Abstract
Cervical spondylolisthesis indicates instability of the spine and can lead to pain, radiculopathy, myelopathy and vertebral artery stenosis. Currently degenerative cervical spondylolisthesis is a wait-and-watch condition with no treatment guidelines. A literature review and discussion will be provided. 8 females presented with neck pain, disability, and history of motor vehicle collision. Radiographs revealed abnormal cervical alignment, spinal canal narrowing, and spondylolistheses. After 30 sessions of Chiropractic BioPhysics® care over 12 weeks, patients reported improved symptoms and disabilities. Radiographs revealed improvements in cervical alignment, spondylolistheses, and spinal canal diameter. Motor vehicle collision may cause instability and abnormal alignment of the cervical spine leading to cervical spondylolisthesis. Improving spinal alignment may be an effective treatment to reduce vertebral subluxation and cervical spondylolistheses and improve neck disability as a result of improved spinal alignment.
Keywords: chiropractic, Chiropractic BioPhysics, adjustment, CBP, spinal instability, cervical spondylolisthesis, cervical spine, posture
CASE SERIES
INTRODUCTION
Spondylolisthesis refers to the slippage of one vertebral body on the vertebra below. It is considered uncommon in the cervical spine when compared to the lumbar spine and is now being recognized as an under-studied condition [1].
The two main types are congenital and acquired spondylolisthesis. Congenital spondylolisthesis is caused by a failure of formation of facet joint in the vertebrae and acquired spondylolisthesis refers to a defect in the pars interarticularis caused by degeneration, trauma, pathology, or surgery [2]. Degenerative cervical spondylolisthesis (DCS) is categorized into 3 different categories dependent on radiographic features, symptoms, and morphology. Each type has a suggested surgical procedure. Stage 1 presents with pain and noticeable facet joint degeneration; surgical recommendations include single level discectomy, repositioning, and fusion. Stage 2 patients will present with radiculopathy or myelopathy with facet degeneration and vertebral body degeneration; surgical recommendations include a multi-level discectomy, repositioning, and fusion. Stage 3 patients are identified with severe myelopathy and spinal deformity; surgical recommendations include corpectomy along with fusion of adjacent segments [1,3,4]. As of 2020, there are no current medical guidelines to follow. Surgery is indicated when the patient’s symptoms continually worsen and there is a proven instability or spinal cord compression [5].
DCS prevalence is estimated to be 5.2% to 11% of the population and is understudied in comparison to the more common lumbar spondylolisthesis. The male-to-female ratio is 1.5 to 1 in grade 1 and 2.2 to 1 in grade 2 spondylolisthesis and there is an increased prevalence after 60 years with a 33.3% prevalence in 20 to 59 years and 66.7% in 60 to 99 years of age [6]. DCS in symptomatic patients was found to be 16.4% prevalence of grade 1 and 3.4% of grade 2 (Table 2). DCS was graded and defined by the following criteria. Grade 1 is defined as 2–3mm of displacement and grade 2 is defined as displacement greater than 3mm [1,7].
Table 2.
Summary table of cervical spondylolisthesis in the sagittal plane
| Spondylolisthesis | Summary |
|---|---|
| Etiology |
|
| Incidence |
|
| Gender Ratio |
|
| Age Predilection |
|
| Risk Factors |
|
| Treatment |
|
| Prognosis |
|
| Findings on Imaging |
|
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When left untreated, DCS can lead to pain, radiculopathy, myelopathy and vertebral artery stenosis [1,5]. DCS is also an indicator of cervical vertebrae instability. This is associated with disc degeneration and facet joint arthropathy [8]. C3–C5 disc levels are the most common levels of DCS.
The natural progression of spondylolisthesis is monitored by radiograph. Currently the literature only shows resolution of non-operative spondylosis in patients with unilateral lesions [2,9]. The progression of the spondylolisthesis includes many variables, but age seems to play a large role [9].
The objective of this case series is to report on the structural, functional, and symptomatic improvements in eight patients with cervical spondylolistheses using Chiropractic BioPhysics? (CBP®). CBP? technique has established a valid healthy, normal, ideal spine model. CBP® has developed valid, reliable examination and assessment methods for spinal posture, alignment, and biomechanics. Chiropractic BioPhysics® has established effective, reproducible treatment methods for spinal correction that have been tested and shown to be effective and superior to various other treatment methods in randomized and non-randomized clinical trials. CBP® does this by normalizing spinal posture, alignment, and biomechanics by applying Mirror Image? exercises, adjustments, traction which, in turn, addresses altered musculature, neurology, and connective tissue, respectively [10]. Mirror Image® exercises strengthen weak musculature and lengthen tight musculature that have adapted to unhealthy posture to correct and maintain corrections in spinal alignment and postural abnormalities. Mirror Image® adjusting stimulates mechanoreceptors and proprioceptors to retrain the body’s central nervous system (CNS) to adapt to normal, healthy posture. Mirror Image® traction allows for viscoelastic deformation of spinal ligaments and corrects the patient’s abnormal posture by initiating muscle and ligament creep creating permanent restorative change [10].
CASE DESCRIPTIONS
Patients
Eight female patients with a mean age of 53.4 ± 9.1 years presented with a chief complaint neck pain (NP), bilateral upper trapezii pain, neck stiffness, restricted cervical range of motion (ROM), and radicular symptoms into the shoulder(s) and(or) arm(s). The patients reported limitations in performing activities of daily living (ADL). The patients reported a mean score of 34.5 ± 5.7% on the self-rating neck disability index (NDI) outcome assessment indicating a mean moderate neck disability [11,12]. The NDI is a patient-reported questionnaire that determines the disability effect of neck pain on a person’s daily life. There are ten questions in the following categories: Pain Intensity, Personal Care, Lifting, Reading, Headaches, Concentration, Work, Driving, Sleeping, and Recreation. There are six answer choices for each question. The answers are scored from 0 (no disability) to 5 (complete disability). The ten scores are totaled, multiplied by two, and are reported from 0–100 often as a percentage (0–100%). “The Neck Disability Index has been used in over 300 publications, translated into 22 languages…and endorsed for use by a number of clinical practice guideline committees…making it the most widely used and most strongly validated instrument for assessing suffering disability in patients with neck pain” [12]. The patients had a history of a motor vehicle collision (MVC). The patients reported that they sought medical treatment and(or) physical therapy greater than 6 months prior to chiropractic care and that their symptoms had not resolved prior to chiropractic care.
Patients were selected from a records review from two chiropractic clinics with advanced training in corrective chiropractic care and that follow CBP® protocols [10]. The patients selected for this case series met certain inclusion criteria. All patients presented with neck pain and disability, a history of motor vehicle collision trauma, and DCS as diagnosed by radiographic analysis. All patients completed a recommended 30 visits which included chiropractic adjustments, exercise, and traction over 12 weeks of corrective chiropractic care with post-treatment radiographs for comparison to pre-treatment radiographs. Patients were excluded from this case series if they had red flags or contraindications for chiropractic adjustments, exercise, or traction to the cervical spine, cervical or cervicothoracic scoliosis, or lateral translations of the head resulting in 7 mm or greater lateral displacement of the second cervical vertebra (C2) with respect to the fourth thoracic vertebra (T4) [13].
Radiographic Analysis
Spinal radiographs are necessary to assess for red flags or contraindications to spinal treatment, pathology, spinal alignment, and vertebral subluxations, such as cervical spondylolisthesis, to determine specific approaches to structural spinal rehabilitation as well as patient progress in a spinal correction plan [14]. The Harrison posterior tangent method provides measurements of regional and intersegmental vertebral angles and regional and intersegmental vertebral translations. Cervical angles are measured by drawing a line tangent to the posterior margin of each vertebral body from C2 to the seventh cervical vertebra (C7). Measurements of a spinal region provide the absolute rotation angle (ARA). Regional anteroposterior (AP) spinal translations can be measured by drawing a vertical line from an inferior landmark and measuring the horizontal displacement to a superior landmark. AP translation of the cervical spine is measured using the posterior, inferior body of C7 as the inferior landmark and the posterior, superior body of C2 as the superior landmark. Intersegmental AP translations are determined by measuring the distance perpendicular to the posterior tangent line of the inferior vertebra to the posterior, inferior aspect of the superior vertebra. Spinal canal diameter (SCD) on radiograph is measured from the closest points between the posterior aspect of a vertebra and the spinolaminar line of adjacent vertebrae. For example, if C2 slips anterior to C3, the SCD would be measured from the inferior end of the spinolaminar line of C2 to the posterosuperior corner of C3. And if C2 slips posterior to C3, the SCD would be measured from the posteroinferior corner of C2 to the superior end of the spinolaminar line of C3 [15].
The spinal postural and radiographic analysis uses a right-hand, thumb-up Cartesian coordinate system to illustrate translations in the coronal, sagittal, and transverse planes and rotations around x, y, and z-axes of the head, thorax, and pelvis [10]. In documenting spinal positioning, the positive or negative sign indicates the direction of translation in or rotation around the x, y, and z-axes in the frontal, sagittal, and horizontal planes. The first letter indicates translation (T) or rotation (R). The second letter indicates the axis in or around which the T or R takes place. The third letter indicates head (H), thorax (T), or pelvis (P) with respect to the body region below. The head is relative to the thorax; the thorax is relative to the pelvis; and the pelvis is relative to the feet. Vertebra then denote the anatomical landmarks involved [10].
Neutral lateral cervical (NLC) radiographs were analyzed using PostureRay® Electronic Medical Records (EMR) Software (PostureCo, Inc., Trinity, FL, USA) per the Harrison Posterior Tangent method for spine views in the sagittal place [16–18]. These examination and analysis methods are valid [19–23], reliable, and repeatable [16–20,24], as is posture [19].
Initial NLC view revealed a mean forward head posture (Tz C2–C7) of 15.1 ± 9.3 mm (ideal is 0.0 mm and average is 15 mm), mean absolute rotational angle from C2 to C7 (ARA C2–C7) of −15.5 ± 15.8° (normal is −42.0° and average is 34°), DCS at 17 intersegmental locations with a mean horizontal displacement (Tz DCS) of 3.1 ± 0.9 mm (as high as 4.5 mm), and a mean SCD at corresponding DCS locations of 14.8 ± 0.6 mm (normal is 17.0 mm) (Figures 1a–8a, Table 1) [3]. AP horizontal displacement of one vertebra on another results in a narrowing of the spinal canal as the spinolaminar line of the vertebra more anterior approximates to the posterior vertebral line of the vertebra more posterior as seen on sagittal spinal radiographs and can result in spinal canal stenosis as shown in the mean values of the Table 1.
Figure 1.
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Figure 2.
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Figure 3.
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Figure 4.
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Figure 5.
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Figure 6.
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Figure 7.
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Figure 8.
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Table 1.
Comparison evaluation of pre-treatment* and post-treatment* clinical findings
| Measurement | Normal | Pre-treatment Mean | Post-treatment Mean | Mean Difference |
|---|---|---|---|---|
| ARA C2–C7 (°) | −42.0 | −15.5 ± 15.8 | −22.1 ± 13.5 | 6.6 |
| Tz C2–C7 (mm) | 0.0 | 15.1 ± 13.9 | 11.8 ± 8.4 | 3.3 |
| Tz DCS (mm) | 0.0 | 3.1 ± 0.9 | 0.5 ± 0.4 | 2.6 |
| Tz SCD at DCS (mm) | 17.0 | 14.8 ± 0.6 | 17.0 ± 0.8 | 2.2 |
| NDI (%) | 0.0 | 34.5 ± 5.7 | 4.3 ± 1.2 | 30.2 |
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*
Treatment is 30 sessions of Mirror Image® spinal exercises, adjustments, and traction over 12 weeks per Chiropractic BioPhysics® protocols explained in the subsection, Interventions and Outcomes, of the Case Descriptions section.
ARA = Absolute Rotational Angle of Measurement
Tz = Translation in the z-axis/sagittal plane
DCS = Degenerative Cervical Spondylolisthesis
SCD = Spinal Canal Diameter
NDI = Neck Disability Index
Xray 1 = Pre-treatment values
Xray 2 = Post-treatment values following 30 sessions over 12 weeks
Description: Table 1 shows mean values of eight patients for absolute rotational angle from C2 to C7, translations in the z-axis (Tz) of the cervical region from C2–C7 and per degenerative cervical spondylolisthesis segments, and neck disability index scores of pre-treatment and post-treatment assessments. Mean ARA C2–C7 improved from −15.5° to −22.1° (normal is −42.0°); mean Tz C2–C7 improved from 28.0 mm to 11.8 mm (normal is 0.0 mm); mean Tz DCS improved from 3.1 mm to 0.9 mm (normal is < 1.0 mm); mean Tz SCD at DCS improved from 14.8 mm to 17.0 mm (normal is 17 mm); and mean NDI improved from 34.5% to 4.3% (normal is 0%). All measurements improved toward normal values.
All patients who met the inclusion criteria had an abnormal ARA C2–C7 consistent with MVC trauma as determined by radiographic examination and analysis.
Interventions and Outcomes
The patients completed 30 sessions of Mirror Image® spinal exercises, adjustments, and traction over 12 weeks per CBP® protocols [10]. The Mirror Image? exercise involved the patient performing the following steps:
Maximum anterior head translation (+TzH)
Anterior head translation causes a coupling pattern of the cervical spine that causes lordosis of the upper cervical spine and kyphosis (reversal of curve) of the lower cervical spine.
While maintaining +TzH, maximum head extension (−RxH)
Maintenance of the anterior head translation allows for the upper cervical spine to maintain its lordosis and maximum head extension allows for the lower cervical spine to move toward a healthy lordotic curve.
While maintaining the −RxH, posterior head translation (−TzH)
The posterior head translation from this position allows for the head to return to a normal postural position while maintaining the induced cervical lordosis from previous movements.
The patient held the final position for 10 seconds before relaxing and repeating for 20 repetitions. Mirror Image® exercises strengthen weak musculature and lengthen tight musculature that have adapted to unhealthy posture to correct and maintain corrections in spinal alignment and postural abnormalities [10]. Mirror Image® adjustments involved using an OMNI elevation adjusting table with sectional drop-mechanisms and setting up the patient in the position obtained during Mirror Image® exercise followed thrust to the mid-lower cervical vertebrae. The Impulse® adjusting instrument (Neuromechanical Innovations, Chandler, AZ, USA) was also used for Mirror Image® adjustments. Mirror Image® adjusting stimulates mechanoreceptors and proprioceptors to retrain the body’s CNS to adapt to normal, healthy posture [10]. Mirror Image® traction was performed using a Universal Tractioning Systems (UTS) Total Spine unit (Universal Tractioning Systems, Inc., Las Vegas, NV, USA). A force combining +TyH and −TzH was applied using a chin-occiput harness and +TzH was applied to the mid-cervical vertebra for periods starting at 4 minutes and increasing by 2 minutes with each visit until 15 minutes was reached. Mirror Image® traction allows for viscoelastic plastic deformation of spinal ligaments [10] and corrects the patient’s abnormal posture by initiating muscle and ligament creep creating permanent restorative change [25].
Re-Exam Findings
After 30 sessions over 12 weeks, the patients reported a mean improvement from 34.5% to 4.3% on the self-rating NDI outcome assessment indicating improvement from moderate to minimal neck disability. Post-treatment NLC radiographs (Figures 1b–8b) were taken and compared with the pre-treatment assessments (Table 1). The re-exam NLC radiographs revealed that mean +TzH improved 3.3 mm from 15.1 mm to 11.8 mm and mean ARA C2–C7 improved 6.6° from −15.5° to −22.1°. Mean horizontal translations at DCS locations improved 2.6 mm from 3.1 mm to 0.5 mm (Table 1). Mean SCD at DCS locations improved 2.2 mm from 14.8 mm to 17.0 mm.
DISCUSSION
Chiropractic Management
There is a lack of evidence reporting on the effects of chiropractic management of DCS and almost all studies focus on the reduction of symptoms with no measured reduction of spondylolisthesis. There is only one case published by Fedorchuk, Lightstone, and Cohen that shows both reduction in symptoms and reduction of spondylolisthesis measurements [26].
Fedorchuk, Lightstone, and Cohen presented a case of 52-year-old female with severe neck pain, neck stiffness, thoracic pain, and lower neck swelling [26]. She denied a history of trauma. As per CBP? protocol, cervical radiographs were taken before chiropractic care. Findings included anterior translations at C4–C5 2.4 mm, C6–C7 0.6 mm, and C7–T1 1.4 mm. In addition to posterior translations at C2–C3 2.0 mm, C3–C4 1.3 mm, and C5–C6 2.2 mm. There was an anterior head translation of 19.66 mm and an ARA C2–C7 of −22.8° (ideal is −42° and average is 34.0°). Chiropractic treatment included spinal manipulative therapy and Mirror Image? adjustments, traction using the Denneroll™ spinal orthotic, and exercises [26]. Post –treatment radiographs showed a reduction of anterior translations at C4–C5 of 1.7 mm, C6–C7 of 0.9 mm, and C7–T1 was reduced 1.3 mm. Posterior translation reduced at C2–C3 1.1 mm, C3–C4 0.5 mm, and C5–C6 1.5 mm. The anterior head translation reduced from 19.6 to 9.0 mm, and the ARA C2–C7 improved from −22.8° to −26°. The patient also reported a resolution in her neck pain, stiffness, tension, and swelling [26].
Spinal Alignment and Posture
Prevalence of DCS may be more common than previously thought [1]. DCS has been showed to be caused by sagittal cervical curve mal-alignment, facet joint angles, disc degeneration, and facet joint arthrosis all altering biomechanics which lead to increased stress with flexion and extension and may damage the disc and ligaments allowing for the slippage to occur [8].
There are many proposed mechanisms of DCS. Woiciechowsky proposes the idea that instability will cause the damage to the ligaments and the disc causing the vertebral body to horizontally displace [8]. Most of the time, neck pain is the first symptom and is experienced before facet and disc degeneration take place [8]. If patients with neck pain are evaluated for instability before there is damage to the facet joints, ligaments, and discs, degenerative cervical spondylolisthesis may be slowed or prevented.
Jun et al. showed that congenital anatomy has influence over the sagittal lordosis of the cervical spine [27]. T1 slope angle has a direct influence over the prevalence of DCS. Jun et al. theorized that T1 slope is an important factor in the sagittal cervical alignment, which will cause anterior translation of the body’s center of gravity leading to disc degeneration and collapse accelerated by arthrosis in the posterior facets [27]. Hypermobility, sliding force, and loss of cervical lordosis cause stress at the disc and facet joints especially in the mid-cervical region which accounts for the higher prevalence of the DCS in the mid-cervical spine [27].
Degenerative changes in the cervical spine has been shown been shown to increase as the cervical sagittal alignment is altered. It is well documented in the literature that cervical lordosis is associated with nerve entrapment, pain, and degeneration of the cervical spine [28].
Differential Diagnosis
The differential diagnosis for DCS include cervical fracture, cervical canal stenosis, cervical disc degeneration, and cervical facet dislocation or arthropathy [3]. These conditions often present with the similar clinical symptoms, such as neck pain and radiculopathy. However, cervical spondylolisthesis is often made worse with extension and can be asymptomatic (Table 2) [3].
Strengths and Limitations
This case series provides a clear objective and well-defined protocol. This case series is not randomized or blinded which lends itself to selection bias. However, this case series provides explicit inclusion and exclusion criteria and consecutive patient selection. This helps to limit selection bias. Additionally, this case series includes objective and subjective clinically relevant outcomes with valid and reliable quantified measurements. This helps to strengthen the value of the series.
This case series is retrospective and contains a small number of participants (n=8) which limit its generalizability to larger populations of patients.
CONCLUSION
Currently DCS is a wait-and-watch condition with no treatment guidelines. CBP? focuses on restoring healthy alignment and biomechanics of the spine and posture [10]. This case series would have benefited from magnetic resonance imaging (MRI) of the cervical spine to determine any soft tissue damage as well as spinal cord compression and canal stenosis. Computed Tomography (CT) of the cervical spine can show a more accurate slippage measurement of the vertebrae before and after treatment.
In this case series, all patients who met the inclusion criteria had an abnormal ARA C2–C7 with buckling of the cervical spine consistent with MVC trauma as determined by radiographic examination and analysis. Motor vehicle trauma may cause a buckling effect to the cervical spine and damage to the ligaments of the cervical spine leading to instability and abnormal cervical alignment that culminate in degenerative cervical spondylolisthesis.
This case series shows that CBP® spinal rehabilitation may be an effective conservative, non-surgical treatment for DCS and associated symptoms including neck pain and cervical radiculopathy. By using CBP® spinal rehabilitation to improve spinal alignment and postural distortions, the need for medical or invasive surgical procedures may be negated. Future prospective studies involving larger populations, multiple clinic sites, controlled and experimental groups, and long-term follow-ups, will shed more light on the effectiveness and reliability of CBP® in correcting cervical spondylolisthesis and the associated functional and symptomatic effects and pathologies.
TEACHING POINT
Multiple cervical degenerative spondylolistheses with up to 4.5 mm of horizontal displacement may be reduced or corrected by using corrective spinal rehabilitation. By using corrective spinal rehabilitation to improve sagittal spinal alignment and posture, the need for medical or invasive surgical procedures may be negated for patients with symptomatic severe and moderate degenerative cervical spondylolisthesis.
Table 3.
Differential diagnosis table for cervical spondylolisthesis in the sagittal plane and appropriate imaging
| Differential Diagnoses | Plain Radiography | Magnetic Resonance Imaging | Computed Tomography Myelography | Computed Tomography |
|---|---|---|---|---|
| Degenerative Cervical Spondylolisthesis |
|
|
|
|
| Cervical Fracture |
| |||
| Cervical Canal Stenosis |
|
|
| |
| Cervical Disc Degeneration |
| |||
| Cervical Facet Dislocation |
| |||
| Cervical Facet Arthropathy |
|
|
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ACKNOWLEDGEMENTS
The authors would like to acknowledge Chiropractic BioPhysics® NonProfit (a spine research foundation in Eagle, ID, USA) and the Institute for Spinal Health and Performance (a spine research institute in Cumming, GA, USA) for their support.
ABBREVIATIONS
| ADL | Activity of Daily Living |
| AP | Anterioposterior |
| ARA | Absolute Rotational Angle |
| ARA C2–C7 | Absolute Rotational Angle from C2 to C7 |
| C2 | Second Cervical Vertebra |
| C7 | Seventh Cervical Vertebra |
| CBP® | Chiropractic BioPhysics® |
| CNS | Central Nervous System |
| CR | Central Ray |
| CT | Computed Tomography |
| DCS | Degenerative Cervical Spondylolisthesis |
| EMR | Electronic Medical Records |
| FFD | Film Focal Distance |
| kVp | kilovoltage peak |
| mA | milliampere |
| mAs | milliampere second |
| mm | millimeter |
| MRI | Magnetic Resonance Imaging |
| MVC | Motor Vehicle Collision |
| NDI | Neck Disability Index |
| NLC | Neutral Lateral Cervical |
| NP | Neck Pain |
| ROM | Range of Motion |
| −RxH | Extension of the Head |
| SCD | Spinal Canal Diameter |
| Spinal Alignment Shorthand | |
| +/−_ _ _ | direction of movement per the Cartesian coordinate systsem |
| T_ _ | Translation along an axis per the Cartesian coordinate system |
| R _ _ | Rotation around an axis per the Cartesian coordinate system |
| _x_ | x-axis (in the body’s frontal plane) per the Cartesian coordinate system |
| _y_ | y-axis (in the body’s sagittal plane) per the Cartesian coordinate system |
| _z_ | z-axis (in the body’s transverse plane) per the Cartesian coordinate system |
| _ _ P | Pelvis (in relation to the feet) |
| _ _ T | Thoracic cage (in relation to the pelvis) |
| _ _ H | Head (in relation to the thoracic cage) |
| Spine Segment Shorthand | |
| C_ | Cervical Region (7 vertebrae) |
| T_ | Thoracic Region (12 vertebrae) |
| L_ | Lumbar Region (5 vertebrae) |
| S_ | Sacral Region (4 vertebrae) |
| _# | the number of the vertebra in the spinal region numbered from superior to inferior |
| T4 | Fourth Thoracic Vertebra |
| Tz | Translation in the z-axis/sagittal plane |
| +TzH | Anterior Translation of the Head |
| −TzH | Posterior Translation of the Head |
| UTS | Universal Tractioning System |
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