Is Visual Vertical Perception Altered in Children and Adolescents with Spinal Misalignment? A Cross-Sectional Study

Background/Objectives. Spinal misalignment in childhood and adolescence may be associated with altered sensory integration and body representation. The subjective visual vertical reflects visual, vestibular, and somatosensory integration, but its relationship with pediatric spinal misalignment remains uncertain. This study investigated the subjective visual vertical using two complementary paradigms. Methods. This exploratory, single-center, cross-sectional study included participants aged 7-17 years with clinically identified spinal misalignment. Participants underwent standardized physiatric assessment and subjective visual vertical testing using a luminous-line test and the Bucket Test. Spearman's rank correlations examined associations with clinical and radiographic variables, with false-discovery-rate control using the Benjamini-Hochberg procedure. Radiographic analyses were restricted to participants with available imaging. Results. Fifty-seven participants were included (mean age 12.8 years, SD 2.25), and all completed both tests. Mean subjective visual vertical was 0.053° (SD 0.953) with the luminous-line test and -0.561° (SD 1.165) with the Bucket Test. Radiographs were available for 21 participants. No association remained significant after false-discovery-rate correction. Two luminous-line associations were nominally significant before correction: primary lumbar curve presence (ρ = -0.278, p = 0.036) and secondary thoracolumbar curve presence (ρ = -0.324, p = 0.015); both had q = 0.721. The tests were moderately correlated (ρ = 0.493, p < 0.001). Radiographic sensitivity and subgroup analyses showed no significant findings. Conclusions. Subjective visual vertical was not robustly associated with spinal misalignment characteristics in this modest, clinically heterogeneous cohort. Larger controlled studies with standardized imaging and adequately powered severity groups are required.