain (LBP) and classified into FHP and non-FHP groups using a predefined CVA threshold as a pragmatic stratification criterion. Sixteen SB parameters spanning the cranio-cervical, thoracic, lumbo-pelvic, and global regions were analysed using group comparisons, age-adjusted regression, and correlation analyses.

Individuals with FHP showed greater upper cervical extension and higher values of cervical sagittal vertical axis, T1 slope, thoracic kyphosis, and global sagittal vertical axis, while lumbar lordosis and spinopelvic parameters remained comparable between groups. In non-FHP individuals, subaxial cervical alignment (C2-C7) was associated with global alignment. However, these relationships were absent in the FHP group, with correlations shifting toward the upper cervical parameters (C0-C1, C0-C2) including associations with pelvic parameters, and the T1 slope, which showed stronger associations across cervical and global alignment.

These findings suggest a redistribution of sagittal alignment relationships toward the upper cervical and cervico-thoracic regions in FHP, while lumbar structural alignment remains preserved, highlighting the limitations of CVA-centric frameworks for capturing whole-spine postural adaptations.