Asthma-related mortality in Italian children and adolescents.

Musculoskeletal conditions represent one of the leading sources of economic burden and reduced productivity worldwide [, ]. Among postural deviations, forward head posture (FHP) is common, with high prevalence reported in young adults, including rates approaching 73% []. This postural condition is often linked to prolonged screen exposure [] and suboptimal occupational ergonomics []. Alterations in head and neck positioning due to FHP significantly modify cervical alignment [, ]. This misalignment was associated with neck-related pain, disability, and degeneration, which may contribute to reduced physical function and poorer neck-related health status []. These conditions are estimated to affect 269 million individuals globally by 2050 []. Sagittal balance (SB) is the assessment of the spine from the lateral view, often using radiographic imaging. This approach is used in clinical practice and for mechanical interpretation in the standing position []. In this context, SB becomes an important evaluation in FHP, where the body’s center of mass is mechanically shifted forward, bringing the head forward relative to the trunk [, ]. This displacement is accompanied by gaze horizontalization control, which accommodates the head within the overall spinal balance. Biomechanically, the craniovertebral junction [, ], particularly the C0-C2 cervical, is responsible for this coordination to maintain horizontal gaze. This region is defined as the upper cervical area and plays a unique functional role due to its distinct anatomy and mechanics. The upper cervical region differs from the typical vertebral structure due to its larger range of motion [, ]. In FHP, the skull condyle allows an anteroposterior rotation towards the posterior part of the condyle []. This shift often leads to increased extension of C0-C2 lordosis, while subaxial cervical spine C2-C7 lordosis decreases, acting inversely [, ]. As most SB studies take C2-C7 alignment as a representation of the entire cervical spine, the upper cervical region C0-C2 remains overlooked [, ], despite its key role in gaze-related postural adaptation []. Such reciprocal behaviour between the upper and lower cervical spine suggests an alignment pattern that may extend beyond the cervical region, potentially involving thoracic and lumbo-pelvic alignment as part of a whole-spine sagittal alignment framework [, ].