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Tuesday, June 6, 2023

Roentgenographic Findings in the Cervical Spine in Asymptomatic Persons

Brent Brookbush

Brent Brookbush


Research Review: Roentgenographic findings in the cervical spine in asymptomatic persons: A ten-year follow-up.

By Amy Martinez DPT, PT

Edited by David Boettcher MSc, BA, NASM CPT, PES & CES & NPTI

Edited by Brent Brookbush DPT, PT, COMT, MS, PES, CES, CSCS, ACSM H/FS

Original Citation:

Gore, R. (2001). Roentgenographic findings in the cervical spine in asymptomatic persons: A ten-year follow-up. Spine, 26 (22), 2463-2466. -ABSTRACT


Research suggests that 20% of the population may experience neck pain at some point in their lives (1-4). Research has demonstrated correlation between neck pain and cervical malalignment (5), changes in scapular mechanics and alterations in activity of the trapezius and serratus anterior  (8,9). This 2001 prospective study, by an American researcher, established a correlation between chronic neck pain, cervical spine subluxations and degenerative changes. The findings suggest cervical joint mobility should be assessed in those who exhibit signs of neck pain, cervical dysfunction and/or upper body dysfunction (UBD) .

Cervical x-ray lateral view
Caption: Cervical x-ray lateral view

Lateral view of cervical spine x-ray - By Stillwaterising - Own medical image, work for hire, CC0 1.0 Universal Public Domain Dedication, https://commons.wikimedia.org/wiki/File:Cervical_Xray_Lateral_View.jpg

Study Summary

Study DesignProspective Study
Level of EvidenceIII - Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies
Participant CharacteristicsDemographics
  • Number of participants: 159
  • Gender: 77 males, 82 females
  • Age range: 20-65

Inclusion Criteria:

  • All participants were asymptomatic, with no pain in the cervical spine.

Exclusion Criteria:

  • Any pre-existing pain or pathology in the cervical spine.
  • Participants were divided among age groups.
  • Lateral Roentgenographics (X-rays) were taken of each participant in a comfortable standing position facing forward.
  • Measurements were taken for:
    • Cervical lordosis
      • Measured as the angle between a line parallel to the posterior surface of C2 and posterior surface of C7.

    • Disc space narrowing
    • Endplate sclerosis
    • Anterior and posterior osteophyte formation
    • Congenital abnormalities
    • Vertebral body subluxations at each level

  • At the 10-year follow-up, the X-ray procedure was repeated on all participants that could be located.
  • Participants also completed a short questionnaire to determine if they had experienced neck pain during the past decade.
  • The initial and follow-up X-rays were compared.
Data Collection and AnalysisData Collection
  • A numerical grading system was designed to record the severity of degenerative changes at each inter-vertebral space.
    • "0" - indicated no signs of change
    • "1" -  indicated 25% decrease in disc space, barely visible vertebral body endplate sclerosis and osteophyte formation.
    • "2" - indicated 50% decrease in disc space, moderate vertebral body endplate sclerosis and osteophyte formation.
    • "3" - indicated 75% decrease in disc space, severe vertebral body endplate sclerosis and osteophyte formation.

Data Analysis

  • A composite index was created by combining the numerical rankings of the degenerative changes, establishing a cumulative degenerative index value.
  • Fisher's Exact Test was used to test for associations between two variables in uni-variate associations.
    • The odds ratio was used for 2 x 2 tables.

  • Partial Spearman rank and Kendall's tau-b correlation coefficient were used to measure correlations between lordosis and the degenerative index, while controlling for age.
  • Binary logistic regression was used to analyze multivariate relations for predicting pain and subluxations.
    • Odds ratio were reported for all significant associations.

Outcome Measures
  • Self-reported neck pain
  • Number of vertebral body subluxations
  • Severity of degenerative changes
  • The most frequent and severe sites of degenerative changes were observed between C5-C6 and C6-C7.
    • The increase in the degenerative index was significant for all vertebral structures from C3-C7.

  • 57 participants showed no degenerative changes between their initial and follow up X-ray.
  • 30 participants showed no degenerative changes on their initial X-ray but developed at least one degenerative change over the 10-year period.
  • 72 participants showed degenerative changes on their initial X-ray.
    • 70 of whom exhibited a progression of the degenerative changes over the 10-year period.
    • 2 of whom had no change over the 10-year period.

  • An initial degenerative index at C6-C7 was associated with the development of pain during the 10-year period (P=0.0037).
  • Average age of initial X-ray was 52, with an age range between 32-56.


  • 24 participants reported experiencing pain during the 10-year period.
    • 20 had no occurrence of a neck injury.
    • 4 reported pain as a result of a traumatic episode.

  • Of these 24 participants:
    • 17 reported posterior neck pain.
    • 5 reported occipital headaches
    • 2 reported radicular pain

  • Average age at onset of pain was 48.1
Researchers' Conclusions

The number of subluxations and severity of degenerative changes in the cervical spine increased with age. Over a 10-year period, 15% of the participants reported developing pain, which correlates with additional research (1-4). Degenerative changes at C6-C7 visible on an initial X-ray was a statistically significant predictor of pain.

Cervical Distraction Test

How this study contributes to the body of research:

This prospective study compared the lateral x-rays of 159 asymptomatic participants with 10-year follow-up. Outcomes included degrees of cervical lordosis, degenerative changes and incidence of self-reported neck pain. A previous cross-sectional study demonstrated a correlation between the level of spinal degeneration and chronic neck pain (10). Unique to this study, participants were initially asymptomatic and re-evaluated ten years later, allowing for correlations to be determined between the assessed signs of degeneration and increased risk of future neck pain.

How the Findings Apply to Practice:

The findings of this prospective study imply a correlation between cervical degenerative changes and increased incidence of neck pain, especially when degenerative changes are noted at the C6-C7 level. This may suggest that it is possible to develop screening methods that would be predictive of future pain and injury, based on measurable impairments (e.g. range of motion) correlated with these dysfunctions. Human movement professionals should consider the addition of cervical movement assessments and techniques for addressing cervical impairments prior to the onset of pain and injury.


  • Prospective studies are relatively rare in human movement science. This study began with asymptomatic individuals and followed up ten-years later, providing evidence that impairment may be a cause and/or a predictor of pain.
  • The researcher investigated correlations between findings and age, to aid in isolating predictive factors from age-related changes.
  • The researcher was blind to the participant's pain status at the time time of the X-ray, minimizing tester bias.

Weakness and limitations

  • At the follow-up session participants were asked if they had experienced pain over the ten-year period. This long-time period may have introduced errors due to memory recall. A more frequent follow-up, or series of follow-ups, may help to improve the results.
  • The researcher evaluated lateral X-rays, which limits evaluation of facet changes; additional X-ray angles and functional evaluations may enhance predictive reliability and clinical applicability.
  • The term "subluxation" is not well defined in this study.

How the study relates to Brookbush Institute Content?

The Brookbush Institute (BI) continues to refine and develop predictive models of dysfunction, including Cervicothoracic Dysfunction (CTD) and Upper Body Dysfunction (UBD) , with the intent of optimizing evidence-based education and practice. This study supports the assertion that dysfunction is predictive and perhaps causative of cervical spine pain. The BI will continue to pursue optimal practice by integrating research, with practical application and outcomes, in pursuit of refining practice.

The following videos illustrate some techniques commonly recommended by the Brookbush Institute for Upper Body Dysfunction and  Deep Cervical Flexor Activation:

Cervical Lateral Flexion Goniometry

Cervical Distraction Test

Cervical Fascia Instrument Assisted Soft-Tissue Manipulation

Cervical Spine Posterior to Anterior Mobilization

Cervical Manipulation

Deep Cervical Flexor Isolated Activation

Combined Deep Cervical Flexor and External Rotator Activation

Deep Cervical Flexor Reactive Activation


  1. Bovim, G., Schrader, H., & Sand, T. (1994). Neck pain in the general population. Spine19(12), 1307-1309.
  2. Côté, P., Cassidy, J. D., Carroll, L. J., & Kristman, V. (2004). The annual incidence and course of neck pain in the general population: a population-based cohort study. Pain112(3), 267-273.
  3. Mäkela, M., Heliövaara, M., Sievers, K., Impivaara, O., Knekt, P., & Aromaa, A. (1991). Prevalence, determinants, and consequences of chronic neck pain in Finland. American journal of epidemiology134(11), 1356-1367.
  4. Picavet, H. S. J., & Schouten, J. S. A. G. (2003). Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC3-study. Pain102(1-2), 167-178.
  5. Bogduk, N. (1995). The anatomical basis for spinal pain syndromes. Journal of Manipulative and Physiological Therapeutics18(9), 603-605.
  6. Falla, D., Jull, G., & Hodges, P. W. (2004). Feedforward activity of the cervical flexor muscles during voluntary arm movements is delayed in chronic neck pain. Experimental brain research, 157(1), 43-48.
  7. Falla, D., O’Leary, S., Farina, D., & Jull, G. (2011). Association between intensity of pain and impairment in onset and activation of the deep cervical flexors in patients with persistent neck pain. The Clinical journal of pain, 27(4), 309-314.
  8. Helgadottir, H., Kristjansson, E., Einarsson, E., Karduna, A., & Jonsson, H. (2011). Altered activity of the serratus anterior during unilateral arm elevation in patients with cervical disorders. Journal of electromyography and kinesiology, 21(6), 947-953.
  9. Thigpen CA, Padua DA, Michener LA, Guskiewicz K, Giuliani C, Keener JD, Stergiou N. (2010). Head and shoulder posture affect scapular mechanics and muscle activity in overhead tasks. Journal of Electromyography and Kinesiology. 20: 701-709.
  10. Marchiori, D. M., & Henderson, C. N. (1996). A cross-sectional study correlating cervical radiographic degenerative findings to pain and disability. Spine, 21(23), 2747-2751.
  11. Peolsson, A. L., Peolsson, M. N., & Jull, G. A. (2013). Cervical muscle activity during loaded arm lifts in patients 10 years postsurgery for cervical disc disease. Journal of manipulative and physiological therapeutics, 36(5), 292-299.
  12. Phillip Page, Clare Frank, Robert Lardner, Assessment and Treatment of Muscle Imbalance: The Janda Approach © 2010 Benchmark Physical Therapy, Inc., Clare C. Frank, and Robert Lardner
  13. Shirley Sahrmann and Associates, Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spine © 2011 Mosby, Inc, an affiliate of Elsevier Inc.
  14. Jull, G.A., Falla, D., Vicenzino, B., Hodges, P.W. (2009). The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain. Manual Therapy. 14: 696-701.

© 2019 Brent Brookbush

Questions, comments, and criticisms are welcomed and encouraged