Ross Hauser, MD

Cervical scoliosis describes a sideways curve involving the neck. Cervicothoracic scoliosis involves the transition between the neck and upper back. Someone may notice an uneven shoulder line, a tilted head, or discomfort where the neck meets the shoulders. Others learn about the curve after an X-ray taken for another reason.

The important question is what the curve means for that person. Is it a structural deformity? A compensation for scoliosis farther down the spine? A response to persistent head tilt? Is it progressing, or has it remained stable? And does it explain the symptoms that brought the person to seek help?

At Caring Medical, our discussion of cervical instability emphasizes the supporting ligaments of the neck. However, scoliosis and instability are separate diagnoses. A sideways curve does not establish ligament injury, and neck pain does not establish that the curve is its cause. Understanding those distinctions helps patients assess treatment claims and the research behind them.

What are cervical and cervicothoracic scoliosis?

The cervical spine is the neck; the thoracic spine is the upper and middle back. Their junction includes the transition from the seventh cervical vertebra, C7, to the first thoracic vertebra, T1. The relatively mobile neck meets a region supported by the rib cage.

Scoliosis involves sideways curvature and usually vertebral rotation. A Cobb angle of at least 10 degrees on a standing radiograph is the usual diagnostic threshold. The Cobb angle measures the curve between selected vertebrae; it does not measure pain or ligament strength. (1)

“Cervicothoracic” identifies the region. It does not, by itself, identify the cause, the likelihood of progression, or the best treatment. A high thoracic curve may affect neck position even when the main scoliosis is below the cervical vertebrae.

Scoliosis, cervical kyphosis, and forward head posture are different findings

These terms describe different aspects of alignment:

Several findings can occur together, but one does not prove the others. A person can have scoliosis without cervical instability or have neck pain without a significant sideways curve. Similarly, a straightened neck on a single image is not sufficient evidence of damaged ligaments.

What causes the curvature of the spine in scoliosis?

The explanation depends on the person’s age, history, examination, and imaging. In adolescents, an idiopathic curve is one for which a specific cause has not been identified. Congenital vertebral differences and neuromuscular disorders are other possible causes of spinal deformity. An adult may have a longstanding adolescent curve alongside newer degenerative changes. Other histories that matter include fracture, congenital differences, and previous spinal surgery. A spinal injury can affect alignment or stability, but pain after an injury does not establish scoliosis.

A curve near the neck may also help compensate for a larger curve below it. The body attempts to maintain head position and balance over the pelvis. Consequently, the most visible head or shoulder asymmetry may not identify the primary curve.

Structural curves and flexible curves

A structural curve has more persistent deformity and rotation. A flexible or positional curve changes more substantially when position changes or an underlying contributor is addressed. These are useful distinctions, but they cannot reliably be made from a photograph or a person’s ability to “stand straighter.”

Pain-related guarding can change posture. However, improvement in muscle tension does not necessarily mean a structural scoliosis has been corrected. Conversely, a persistent curve does not mean that pain, strength, or daily function cannot improve.

Persistent head tilt and torticollis

Congenital muscular torticollis involves shortening or tightness of a neck muscle, which can maintain a tilted head position. A retrospective study of 87 patients with this condition and secondary cervicothoracic scoliosis found improvement in spinal alignment after surgical release of the affected muscle. Younger patients generally had greater improvement. (2)

This illustrates why the underlying diagnosis matters. It does not mean that every tilted head represents torticollis, that surgery is necessary for every case, or that an unrelated scoliosis has the same cause.

Cervical scoliosis is more than an angle: what symptoms can occur?

Possible concerns include neck or upper-back discomfort, fatigue with sustained positions, restricted movement, visible shoulder asymmetry, and difficulty keeping the head comfortably centered. Some people have little pain despite a noticeable curve.

The curve’s location, flexibility, associated degeneration, and the condition of muscles, joints, nerves, and supporting tissues may all influence symptoms. The Cobb angle alone cannot answer why an individual hurts.

Arm pain, numbness, weakness, or hand clumsiness require attention to possible nerve or spinal cord involvement. They should not automatically be attributed to scoliosis. Dizziness and headaches also have multiple possible causes; an uneven neck X-ray does not establish their origin.

Persistent symptoms despite exercise, massage, or other treatment

The existing Caring Medical discussion describes patients reporting headaches, jaw symptoms, hearing or memory difficulties, muscle spasm, restricted movement, and arm pain. These reports preserve an important point: the person’s daily experience matters alongside the curve measurement.

However, these symptoms do not all have the same explanation. For example, temporomandibular joint symptoms concern the jaw joint and surrounding muscles; they cannot be diagnosed from a scoliosis image. Hearing or memory difficulties also warrant consideration of causes beyond spinal alignment.

Temporary relief from massage, stretching, or a change in position may reflect reduced muscle guarding. It does not establish that the curve is flexible, that a ligament is damaged, or that surgery will be necessary. Similarly, persistent symptoms after rehabilitation may mean the original diagnosis or the treatment target needs reconsideration. They do not, by themselves, identify instability.

For arm pain in particular, it matters whether symptoms arise from a cervical nerve root, the spinal cord, the brachial plexus, or a peripheral nerve farther down the arm. This distinction becomes especially relevant to the following research.

Thoracic outlet syndrome and cervicothoracic scoliosis

Thoracic outlet syndrome involves compression of nerves or blood vessels near the junction of the neck and chest. It can produce arm pain, tingling, or weakness—symptoms that may overlap with cervical nerve problems.

A 2025 retrospective case series described 10 patients with thoracic outlet syndrome and coexisting mild-to-moderate cervicothoracic scoliosis. Eight underwent thoracic outlet surgery, with reported improvement in pain during follow-up. The researchers proposed that abnormal curvature may alter the space available for nerves and blood vessels. (3)

This small, selected series had no comparison group. It does not establish how often these conditions occur together or prove that scoliosis caused the compression. The operations addressed the thoracic outlet; the study did not test scoliosis correction or Prolotherapy. For patients with arm symptoms, it adds another possible explanation to consider alongside cervical nerve compression and other peripheral nerve disorders.

When symptoms need prompt medical attention

New or worsening weakness, trouble walking, loss of hand coordination, or changes in bladder or bowel control warrant prompt medical assessment. Seek urgent care for a significant injury with severe neck pain or neurological symptoms. Fever with severe spinal pain also needs timely evaluation.

In a child, rapidly increasing asymmetry, substantial unexplained pain, or neurological symptoms deserves evaluation rather than being dismissed as ordinary posture. A visible curve without these symptoms is usually a different situation from an acute neurological change.

What does recent research show about neck and upper-back alignment?

Much of the relevant research concerns adolescent idiopathic scoliosis and the neck’s side-view alignment. That evidence helps explain connections between spinal regions, but it is not interchangeable with research on a primary sideways cervical curve.

Adolescent idiopathic scoliosis, thoracic hypokyphosis, and cervical kyphosis

Thoracic hypokyphosis means that the upper back has less of its usual outward curve. Cervical kyphosis means that the neck’s usual inward curve has reversed. These describe the spine from the side; they are different from the sideways scoliosis measured on the front view.

An adolescent can therefore have a rotational thoracic deformity, a relatively flat upper back, and altered cervical alignment together. Research on this pattern helps explain why concentrating on one curve measurement can miss important information about the rest of the spine.

A 2026 retrospective study compared 199 adolescents with idiopathic scoliosis with 77 controls. Cervical kyphosis was more common in the scoliosis group, but it was also present in many controls. Neck alignment correlated with measures of thoracic alignment and the slope of T1. (4)

This supports considering the neck in relation to the rest of the spine. It also cautions against treating every difference in neck shape as proof of disease or the explanation for symptoms.

A separate retrospective study of 80 adolescents with scoliosis found that greater cervical kyphosis was associated with more cervical disc degeneration on MRI. This was a selected group with available imaging, and the study showed an association rather than proving that one finding caused the other. (5)

The upper thoracic region matters after scoliosis surgery

A 2025 study followed 102 female patients with a particular adolescent scoliosis pattern after correction surgery. Changes in proximal thoracic alignment were associated with changes in cervical alignment. (6)

A 2026 study of 72 surgically treated adolescents with thoracic lordosis found that a lower early postoperative T1 slope was associated with cervical malalignment two years later. T1 slope describes the tilt of the first thoracic vertebra on a side-view image. (7)

These findings reinforce that the neck and upper back work together. They come from specific surgical populations; they do not show that every painful neck needs surgery or that a particular injection treatment changes these relationships.

For a more focused discussion, see our article on adolescent idiopathic scoliosis, thoracic hypokyphosis, cervical kyphosis, and the potential role of cervical instability.

How are cervical and cervicothoracic scoliosis evaluated?

A useful evaluation considers the entire spinal pattern, symptoms, and neurological function. Questions include when asymmetry first appeared, whether it is changing, whether growth remains, and whether there has been injury or previous spinal surgery.

An examination may assess head position, shoulder height, trunk rotation, movement, strength, sensation, reflexes, and walking. Standing imaging can show the curve and overall balance. Comparison with earlier images helps determine whether a change represents progression rather than positioning or measurement variation.

Additional imaging depends on the clinical question. Bending views can help assess flexibility. MRI can investigate the spinal cord, nerve structures, or an atypical presentation. Tests used to investigate suspected instability answer a different question from a standard scoliosis measurement.

A useful report should make clear:

• Where the main curve and any compensating curves are located.
• Whether alignment differs on the front and side views.
• Whether the curve appears flexible, structural, or progressive.
• Whether another condition may explain the symptoms.

An image provides information, but treatment decisions require more than the appearance of the curve.

Treatment options: what is the goal?

Treatment goals may include preventing progression during growth, improving comfort and function, addressing a specific underlying condition, or correcting a substantial deformity. These goals are different. Pain relief is worthwhile, but it should not be described as curve correction without appropriate measurements.

Observation and monitoring

A small, stable curve may require observation rather than an intervention intended to straighten it. In growing children, remaining growth and documented progression affect decisions. Adults with longstanding curves have different concerns from adolescents whose curves are changing during a growth spurt.

“Observation” means following the condition appropriately. It does not mean ignoring new symptoms or assuming that all curves will remain stable.

Exercise and rehabilitation

Exercise can address strength, endurance, movement, and tolerance for daily activities. Scoliosis-specific exercises also aim to teach individualized three-dimensional correction and postural control.

A 2024 systematic review included 13 randomized trials involving 583 adolescents. Evidence for several exercise outcomes remained uncertain, although some approaches may offer benefits, including as an addition to bracing. (8)

Patients should distinguish improved function from proven correction of a structural curve. A generic stretching routine is also different from an individualized scoliosis exercise program. Forceful attempts to “crack” or straighten the neck are not an appropriate substitute for understanding the diagnosis.

Bracing: curve location affects applicability

Bracing has evidence for reducing progression in selected growing adolescents. In the randomized portion of a major trial, treatment success occurred in 75% of braced patients compared with 42% under observation. Success meant reaching skeletal maturity without progression to a curve of 50 degrees or more; it did not mean eliminating scoliosis. (9)

However, brace evidence is not automatically evidence for every curve location. A 2024 randomized trial found better progression control with nighttime bracing than physical activity alone, but it enrolled patients whose curve apex was T7 or below. Its results cannot be directly applied to a high cervicothoracic curve. (10)

The relevant questions include whether a brace can control the specific curve, how much growth remains, and whether progression is occurring. A brace also does not establish or treat every possible source of neck pain.

Surgery

Surgery may be considered for selected progressive or substantial deformities, or when a specific structural problem requires correction. Decisions depend on the diagnosis and overall spinal balance, not simply a cosmetic difference in shoulder height.

The neck–upper-back relationship matters in surgical planning, as the recent studies above demonstrate. Patients considering surgery should understand the intended benefit, which levels would be treated, potential complications, and how the operation could affect movement and adjacent spinal regions.

Adults with adolescent-onset scoliosis: neck alignment after surgery

A retrospective study examined 85 adults whose scoliosis began in adolescence and who underwent corrective surgery for a major thoracic or lumbar curve. At two years, 17 of the 33 patients with preoperative cervical deformity still met the study’s deformity criteria. Health-related quality-of-life outcomes were comparable between the postoperative cervical-deformity and non-deformity groups. (11)

This was surgery for curves below the neck, not a study of cervical scoliosis correction. Persistent cervical malalignment did not automatically mean that the operation had failed or that another operation was necessary. The finding supports considering neck alignment as part of whole-spine assessment; it does not establish cervical ligament laxity as the reason alignment remained abnormal.

Adult cervical deformity surgery: benefits and complications need separate consideration

A different prospective multicenter study followed 133 adults after cervical deformity surgery. Their average age was 62, and most had other medical conditions. At an average follow-up of 1.8 years, 56% had experienced at least one complication and 17% had undergone reoperation. (12)

This was a complex adult deformity population that included several diagnoses, not solely cervical scoliosis. These figures should not be presented as the risk for every patient or every neck procedure. They reinforce the need to weigh the expected functional benefit against the risks of the particular operation and the person’s medical circumstances.

Where do weak or injured cervical ligaments fit?

Our published discussion of chronic neck pain describes how laxity of cervical capsular ligaments may contribute to abnormal movement and symptoms. This is a proposed explanation for some presentations of neck pain; the publication is a narrative review, not a clinical trial demonstrating correction of cervicothoracic scoliosis. (13)

Ligament mechanics during neck movement

Ligaments connect bones and help limit excessive movement; discs, joints, muscles, and other structures also contribute to spinal function. The original article’s spring illustration is an analogy for how supporting tissues accommodate movement.

In flexion, the chin moves toward the chest and many posterior tissues lengthen. In extension, the person looks upward and these tissues generally shorten. Side bending and rotation create different loading patterns on either side. Real ligaments do not function exactly like springs, and their behavior depends on the structure and spinal level.

Normal movement involves changing tissue tension. A stretch seen in an illustration is not evidence of injury. If tissue is injured or unable to restrain abnormal movement, that is a separate clinical problem from merely spending time with the head bent forward.

The springs illustrate movement conceptually; they do not measure ligament damage or establish the cause of scoliosis.

Head position changes the loading of neck tissues. This diagram should not be interpreted as proof that ordinary phone use causes structural scoliosis.

Malrotation of C2: what does the image mean?

C2, the axis, is the second cervical vertebra. Together with C1, the atlas, it forms a major part of the neck’s rotational system. A rotated appearance of C2 on an image can raise questions about position and symmetry, but interpretation depends on how the image was acquired and on other findings.

An isolated image cannot establish the onset of a degenerative cascade, explain every symptom, or predict that scoliosis will develop. Positioning, normal rotational movement, congenital differences, and a genuine structural or stability problem require different interpretations. The distinction matters before attributing a curve to ligament laxity.

This example illustrates the discussion of C2 rotation; it is not a diagnostic template for readers to compare with their own images.

Chronic atlantoaxial instability and an unusual kyphoscoliosis case

Atlantoaxial instability means abnormal stability or excessive movement between C1 and C2. Causes can include trauma, congenital conditions, and inflammatory disease. Kyphoscoliosis combines excessive outward curvature with sideways curvature and rotation. These terms describe different problems, although they can coexist.

Instability and spinal deformity can coexist in particular conditions. A published case described an 11-year-old girl with progressively worsening dorsal kyphoscoliosis. Imaging also showed abnormalities at the skull–neck junction, Chiari formation, and syringomyelia. Dynamic imaging identified atlantoaxial instability. Surgical stabilization was followed by improved spinal alignment, regression of tonsillar herniation, and resolution of the syrinx. (14)

Chiari formation refers here to downward displacement of tissue from the lower part of the brain. Syringomyelia means a fluid-filled cavity within the spinal cord. These were findings in this particular child; they are not expected consequences of every cervical or cervicothoracic curve.

That unusual case is relevant to the interaction between stability and alignment. It cannot establish that ordinary adolescent scoliosis is caused by upper-neck instability, or that nonsurgical ligament treatment would produce the same outcome.

For patients, the practical distinction is straightforward: a suspected painful instability problem needs its own clinical support. The existence of scoliosis alone does not supply that evidence.

Video: cervical scoliosis and instability — a Prolotherapist’s perspective

In this video, Ross Hauser, MD, discusses our perspective on cervical scoliosis, ligament support, and compensatory posture.

The discussion includes spinal rotation, the body’s effort to balance the head, and curve-related exercises or positioning devices. These are a clinical perspective and proposed mechanisms, not proof that instability is the usual cause of scoliosis. The video complements the research; it does not establish structural correction with Prolotherapy.

Prolotherapy for associated cervical pain or instability: what does the research show?

Prolotherapy involves injections intended to stimulate a tissue-healing response. In discussions of neck pain, the proposed target may be injured or lax supporting ligaments. This rationale is different from proving that injections can straighten a structural scoliosis.

A retrospective study involving 21 people with chronic cervical pain reported improvement in symptoms and function after Prolotherapy. The study had no untreated comparison group and relied on patient-reported outcomes. It was not a scoliosis correction trial and did not establish a reduction in cervicothoracic Cobb angles. (15)

The research cited here does not establish Prolotherapy as a treatment that prevents scoliosis progression, replaces indicated bracing, or corrects a structural cervicothoracic deformity. More rigorous research would need to distinguish symptom outcomes from curve measurements and compare treatment with appropriate alternatives.

A person with scoliosis may also have a separate painful soft-tissue problem. Even if treating that problem improves comfort, improved comfort should not be presented as evidence that the scoliosis has been corrected. Decisions about injections require discussion of the proposed target, expected benefit, risks, and the limits of the evidence.

Common patient questions

Can posture or phone use cause cervicothoracic scoliosis?

Sustained positions may aggravate neck discomfort, but this does not establish that phone use created a structural scoliosis. Improving work habits and movement breaks may help comfort without changing the underlying curve.

Does an uneven shoulder mean the curve is getting worse?

Not necessarily. Shoulder position can reflect the curve pattern, muscle activity, or how someone is standing. Progression is assessed with clinical findings and comparable measurements over time, rather than appearance alone.

Can pain improve even if the curve remains?

Yes. Symptoms and spinal shape are related imperfectly. Improvements in strength, movement tolerance, or an associated pain problem may help daily life without producing a measurable change in scoliosis.

Does a mild curve require treatment to prevent future neurological problems?

A mild curve alone does not establish that neurological deterioration will occur. New neurological symptoms need assessment on their own merits. Treatment decisions should reflect the actual diagnosis and risk of progression.

Related symptoms: further reading

These discussions explore separate symptom patterns; their inclusion does not mean that scoliosis causes each condition:

• Cervical vertigo and cervicogenic dizziness and cervicogenic headaches.
• Tinnitus and neck symptoms and difficulty swallowing.
• Cervical dystonia and spasmodic torticollis.
• Neck pain and vision symptoms and chronic fatigue, cervical stenosis, and instability.

Understanding the curve and the symptoms together

Cervicothoracic scoliosis deserves attention to both the neck and the rest of the spine. The most useful explanation identifies what is curved, whether it is changing, and which findings plausibly account for the person’s symptoms.

A useful question is what a proposed treatment is intended to accomplish: symptom relief, improved function, progression control, or structural correction. Clear goals make the benefits and limitations of treatment easier to understand.

This article provides general educational information and does not replace an individual medical evaluation or diagnosis.

References

1 Negrini S, Donzelli S, Aulisa AG, Czaprowski D, Schreiber S, de Mauroy JC, Diers H, Grivas TB, Knott P, Kotwicki T, Lebel A, Marti C, Maruyama T, O’Brien J, Price N, Parent E, Rigo M, Romano M, Stikeleather L, Wynne J, Zaina F. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis and Spinal Disorders. 2018;13:3. doi:10.1186/s13013-017-0145-8. [Google Scholar]
2 Kim JH, Yum TH, Shim JS. Secondary Cervicothoracic Scoliosis in Congenital Muscular Torticollis. Clinics in Orthopedic Surgery. 2019;11(3):344-351. doi:10.4055/cios.2019.11.3.344. [Google Scholar]
3 Bowman KM, Ansari DS, Hanna AS. Thoracic outlet syndrome associated with cervicothoracic scoliosis. Surgical Neurology International. 2025;16:210. doi:10.25259/SNI_330_2024. [Google Scholar]
4 Qin F, Ma J, Shen Y, Tileinge HN, Ying X. Morphological changes of the cervical spine in adolescent idiopathic scoliosis and correlation analysis. BMC Musculoskeletal Disorders. 2026;27(1):626. doi:10.1186/s12891-026-10014-9. [Google Scholar]
5 Lin A, Skaggs DL, Andras LM, Tolo V, Tamrazi B, Illingworth KD. Increasing Cervical Kyphosis Correlates With Cervical Degenerative Disk Disease in Patients With Adolescent Idiopathic Scoliosis. Spine. 2024;49(7):486-491. doi:10.1097/brs.0000000000004824. [Google Scholar]
6 Lin X, Suzuki S, Takeda K, Iga T, Okubo T, Ozaki M, Tsuji O, Nagoshi N, Matsumoto M, Nakamura M, Watanabe K. Proximal Thoracic Alignment Change Influences Cervical Sagittal Alignment After Correction Surgery in Patients With Lenke Type 2 Adolescent Idiopathic Scoliosis. Neurospine. 2025;22(2):354-363. doi:10.14245/ns.2449254.627. [Google Scholar]
7 Kato S, Suzuki S, Takeda K, Iga T, Okubo T, Ozaki M, Nagoshi N, Matsumoto M, Nakamura M, Watanabe K. Early postoperative T1 slope is associated with 2-year cervical sagittal malalignment in Lenke 1-2 AIS with thoracic lordosis. Spine Deformity. 2026; published online. doi:10.1007/s43390-026-01518-4. [Google Scholar]
8 Romano M, Minozzi S, Bettany-Saltikov J, Zaina F, Chockalingam N, Kotwicki T, Maier-Hennes A, Arienti C, Negrini S. Therapeutic exercises for idiopathic scoliosis in adolescents. Cochrane Database of Systematic Reviews. 2024;2:CD007837. doi:10.1002/14651858.cd007837.pub3. [Google Scholar]
9 Weinstein SL, Dolan LA, Wright JG, Dobbs MB. Effects of bracing in adolescents with idiopathic scoliosis. New England Journal of Medicine. 2013;369(16):1512-1521. doi:10.1056/nejmoa1307337. [Google Scholar]
10 Charalampidis A, Diarbakerli E, Dufvenberg M, Jalalpour K, Ohlin A, Ahl AA, Möller H, Abbott A, Gerdhem P, CONTRAIS Study Group. Nighttime Bracing or Exercise in Moderate-Grade Adolescent Idiopathic Scoliosis: A Randomized Clinical Trial. JAMA Network Open. 2024;7(1):e2352492. doi:10.1001/jamanetworkopen.2023.52492. [Google Scholar]
11 Nagoshi N, Yagi M, Daimon K, Suzuki S, Tsuji O, Okada E, Fujita N, Nakamura M, Matsumoto M, Watanabe K. Changes in Cervical Spinal Alignment After Thoracolumbar Corrective Surgery in Adult Patients With Adolescent Idiopathic Scoliosis. Spine. 2020;45(13):877–883. doi:10.1097/BRS.0000000000003410. [Google Scholar]
12 Smith JS, Buell TJ, Shaffrey CI, Kim HJ, Klineberg E, Protopsaltis T, Passias P, Mundis GM, Eastlack R, Deviren V, Kelly MP, Daniels AH, Gum JL, Soroceanu A, Gupta M, Burton D, Hostin R, Hart R, Lafage V, Lafage R, Schwab FJ, Bess S, Ames CP. Prospective multicenter assessment of complication rates associated with adult cervical deformity surgery in 133 patients with minimum 1-year follow-up. Journal of Neurosurgery: Spine. 2020;33(5):588–600. doi:10.3171/2020.4.SPINE20213. [Google Scholar]
13 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The Open Orthopaedics Journal. 2014;8:326-345. doi:10.2174/1874325001408010326. [Google Scholar]
14 Goel A, Biswas C, Shah A, Darji H, Bhambere S, Hawaldar A. Atlantoaxial Instability as a Cause of Craniovertebral and Cervical Spinal Alterations and Dorsal Kyphoscoliosis. World Neurosurgery. 2020;144:39-42. doi:10.1016/j.wneu.2020.07.223. [Google Scholar]
15 Hauser RA, Steilen D, Gordin K. The Biology of Prolotherapy and Its Application in Clinical Cervical Spine Instability and Chronic Neck Pain: A Retrospective Study. European Journal of Preventive Medicine. 2015;3(4):85–102. doi:10.11648/j.ejpm.20150304.11. [Google Scholar]