The significant mass of the head is supported by the cervical spine, and significant deviation from normal alignment increases cantilever loads and muscular activity. In addition, the flexible, mobile cervical segment is connected to the relatively fixed thoracic spine.

The T1 inclination will determine the amount of subaxial lordosis required to maintain the center of gravity of the head in a balanced position and will vary depending on global spinal alignment as measured by the sagittal vertical axis (SVA) and by inherent upper thoracic kyphosis.

The radiographic parameters that effect health-related quality of life scores are not well defined in comparison with global/pelvic parameters in thoracolumbar deformity. Chin-brow vertical angle, cervical SVA (C2 SVA), and regional cervical lordosis should all be considered in preoperative planning strategies involving standing 3-ft radiographs in which the external auditory canal (approximation of head center of mass) to femoral heads are visible.

At the craniocervical junction, an anterior approach with initial anterior linear osteotomy, posterior release and reduction of facet-joint subluxation, and segmental stabilization may be used. A SmithPetersen osteotomy, a pedicle subtraction osteotomy, or a circumferential osteotomy may be used at the mid cervical to cervicothoracic junction to achieve the desired correction.

Intraoperative imaging guidance systems and intraoperative neuromonitoring can help prevent complications related to the osteotomy. Furthermore, all-posterior approaches may reduce, but do not eliminate, swallowing dysfunction.

360 and 540 techniques are best for restoring mid subaxial lordosis while C7 pedicle subtraction osteotomy is best for correction of cervical sagittal imbalance.