Normal sagittal profile of the cervical spine - must the cervical spine always be lordotic?

Background. The cervical spine is very complex, and it allows the largest range of motion relative to the rest of the spine. The fundamental function of the cervical spine is to maintain the head balanced over the trunk and to maintain horizontal gaze. The cervical spine must be both stable and flexible to guarantee function. Changes of the sagittal profile of the cervical spine may affect function and quality of life. The relationship between full body alignment and maintaining gaze necessitates a thorough understanding of the cranio-spino-pelvic alignment as a component of balance. Question. Now the question is, what kind of sagittal profile does the cervical spine need for proper function? In the literature, normal sagittal alignment of the cervical spine is controversial. In general, there is the assumption that the alignment is lordotic. Does the data in the literature support this? Results. The present literature review supports the following facts: Ideal cervical spine alignment is mostly lordotic, but not always; ideal cervical spine alignment can be lordotic, neutral or kyphotic; ideal cervical spine alignment is driven by the necessity of supporting the head and maintaining horizontal gaze; the cervical spine is in harmony with regional alignment (thoracic kyphosis) and sagittal global alignment (SVA): TK (up arrow) -> T1 Slope (up arrow) -> CL (up arrow), TK (down arrow) -> T1 Slope (down arrow) -> CL (down arrow), SVA > 50mm: the cervical curve should be lordotic to maintain horizontal gaze, SVA < 0mm: the cervical curve should be kyphotic to maintain horizontal gaze.