A comprehensive analysis of the association of psychological profiling and sagittal balance parameters with neck pain in a non-deformity cervical spondylosis population: A prospective two-centers cross-sectional study

Abstract Purpose to comprehensively identify determining factors of perceived neck pain in a non-deformity population, integrating psychological and sagittal balance parameters. Methods a cross-sectional study of prospectively collected data was conducted on patients admitted for cervical spondylosis at two tertiary university hospitals between April 2024 and August 2025. Eligible cases were retrieved from the PANDA Registry. Records were excluded if standing X-ray was unavailable and/or not-evaluable (e.g. shoulder prosthesis); or if the admission pathology involved the cranio-cervical junction, tumors, deformities, spinal cord disease, or infections. Preoperative data included demographic, clinical (VAS neck), psychological (SCL-27, I-TIPI, CD-RISC10), and sagittal balance variables (McGregor slope, C1–C2 lordosis, C2 slope, C2–C7 lordosis, cSVA, T1 slope, cervical mismatch). Correction for multiple comparisons was applied within pre-specified hypothesis domains. Results one-hundred-thirty records were included. Intra-rater reliability for radiographic parameters was excellent (> 0.9). After categorization of patients by neck pain severity, pairwise analysis showed that only C1–C2 lordosis remained significantly higher in patients exhibiting severe neck pain (VAS < 7 vs. VAS ≥ 7). When stratified for moderate-to-severe neck pain (VAS ≥ 4), several SCL-27 scales, namely dysthymic, vegetative, agoraphobic, sociophobic, and GSI scores, and C1C2 lordosis showed significant differences. Correlation analysis using VAS neck as the dependent variable demonstrated a significant positive correlation with SCL-27 dysthymic and vegetative scores. C1–C2 lordosis showed a significant inverse correlation with neck pain. In univariate analysis, only SCL-27 dysthymic, vegetative, and GSI scores emerged as significant univariate associations of VAS neck. After correction for multiple comparisons, the SCL-27 vegetative, dysthymic and GSI scores retained significance, whereas C1–C2 lordosis did not. Conclusion in a non-deformity population, sagittal balance parameters alone do not adequately explain patient-perceived neck pain. These findings support the preoperative use of psychological assessments, especially the SCL-27, as a useful tool in preoperative screening and individualised counselling.