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The Effect of Different Pillow Heights on the Parameters of Cervicothoracic Spine Segments



Objective: To investigate the effect of different pillow heights on the slope of the cervicothoracic spine segments. Methods: A prospective analysis of data from 16 asymptomatic adults (aged 20 to 30 years) was carried out. Exclusion criteria were history of injury or accident to the cervicothoracic spine, cervicothoracic spine surgery, or treatment for neck symptoms. We used three different pillow heights: flat (0 cm), 10-cm, and 20-cm pillows. Cervical sagittal parameters, measured with radiography, included; C2-7 Cobb's angle, T1 slope (T1S), thoracic inlet angle (TIA), and neck tilt (NT). Statistical analyses were performed using Spearman correlation coefficients. Results: As the height of the pillow increased, the T1S & C2-7 Cobb's angle increased while the NT values tended to decrease. The TIA values, however, remained constant. Additionally, there was a statistically significant sex difference in T1S with the 0-cm pillow (p=0.01), and in NT with the 20-cm pillow (p=0.01). Conclusion: From the data obtained in this study, we recommend that the most suitable pillow height is 10 cm, considering the normal cervical lordosis.
pISSN 1738-2262/eISSN 2093-6729
Korean J Spine 12(3):135-138, 2015 www.e-kj s. org
© 2015 The Korean Spinal Neurosurgery Society 135
The Effect of Different Pillow Heights on the Parameters of
Cervicothoracic Spine Segments
Hyung Cheol Kim, Hyo Sub Jun, Ji Hee Kim, Jun Hyong Ahn, In Bok Chang,
Joon Ho Song, Jae Keun Oh
Department of Neurosurgery, Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
Objective: To investigate the effect of different pillow heights on the slope of the cervicothoracic spine segments.
Methods: A prospective analysis of data from 16 asymptomatic adults (aged 20 to 30 years) was carried out. Exclusion
criteria were history of injury or accident to the cervicothoracic spine, cervicothoracic spine surgery, or treatment for neck
symptoms. We used three different pillow heights: flat (0 cm), 10-cm, and 20-cm pillows. Cervical sagittal parameters, measu-
red with radiography, included; C2-7 Cobb’s angle, T1 slope (T1S), thoracic inlet angle (TIA), and neck tilt (NT). Statis- tical
analyses were performed using Spearman correlation coefficients.
Results: As the height of the pillow increased, the T1S & C2-7 Cobb’s angle increased while the NT values tended to
decrease. The TIA values, however, remained constant. Additionally, there was a statistically significant sex difference in T1S
with the 0-cm pillow (p=0.01), and in NT with the 20-cm pillow (p=0.01).
Conclusion: From the data obtained in this study, we recommend that the most suitable pillow height is 10 cm, considering
the normal cervical lordosis.
Key Words: Pillow
Cervical spine
Received: June 4, 2015
Revised : Aug ust 13, 2015
Accepted: August 20, 20 15
Corresponding Author: Jae Keun Oh, MD
Department of Neurosurgery, Hallym University Sacred Heart Hospital,
22, Gwanpyeong-ro 170beon-gil, Dongan-gu, Anyang-si, Gyeonggi-do
14068, Korea
Tel: +82-31-380-3771, Fax: +82-31-380-4118
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licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution,
and reproduction in any medium, provided the original work is properly cited.
Many patients present with symptoms related to the cervico-
thoracic spine, such as neck pain, scapular pain, and head-
aches7). Changing pillows can significantly relieve cervical pain,
scapular pain, and headaches2,5-7,9) , although many people
appear to have made poor pillow choices, as low pillow com-
fort and cervicothoracic symptoms upon waking are commonly
reported4). While patients continue to seek advice on pillow
choice, there has been limited research to assess the effects
of varying pillow heights on cervical spine posture. As such,
appropriate recommendations cannot as yet be made.
This study reports the effects of three different pillow hei-
ghts on the slope of the cervicothoracic spine segments when
resting in the supine position.
1. Study Participants
A cohort of 16 asymptomatic adult volunteers, aged bet-
ween 20 and 30 years, were enrolled in this study. All partici-
pants provided written informed consent prior to inclusion.
We included individuals who had no history of any spinal
diagnosis, symptoms, or treatment, and excluded cases where
there was an accident or injury to the cervicothoracic spine
in the preceding year. Patients currently receiving treatment
for neck symptoms were also excl uded.
2. Preparation and Test Position
Participants were permitted to sit up briefly to stretch and
move their necks between each pillow trial. Participants assumed
a standard supine position with their head resting on the pillow
with the external occipital protuberance at the center of the
pillow. Participants lay with their eyes facing the ceiling.
3. Analysis of Simple Radiographs
We measured four morphological parameters. These para-
Kim HC et al.
Fig. 1. Schematic drawing of the measured angles of the cervico-
thoracic spine segments. a: Neck tilt; b: T1 slope; c: Thoracic
inlet angle; d: C2-7 Cobb’s angle.
Fig. 2. Photographs of participants in supine position using pillows of varying height. (A) 0 cm; (B)
10-cm pillow; (C) 20-cm pillow.
Table 1. Parameters of cervicothoracic spine segments*
Total Male Female
Sitting 22.82±5.54 19.21±4.65 26.43±3.79
0 cm 12.92±5.71 8.76±2.11 17.07±5.09
10 cm 17.33±7.42 11.72±5.15 22.94±4.42
20 cm 28.79±5.71 27.74±6.28 29.82±5.29
Sitting 43.98±5.60 41.82±5.99 46.14±4.54
0 cm 51.27±8.13 51.26±10.84 51.27±4.90
10 cm 45.80±9.52 39.70±4.53 51.89±9.43
20 cm 43.11±13.03 33.69±7.02 52.54±10.58
Sitting 9.15±4.95 8.96±4.68 9.33±5.53
0 cm 10.34±7.37 9.16±4.86 11.52±9.47
10 cm 14.93±6.77 16.46±6.97 13.40±6.65
20 cm 17.40±7.33 19.46±6.24 15.34±8.16
TIA (°)
Sitting 66.80±7.14 61.03±2.83 72.57±5.02
0 cm 64.18±9.49 60.02±11.22 68.34±5.23
10 cm 63.12±14.55 51.42±6.21 74.83±10.10
20 cm 71.89±13.02 61.43±6.08 82.35±8.07
*Data are presented as mean±standard deviation
meters consisted of the thoracic inlet angle (TIA), T1 slope
(T1S), neck tilt (NT), and C2-7 Cobb’s angle. As depicted in
Fig. 1, the TIA was considered the angle formed by a line
from the center of the T1 upper endplate (T1UEP) vertical
to the T1UEP, and a line connecting the center of the T1UEP
and the upper end of the sternum. The T1S was defined as
the angle formed between the horizontal plane and the T1UEP.
The NT was defined as the angle formed by a line drawn in
the upper end of the sternum and a line connecting the center
of the T1UEP and the upper end of the sternum. The C2-C7
angle was measured by the formal Cobb methods as the angle
between the horizontal line of the C2 lower endplate and the
horizontal line of the C7 lower endplate (Fig. 1).
4. Statistical Analysis
The PACS system (p view, INFINITT, Seoul, Korea) was
determined by one observer for the measurement. Each para-
meter was independently measured twice. The mean and stan-
dard deviations of all measurements were calculated.
Correlations between parameters of interest in this study
were analyzed with the Mann-Whitney test and Spearman
coefficients. All statistical analyses were performed using SPSS
(version 18.0, SPSS, Chicago, IL, USA). Data are presented
as mean±standard deviation. A p<0.05 was considered statis-
tically significant.
The mean ages of the study participants were 29.38±2.23
and 29.25±3.11 years for men and women, respectively. Table
1 shows the mean values for each of the measured parameters
stratified by sex. With a greater pillow height, the T1S and
C2-7 Cobb’s angle seen on radiographs were greater. For pillow
heights of 0, 10, and 20 cm, the T1S were 12.92±5.71°, 17.33
±7.42° and 28.79±5.71°, respectively; and the C2-7 Cobb’s
angles were 10.34±7.37°, 14.93±6.77°, and 17.40±7.33°,
respectively. Additionally, with increasing pillow height, the
Effect of Pillow Heights on the Cervical Spine
Korean J Spine 12(3) September 2015
NT value tended to decrease, and the TIA values remained
constant with the 0 cm and 10 cm pillow. However, the TIA
values with 20-cm pillow were different from the other pillow
The TIA with the 10 cm pillow had a significant correlation
(p<0.05) with the T1S with the 10 cm pillow (r=0.829) and
the NT with the 10 cm pillow (r=0.812). In addition, the TIA
with the 20 cm pillow had a significant correlation (p<0.05)
with the NT with the 20 cm pillow (r=0.821).
There were, however, no statistically significant differences
in the measured parameters between male and female study
participants, with the exception of differences in T1S with the
0 cm pillow (p= 0.01) and the NT with the 20 cm pillow (p=
As is already known, optimal sagittal alignment of the spine
occurs when all components are in proper balance14). The glo-
bal balance and regional balance alignment is maintained in
each curvature8). If this balance is altered, clinical symptoms
related to unbalanced alignment arise.
The T1S and other cervical parameters have been identified
as radiographic parameters that are greatly correlated with cer-
vical sagittal balance10). Indeed, the T1 sagittal angle is a mea-
surement that may be very useful in evaluating sagittal balance.
In particular, it has great utility where long films cannot be
obtained11). Lee et al.12) reported that the TIA and T1S could
be used to predict the physiological alignment of the cervical spine
on radiographs. Patrick et al.11) demonstrated that patients
whose T1S value falls outside the range of 13° to 25° should
be sent for full-column radiographs for complete evaluation
of their sagittal balance. On the other hand, although patients
with a T1S value between 13° and 25° mostly had better sagittal
balance than patients with values outside this range, its occur-
rence does not guarantee normal sagittal balance. Unfortuna-
tely, there are no studies to date that have established norma-
tive sagittal T1S values. However, in the aforementioned study
by Patrick et al.14), their analysis has shown that when the
T1S was higher than 25°, all patients had at least 10 cm of posi-
tive sagittal imbalance. Their study also showed that patients
with a negative sagittal balance had mostly low T1S values,
usually below 13° of angulation11). In our study, we found that
the T1S value with the 10 cm pillow height was between 13°
and 25° for normal sagittal balance. We could advise that the
10 cm pillow height is most suitable for optimal cervical align-
ment. However, the pillow height of 10 cm is just a numerical
value taking into consideration only the cervical parameter and
not considering the comfort and satisfaction of patients. The-
refore, this value is not an absolute figure.
Although T1S is influenced by aging or posture, it is not
a constant parameter. On the other hand, TIA does not change
with position or increase of thoracic kyphosis under any con-
dition, similar to the pelvic inlet of the pelvis. The TIA is
a constant parameter because, anatomically, the cervical spine
is placed on top of the TI, a fixed circular bony structure
without range of motion that is composed of the T1 vertebral
body, the first ribs on both sides, and the upper part of the
sternum17). The sagittal balance of the cervical spine adjusts
and can be influenced by the shape and orientation of T1.
They concluded that the C2-C7 angle increases with increasing
T1S by radiography. Park et al.14) assessed the sagittal para-
meters of the cervical spine using CT scans in the supine posi-
tion and concluded that the C2-C7 angle increased as the
T1S increased. They also reconfirmed that the TIA can be consi-
dered as a fixed reference value14). However, in our study,
we measured different TIA values with the 20 cm pillow than
other pillow height. Although there are many reasons for this,
we thought an error possibly occurred when measuring the
angle and the higher pillow height changed the TIA. Additio-
nal investigations and considerations of the differences in T1A
are necessary.
Loss of cervical lordosis is a complicating factor in the treat-
ment of the cervical spine, and understanding the effects and
prognosis of a loss of cervical lordosis is crucial to treatment.
However, an embryological basis can be helpful for understan-
ding the pathogenesis of cervical lordosis. In 1977, Bagnall
et al.1) demonstrated that cervical lordosis is formed at 9.5
weeks of gestation. In 195 fetuses, they found that at 9.5 weeks,
83% of fetuses have cervical lordosis, 11% have a military
configuration, and only 6% of fetuses are in the kyphotic posi-
tion of the cervical spine1). In other words, by 9.5 weeks 94%
of fetuses begin to use their posterior cervical muscles to begin
forming the cervical curve. The lordosis begins to form before
birth, and once the child begins to lift his/her head, the lordo-
sis becomes clearer. Cervical lordosis has been theorized to
exist for biomechanical reasons related to weight distribution,
structural support, energy efficiency, and shock absorption.
In daily activity, cervical lordosis better distributes forces than
a cervical spine which has lost its normal lordosis3). Some
studies also reported that an asymptomatic cervical spine did
not always show normal lordotic alignment, as kyphotic align-
ment was revealed in 2% to 35% of individuals8,13,16).
Although the Cobb method works well for the rectangular
vertebrae of the thoracic and lumbar spine, it may be less pre-
cise for measuring the cervical spine, which has trapezoidal
vertebrae13). The Gore method, which uses the posterior verte-
bral body line as opposed to the superior and inferior end
plate lines used by the Cobb method, is considered to be more
Kim HC et al.
reproducible when measuring the cervical sagittal alignment15).
In the present study, however, we did not use the Gore method,
because the Cobb method was more familiar and generally known.
A limitation of the present study is the uneven distribution
of data in the cohort. To estimate the result for a normative
cohort we included only 16 individuals. Since our cohort might
not contain all the representative patterns of sagittal alignment,
we analyzed the non-parametric statistical test. An additional
study, with a larger number of cases, is still needed to be able
to carry out an age, body weight, height, and sex-matched
controlled investigation and confirm the result of the current
study. In other words, our study is a preliminary study, so
further studies with more participants are needed in the future.
Nevertheless, the study participants included were healthy,
young, and without a history of spinal problems. In addition,
our study did not evaluate the comfort, pain relief, and level
of satisfaction of each pillow, Therefore, further study is requi-
red. An active discussion about the T1S and cervical sagittal
alignment is also in progress. Some studies propose an appro-
ximate average value for cervical sagittal alignment, but there
is no “gold standard” established as yet, and additional inves-
tigations of cervical alignment are still necessary.
From the data obtained in this study, we recommend that
the most suitable pillow height is 10 cm considering the normal
cervical lordosis. Additionally, the NT value decreased with
increasing pillow height, whereas TIA values tended to remain
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cervicobrachialgia: a prospective and randomized clinical trial.
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... The details of some important articles were included in this review. The following data were extracted from each study: (1) Table 1: Selection of subjects and pillow samples; (2) Kim et al. (2015) [21] Parameters of Cervicothoracic Spine Segments ...
... The details of some important articles were included in this review. The following data were extracted from each study: (1) Table 1: Selection of subjects and pillow samples; (2) Kim et al. (2015) [21] Parameters of Cervicothoracic Spine Segments ...
... Scope/Objective Key Findings Spinal alignment Kim et al. (2015) [21] Crossover design ...
Full-text available
(1) Background: Sleep problems have become one of the current serious public health issues. Pillow height affects the alignment of the cervical spine and is closely related to the mechanical environment of the cervical spine. An appropriate pillow height can provide adequate support for the head and neck to reduce the stress in the cervical spine and relax the muscles of the neck and shoulder, thereby relieving pain and improving sleep quality. (2) Methods: We reviewed the current trends, research methodologies, and determinants of pillow height evaluation, summarizing the evidences published since 1997. In particular, we scrutinized articles dealing with the physiological and mechanical characteristics of the head-neck-shoulder complex. (3) Results: Through the investigation and analysis of these articles, we presented several quantitative and objective determinants for pillow height evaluation, including cervical spine alignment, body dimension, contact pressure, and muscle activity. The measurement methods and selection criteria for these parameters are described in detail. However, the suggested range for achieving optimal cervical spine alignment, appropriate pressure distribution, and minimal muscle activity during sleep cannot yet be identified considering the lack of sufficient evidence. Moreover, there remain no firm conclusions about the optimal pillow height for the supine and lateral positions. (4) Conclusions: A comprehensive evaluation combining the above determinants provides a unique solution for ergonomic pillow design and proper pillow height selection, which can effectively promote the public sleep health. Therefore, it is necessary to develop a reasonable algorithm to weigh multiple determinants.
... Ren et al. (2016) investigated four different pillow heights and found an increase of 66.4% and 25.1% in the cervical angle (CA) and lordosis distance from 110 to 170 mm, respectively, and a reduction of 43.4% in kyphosis distance. The most desirable pillow height was reported as 10 cm based on the electromyography activity of the middle trapezius muscle (Sacco et al., 2015) and the alignment of cervical spine under X-Ray investigation (Kim et al., 2015). It was also reported that the cervico-thoracic spinal segment slope changed based on the texture of the pillow; whereas the shape of the contour or regular shape did not significantly alter the cervico-thoracic spinal segment slope in a sidelying position (Gordon et al., 2011a). ...
... Regarding the impact of the height of pillows on satisfaction rate and sleep quality, the recommended height of regular-shaped pillows was 10-12 cm, which was considered to be the most comfortable range for sleeping (Kim et al., 2015;Sacco et al., 2015;Soal et al., 2019). However, they only investigated the short-term effect. ...
Background Neck pain is a prevalent condition that can adversely affect quality of life, productivity at work, and sleep quality. The aim of this systematic review and meta-analysis was to identify clinical trials assessing the effect of different types of pillows on neck pain, waking symptoms, neck disability, sleep quality, and spinal alignment. Methods We systematically searched CINAHL Complete, Cochrane Library, EMBASE, Medline, Pubmed and Psychinfo databases from inception to September 2020. Two reviewers independently assessed the articles and evaluated the methodological quality using PEDro. Findings Thirty-five articles fulfilled the inclusion criteria of the study. There were nine high-quality studies involving 555 participants. The meta-analysis revealed significant differences favouring the use of rubber pillows to reduce neck pain [standardized mean difference (SMD): -0.263; P < 0.001). Moreover, waking pain (SMD: -0.228; P < 0.001) and neck disability (SMD: -0.506; P = 0.020) were reduced while the satisfaction rate was enhanced (SMD: 1.144; P < 0.001) with pillow use. Pillow designs did not influence sleep quality (SMD = 0.047; P = 0.703) in patients with chronic neck pain. Interpretation The use of spring and rubber pillows are effective in reducing neck pain, waking symptoms, and disability and enhancing pillow satisfaction in patients with chronic neck pain. Moreover, there may be no change in the alignment of the cervical spine in the side-lying position, regardless of the use of rubber or feather pillows. Rather, the cervical alignment may be significantly impacted by the shape and height of the pillow.
... It was initially described as a fixed morphological angle [14], although further reports demonstrated a change in this parameter with alterations in the position of neck (flexion versus neutral versus extension) [15]. T1S is the angle between the superior endplate of T1 and the horizontal and has been considered analogous to sacral slope (SS) [9]. ...
... NTA, which has been described analogous to pelvic tilt (PT) is defined as the angle between line connecting sternum and middle of T1 upper end plate and the vertical axis. There has been a recommendation that patients with NTA outside the range of 13˚ and 25˚ need to undergo 36-inch whole spine radiographs [15]. ...
... This may be due to the differences in the effect of gravity on the spine in the erect and the supine position. [36] Thoracic kyphosis decreased in the supine position, and the T1S became more horizontal. Correspondingly, the C2-7 angle decreased in a continuous and compensatory manner. ...
Full-text available
To investigate the relationship between cervical and thoracic sagittal alignment parameters measured by magnetic resonance imaging (MRI) and x-ray in patients with cervical spondylosisData from 120 symptomatic patients who presented with cervical spondylosis between April 2015 and January 2016 were retrospectively analyzed. Patients received both a cervical MRI and a cervical radiograph during a single visit. The thoracic inlet angle (TIA), T1 slope (T1S), neck tilt (NT), C2-C7 angle (C2-C7), and C2-C7 sagittal vertical axis (C2-7 SVA) were assessed. Pearson correlation coefficient, paired t test, and linear regression models were used to analyze parameters obtained by cervical MRI and radiography.The difference in mean thoracic inlet angle x-ray (TIAX) and thoracic inlet angle MRI (TIAM) (TIAM-TIAX) (0.72 ± 5.82°) was not significant (P > .05). There were significant differences in mean T1 slope x-ray (T1SX) and T1 slope MRI (T1SM) (T1SM-T1SX) (-2.55 ± 6.14°), mean neck tilt x-ray (NTX) and neck tilt MRI (NTM) (NTM-NTX) (3.26 ± 6.01°), mean C2-C7 angle x-ray (C2-7X) and C2-C7 angle MRI (C2-7 M) (C2-7M-C2-7X) (-3.57 ± 10.00°), and mean C2-C7 sagittal vertical axis X ray (C2-7 SVAX) and C2-C7 sagittal vertical axis MRI (C2-7 SVAM) (C2-7 SVAM-C2-7 SVAX) (-4.50 ± 1.26 mm) (all P ≤ .001). There were positive correlations between TIAM and TIAX (r = 0.807), T1SM and T1SX (r = 0.581), NTM and NTX (r = 0.759), cervical loidosis MRI and cervical loidosis x-ray (r = 0.666), and SVAM and SVAX (r = 0.226).MRI may be useful to evaluate thoracic inlet and sagittal alignment parameters in patients with cervical spondylosis. Patients with cervical spondylosis may have a relatively low capacity for compensation in the cervical region.
... A previous study has reported that the optimum pillow height is one that maintains optimal head and neck alignment 3) . Recently, a pillow with a B-curve shape has been proposed 4) . ...
Full-text available
[Purpose] The aim of this study was to examine the changes in sternocleidomastoid muscle (SCM) activity when using a cervical support pillow (CSP) and to determine the pillow's effect on satisfaction in asymptomatic participants. [Subjects and Methods] This study followed a cross-over design and the order of the measurements was counterbalanced. Twenty asymptomatic participants were positioned supine for 5 minutes by using either a CSP or a general pillow (GP) while the activity of the SCM was measured using surface electromyography. [Results] The CSP significantly decreased the activity of the SCM compared with the GP, and satisfaction after use of the CSP was significantly greater than that after use of the GP. [Conclusion] This study suggests that the CSP may be effective in preventing unnecessary neck muscle activation during sleep in asymptomatic people.
Background Kyphosis is the most common deformity of the cervical spine leading to development of severe disabilities. In case of fused kyphosis, surgical treatment can be demanding and often requires multiple-step procedures for adequate correction. We present a technique of single-stage pedicle subtraction osteotomy (PSO) of C3 to treat a patient with fused kyphosis of C2 and C3 causing spinal stenosis with subsequent myelopathy. Methods A 53-year-old man presented with progressive myelopathy not able to walk with 6/18 points on the modified Japanese Orthopedic Association scale. Horizontal gaze was lost due to cervical kyphosis. Magnetic resonance imaging (MRI) revealed a cervical kyphosis causing stenosis, cord compression, and kinking; computed tomography (CT) showed substantial anterior and posterior fusion of C2 and C3. Results Surgery included decompression via laminectomy of C2 to C6 in combination with PSO of C3 and additional dorsal instrumentation of C2 to C6. Cervical spinal alignment was corrected, as the C2–C4 Cobb angle was reduced from 48.9 to 20.6 degrees. Horizontal gaze was restored. Postoperative MRI demonstrated full decompression of the cord without kinking of the vertebral arteries. No complications were noted. The patient recovered well with restoration of his ability to walk. Conclusion Single-stage pedicle subtraction closing wedge osteotomy in the upper cervical spine, although a demanding surgical procedure, is an alternative treatment option in selected cases of fused and severe cervical kyphosis. In contrast to multiple-step approaches, the single-stage procedure could reduce operating time and may thus decrease complications.
Introduction: Sleep is beneficial and necessary for nearly every tissue in and function of the human body. A lack of sleep can lead to many health hazards including depression, heart disease, obesity, hypertension, and diabetes. Utilizing an appropriate pillow can promote optimal spinal alignment, thus improving sleep quality and duration. The purpose of this study was to analyze available literature and determine the level of evidence that different pillow parameters have (material, height, shape, and thermal properties) to promote and enhance sleep quality, spinal alignment, and to decrease waking symptoms. Methods: Following detailed and systematic search in major ergonomics-related data bases (PubMed, CINAHL, Science Direct, & Google Scholar) by independent searchers applying systematized search processes, eleven articles qualified for inclusion in this review (309 participants). The methodological qualities of included articles were assessed by two independent raters utilizing the PEDro scale and the Modified PEDro Scale for Ergonomics Research (MPSER). Similarly, the authors utilized the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the quality of evidence that these articles established. Results: There is moderate evidence that some of the following pillow parameters could improve sleep quality/spinal alignment, and decreasing sleep-related neck pain. The parameters are; a latex pillow material, a contoured pillow design (higher sides to accommodate side sleepers and a lower, flattened middle to accommodate back sleepers), a seven to eleven centimeters height of the unloaded central part of the pillow, and a cooling surface. Conclusion: Patients/clients are encouraged to consider as many of the above mentioned parameters as possible when choosing a new pillow that fits their individual needs of promoting sleep comfort.
Cervical spine deformities can have a significant negative impact on the quality of life by causing pain, myelopathy, radiculopathy, sensorimotor deficits, as well as inability to maintain horizontal gaze in severe cases. Many different surgical options exist for operative management of cervical spine deformities. However, selecting the correct approach that ensures the optimal clinical outcome can be challenging and is often controversial. We aim to provide an overview of cervical spine deformity in a 3-part series covering topics including the biomechanics, radiographic parameters, classification, treatment algorithms, surgical techniques, clinical outcome, and complication avoidance with a review of pertinent literature.
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We performed a retrospective analysis of medical records and radiographic images of patients who never underwent spinal treatment including diagnosis. The objective of this study is to explain the biomechanical and physiologic characteristics of cervical alignment related to thoracic inlet angle including T1 slope changes in each individual. We reviewed the cervical CT radiographs of 80 patients who visited ENT outpatient clinic without any symptom, diagnosis and treatment of cervical spine from January 2011 to September 2012. All targeted people were randomized without any prejudice. We assessed the data-T1 slope, Cobb's angle C2-7, neck tilt, sagittal vertical axis (SVA) C2-7 and thoracic inlet angle by the CT radiographs. The relationships between each value were analyzed and we concluded that Cobb's angle C2-7 gets higher as the T1 slope gets higher, while the SVA C2-7 value decreases. We propose that the T1 slope is background information in deciding how much angle can be made in the cervical spinal angle of surgical lordotic curvature, especially severe cervical deformity.
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Purpose: To describe the performance of the pillow that participants usually slept on with respect to retiring and waking cervico-thoracic symptoms, pillow comfort, and sleep quality. Methods: Participants (n=106) were systematically recruited for a field trial comparing their own pillow and five trial pillows. Participants provided daily retiring and waking symptom reports and sleep-quality and pillow-comfort ratings prospectively for 1 week on each pillow. Linear and logistic regression models were used to investigate the relationship between pillow use, age, gender, sleep quality, pillow comfort, and waking and temporal (overnight) symptom reports. Results: No waking symptoms were reported by 42.5% of participants on their own pillow. Regular waking symptoms, failure to relieve retiring symptoms, uncomfortable pillows, and/or poor-quality sleep were reported by over 50% of participants. All participants who reported poor sleep quality also reported poor pillow comfort. Pillow-comfort reports were not related to any waking symptom report; however, reports of poor sleep quality were significantly related to waking cervical stiffness (adjusted odds ratio [AOR]=4.3 [Confidence Interval (CI): 1.3–15.6]) and scapula pain (AOR=6.1 [CI: 1.1–31.6]). Feather pillow users provided consistently low reports of pillow comfort and sleep quality. Conclusion: Many participants appear to have made poor pillow choices, as poor sleep quality, low pillow comfort, and waking symptoms were common. Further research is required to understand why people choose particular pillows to sleep on, as well as to identify the best fit between person and pillow to optimize sleep quality and reduce waking symptoms.
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Many patients ask for advice about choosing a pillow. This research was undertaken to determine if pillow type alters cervico-thoracic spine position when resting in the side-lying position. To investigate the effect of different pillow shape and content on the slope of cervico-thoracic spine segments when side lying. The study was a randomized blinded comparative trial set in a laboratory that replicated a bedroom. The subjects were side sleepers aged over 18 years. Exclusion criteria were history of surgery to the cervico-thoracic spine, an injury or accident to the cervico-thoracic spine in the preceding year, or currently receiving treatment for neck symptoms. Each participant rested in a standardized side-lying position for 10 minutes on each of the trial pillows: regular shaped polyester, foam, feather, and latex pillows, and a contour shaped foam pillow. Reflective markers were placed on external occipital protuberance (EOP), C2, C4, C7, and T3, and digital images were recorded of subjects at 0 and 10 minutes on each pillow. Images were digitized using each reflective marker and the slope of each spinal segment calculated. Univariate analysis of variance models were used to investigate slope differences between pillows at 0 and 10 minutes. Significance was established at P < 0.01 to take account of chance effects from repeated measures and multiple comparisons. At 0 and 10 minutes, the EOP-C2, C2-C4, and C4-C7 segmental slopes were significantly different across all pillows. Significant differences were identified when comparing the feather pillow with the latex, regular and contour foam pillows, and when comparing the polyester and foam contour pillows. The regular and contour foam pillows produced similar slopes at all spinal segments. Cervico-thoracic spinal segment slope alters significantly when people change from a foam, latex, or polyester pillow to a feather pillow and vice versa. The shape of a foam pillow (contour versus regular shape) does not significantly alter cervico-thoracic spinal segment slope.
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Pillows are intended to support the head and neck in a neutral position to minimize biomechanical stresses on cervical structures whilst sleeping. Biomechanical stresses are associated with waking cervical symptoms. This paper adds to the scant body of research investigating whether different pillow types produce different types and frequencies of waking symptoms in asymptomatic subjects. A random-allocation block-design blinded field trial was conducted in a large South Australian regional town. Subjects were side-sleepers using one pillow only, and not receiving treatment for cervicothoracic problems. Waking cervical stiffness, headache and scapular/arm pain were recorded daily. Five experimental pillows (polyester, foam regular, foam contour, feather, and latex) were each trialed for a week. Subjects' 'own' pillow was the control (a baseline week, and a washout week between each experimental pillow trial week). Subjects reported waking symptoms related to known factors (other than the pillow), and subjects could 'drop out' of any trial pillow week. Disturbed sleep unrelated to the pillow was common. Waking symptoms occurring at least once in the baseline week were reported by approximately 20% of the subjects on their 'own' pillow. The feather trial pillow performed least well, producing the highest frequency of waking symptoms, while the latex pillow performed best. The greatest number of 'drop outs' occurred on the feather pillow. The foam contour pillow performed no better than the foam regular pillow. 'Own' pillows did not guarantee symptom-free waking, and thus were a questionable control. The trial pillows had different waking symptom profiles. Latex pillows can be recommended over any other type for control of waking headache and scapular/arm pain.
Retrospective study. The purpose of this study was to analyze the relationship of the parameters of cervical sagittal alignment between those obtained from cervical CT and those obtained from radiography, as well as to determine which parameter would help predict physiological lordosis of the cervical spine. Sagittal balance in the cervical spine is as important as the pelvic incidence and is related to the concept of T1 slope. However, many articles including this article based on unclear cervical x-ray radiographs could weakly explain the parameters. To overcome the fundamental limitation of x-ray radiographs, Hallym University Sacred Heart Hospital reported the strong correlation between T1 slope and cervical lordosis on the cervical dimensional CT scans like result by checking by the cervical x-ray radiographs. A retrospective analysis of data from 50 asymptomatic adults in whom both cervical CT scans and cervical radiograph were obtained at the same time. The T1 slope, Cobb angle C2-C7, neck tilt, and thoracic inlet angle (TIA) obtained from the CT scans and radiographs were assessed. The T1 slope on x-ray was significantly correlated with the T1 slope on CT. The mean of the T1 slope on x-ray was larger than the mean of the T1 slope on CT (3.3° ± 6.1°). More cervical spine lordosis was evident on the cervical radiograph than on the cervical CT scan (5.93° ± 9.0°). No significant difference was seen between the TIA on x-ray and the TIA on CT (TIA on x-ray - TIA on CT, -0.1 ± 7.6, P = 0.959). This difference may be due to the differing effect of gravity upon the spine between the upright versus the supine position. Accordingly, TIA and T1 slope may be used as a guide for the assessment of sagittal balance of the cervical spine.Level of Evidence: N/A.
A prospective radiographic study. To analyze the relationship between craniocervical sagittal balance and thoracic inlet (TI) alignment and to present the parameters that would help predict physiological lordosis of the cervical spine. The physiological cervical lordosis (CL) and related factors has not been clearly defined yet. No studies have reported correlations between TI alignment and sagittal balance of the cervical spine. Cervical spine lateral radiograph of 77 asymptomatic adult volunteers (aged between 21 and 50 y) were taken to analyze the following parameters. (1) Thoracic inlet parameters: thoracic inlet angle (TIA), T1 slope, neck tilting (NT); (2) cervical spine parameters: C0-2 angle, C2-7 angle, % ratio of (C0-2/C0-7 angle), (C2-7/C0-7 angle), and cervical tilting; (3) cranial parameters: C0 angle, cranial offset, and cranial tilting. Statistical analysis was performed using the Pearson correlation coefficients and multiple regression analysis. The mean TIA, T1 slope, NT were 69.5, 25.7, and 43.7, respectively. The mean C0-2 angle, C2-7 angle, C0 angle, cranial offset, cervical tilting, and cranial tilting were -22.4 degrees, -9.9 degrees, -9.3 degrees, 20.9 mm, 18 degrees, and 7.7 degrees, respectively. The ratio of C0-2:C2-7 angle was maintained as 77:23% and cervical tilting:cranial tilting was 70.2:29.8%. A significant correlation was found between TIA and T1 slope (r=0.694), T1 slope and C2-7 angle (r=-0.624), C2-7 angle and C0-2 angle (r=-0.547), C0-2 angle and cranial offset (r=-0.406). The thoracic inlet alignment had significant correlations with craniocervical sagittal balance. To preserve physiological NT around 44 degrees, large TIA increased T1 slope and CL and vice versa. TIA and T1 slope could be used as parameters to predict physiological alignment of the cervical spine. The results of this study may serve as baseline data for the evaluation of sagittal balance or planning of a fusion angle in the cervical spine.
To determine the effectiveness (at the 0.1 level of statistical significance) of the Align-Right (roll-shaped) cervical pillow (ARCP) on neck pain severity and headache/neck pain medication use in chronic neck pain subjects. The design was a "before/after" (i.e., a "pre/post" trial). Twenty-eight subjects, 25-45 yr of age with cervical spine pain of biomechanical origin of > 2 on an 11-point ordinal pain scale. The primary outcome measure was severity of morning and evening neck pain. The secondary outcome measure was daily quantity of analgesics ingested. The data were analyzed descriptively and inferentially for clinically and statistically significant pre/post intervention differences. Eligible subjects who successfully finished a 2-wk baseline data-gathering period by mailing in two properly completed diaries each received a pillow and four more diaries (to be filled in over the subsequent 4 wk). Three repeated-measures analyses of variance were performed using the Bonferroni-corrected level of statistical significance of 0.03. Ninety-five percent confidence intervals (for paired-samples mean differences) were also calculated for those pre/post differences that seemed descriptively clinically important. The clinically and statistically significant reductions in neck/shoulder pain severity in this sample of chronic neck pain subjects suggest that the ARCP is an effective therapy for target populations with the same profile as this sample. Patient characteristics predicting suitability were not studied in this project. The results suggest that the ARCP has clinically important beneficial effects on the neck pain severity of most chronic neck-pain sufferers. Further randomized clinical trial research comparing the ARCP with other commonly used cervical pillows is recommended.
A balanced sagittal alignment of the spine has been shown to strongly correlate with less pain, less disability, and greater health status scores. To restore proper sagittal balance, one must assess the position of the occiput relative to the sacrum. The assessment of spinal balance preoperatively can be challenging, whereas predicting postoperative balance is even more difficult. This study was designed to evaluate and quantify multiple factors that influence sagittal balance. Retrospective analysis of existing spinal radiographs. A retrospective review of 52 adult spine patient records was performed. All patients had full-column digital radiographs that showed all the important skeletal landmarks necessary for accurate measurement. The average age of the patient was 53 years. Both genders were equally represented. The radiographs were measured using standard techniques to obtain the following parameters: scoliosis in the coronal plane; lordosis or kyphosis of the cervical, thoracic, and lumbar spine; the T1 sagittal angle (angle between a horizontal line and the superior end plate of T1); the angle of the dens in the sagittal plane; the angle of the dens in relation to the occiput; the sacral slope; the pelvic incidence; the femoral-sacral angle; and finally, the sagittal vertical axis (SVA) measured from both the dens of C2 and from C7. It was found that the SVA when measured from the dens was on average 16 mm farther forward than the SVA measured from C7 (p<.0001). The dens plumb line (SVA(dens)) was then used in the study. An analysis was done to examine the relationship between SVA(dens) and each of the other measurements. The T1 sagittal angle was found to have a moderate positive correlation (r=0.65) with SVA(dens), p<.0001, indicating that the amount of sagittal T1 tilt can be used as a good predictor of overall sagittal balance. When examining the other variables, it was found that cervical lordosis had a weak correlation (r=0.37) with SVA(dens) that was unexpected, given that cervical lordosis determines head position. Thoracic kyphosis also had a weak correlation (r=0.26) with SVA(C1), which was equally surprising. Lumbar lordosis had a slightly higher correlation (r=0.38), p=.006, than the cervical or thoracic spine. A multiple regression was run on the data to examine the relationship that all these independent variables have on SVA(dens). SPSS (SPSS, Inc., Chicago, IL, USA) was used to create a regression equation using the independent variables of T1 sagittal angle, cervical lordosis, thoracic kyphosis, lumbar lordosis, sacral slope, pelvic incidence, and femoral-sacral angle and the dependent variable of SVA(dens). The model had a strong correlation (r=0.80, r(2)=0.64) and was statistically significant (p<.0001). The T1 sagittal angle was the variable that had the strongest correlation with the SVA(dens) Spearman r=0.65, p<.0001, followed by pelvic incidence, p=.002, and lumbar lordosis, p=.006. We also observed that when the T1 tilt was higher than 25°, all patients had at least 10 cm of positive sagittal imbalance. In addition, patients with negative sagittal balance had mostly low T1 tilt values, usually lower than 13°. The other variables were not shown to have a statically significant influence on SVA. This analysis shows that many factors influence the overall sagittal balance of the patient, but it may be the position of the pelvis and lower spine that have a stronger influence than the position of the upper back and neck. Unfortunately, to our knowledge, there are no studies to date that have established a normal sagittal T1 tilt angle. However, our analysis has shown that when the T1 tilt was higher than 25°, all patients had at least 10 cm of positive sagittal imbalance. It also showed that patients with negative sagittal balance had mostly low T1 tilt values, usually below 13° of angulation. The T1 sagittal angle is a measurement that may be very useful in evaluating sagittal balance, as it was the measure that most strongly correlated with SVA(dens). It has its great utility where long films cannot be obtained. Patients whose T1 tilt falls outside the range 13° to 25° should be sent for full-column radiographs for a complete evaluation of their sagittal balance. On the other hand, a T1 tilt within the above range does not guarantee a normal sagittal balance, and further investigation should be performed at the surgeon's discretion.
A random allocation single blind block design pillow field study was undertaken to investigate the behaviour of cervico-thoracic spine pain in relation to pillow use. Participants (N=106) who reported preference for side sleep position with one pillow were recruited via a telephone survey and newspaper advertisement. They recorded sleep quality and pillow comfort ratings, frequency of retiring and waking cervical pain and duration of waking cervical pain while sleeping for a week on their usual pillow, polyester, foam, feather and rubber pillows of regular shape and a foam contour pillow. Analysis was undertaken comparing sleep quality, pillow comfort, waking and temporal cervical pain reports, between the usual pillow and the trial pillows, between pillows of differing content and foam pillows of differing shape. This study provides evidence to support recommendation of rubber pillows in the management of waking cervical pain, and to improve sleep quality and pillow comfort. The rubber pillow performed better than subjects' own pillow in most instances. Subjects' own pillow performed similarly to foam and polyester pillows, and there is no evidence that the use of a foam contour pillow has advantages over the regular shaped pillows. Feather pillows should not be recommended.
The objective of this study was to investigate the long-term efficacy of inpatient rehabilitation using sleeping neck support in patients suffering from chronic cervicobrachialgia. A prospective, randomized clinical trial with a 12-month follow-up was done. A total of 149 patients suffering from chronic cervicobrachialgia received a 4-week inpatient rehabilitation programme. The patients were randomly divided into two groups. The patients in one group were given a special neck pillow to use during and after the rehabilitative treatment (n=76); the patients in the other group were not given the pillow (n=73). Two weeks before, during, and after (3, 6, 9, and 12 months) the 4-week treatment period, the patients completed a questionnaire dealing with the intensity of their cervicobrachial complaints (pain intensity, muscular tension, paraesthesia, and sleep disorders caused by pain or paraesthesia). During the inpatient treatment period, no significant differences were detected between the groups; however, 1-12 months after discharge, the group with sleeping neck support showed a significantly (P<0.05) smaller increase in the intensity of cervical spine pain. Sleep disturbances caused by pain were also reduced significantly (P<0.001 after 3 months, respectively, P<0.05 after 12 months). Inpatient rehabilitative treatment has sustained effects in patients suffering from chronic cervicobrachialgia, particularly when a sleeping neck support is added.