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Association between the anterior tilt slope and spinal sagittal parameters in asymptomatic adults from Southern China
Changhe Liao1, Haifeng Liang1, XinMiao Yu1
1Department of Orthopaedics, Panyu Hospital of Chinese Medicine, Guangzhou University of Chinese Medicine, 511400, Guangzhou, China.
Objective:
To introduce and validate the Anterior Tilt Slope (ATS) as a novel angular parameter for quantifying cervical forward inclination in asymptomatic young adults, and to examine its associations with cervical and global spinal sagittal parameters.
Methods:
In this single-center retrospective study, 341 asymptomatic subjects (18-45 years) who underwent standing full-spine radiographs (AP/Lateral) between May 2023 and May 2025 were analyzed. Cervical parameters (CL, O-C2, C1-7, T1S, cSVA, Borden, ATS), thoracic kyphosis (TK), and spinopelvic parameters (LL, SS, PI, PT, SVA) were measured on PACS by two spine surgeons (twice, averaged). ATS was graded as type I < 5°, II 5-10°, III 10-15°, IV ≥ 15°. Normality was tested with Kolmogorov-Smirnov; group comparisons used t-test/ANOVA with Bonferroni; correlations used Pearson's r (two-tailed α = 0.05). Post hoc power analysis was performed.
Results:
The cohort included 119 males (39%) and 222 females (61%), mean age 25.17 years; overall ATS was 8.17 ± 4.63°. Distribution across ATS grades: I (n = 96), II (n = 134), III (n = 82), IV (n = 29). ATS correlated strongly with cSVA (r = 0.767, P < 0.01) and moderately with T1S (r = 0.482, P < 0.01), and positively with TK (r = 0.252, P < 0.01) and SVA (r = 0.187, P < 0.01); no significant correlations were observed with LL, PI, PT, SS, age, or sex (all P > 0.05). cSVA and T1S increased progressively with higher ATS grades (both P < 0.001). Sex-stratified analyses showed differences in CL, Borden, and C1-7 in certain grades, whereas ATS itself was sex-independent. Statistical power was adequate for main effects.
Conclusions:
ATS provides a robust quantification of cervical forward inclination in asymptomatic individuals, closely linked to cSVA, T1S, and global sagittal alignment, with limited association to spinopelvic parameters-highlighting the pivotal role of the cervicothoracic junction in early sagittal compensation. ATS is a useful complement to cSVA for posture screening, outcome assessment, rehabilitation planning, and potentially surgical decision-making.
