STUDY DESIGN: In vitro cadaveric study of thoracic spinal cord intramedullary pressure (IMP) in kyphotic deformity. OBJECTIVE: To define the relationship between thoracic spinal kyphotic deformity and spinal cord IMP. SUMMARY OF BACKGROUND DATA: Previous studies of asymptomatic volunteers have revealed that there is wide variation in regional sagittal neutral upright thoracic spinal alignment with "normal" thoracic T4-T12 kyphosis ranging up to approximately +69° for 98.5% of the asymptomatic adult population. We sought to determine whether IMP changes in response to increasing thoracic kyphosis. METHODS: In 8 fresh-frozen cadavers, a progressive kyphotic deformity was created. Cadavers were positioned sitting with physiological thoracic kyphosis, head stabilized using a skull clamp, and spine segmentally instrumented from occiput to L2. The T3-T4 ligamentum flavum was removed, dura opened, and 3 pressure sensors were advanced caudally to T4-T5, T7-T8, and T11-T12 within the cord parenchyma. A stepwise thoracic kyphotic deformity was then induced by sequentially releasing and retightening the skull clamp while distracting posterior short segment rods and closing anterior segmental osteotomies. After each step, fluoroscopic images and pressure measurements were obtained; the T4-T12 Cobb angle was measured. RESULTS: Minor IMP increases of 2 to 5 mm Hg were observed at 1 or more spinal cord levels in 1 of 8 cadavers when the Cobb angle was less than +51° and in 4 of 8 cadavers when the angle was more than +51° and less than +63°. For Cobb angles more than +51° and less than +63°, a statistically significant, minor increase in IMP was detected at the T7-T8 level only (P = 0.02). At Cobb angles exceeding +63°, ΔIMP progressively increased at 1 or more spinal cord levels in 8 of 8 cadavers. Cobb angles ranging from +63° to +149° resulted in statistically significant increases in IMP ranging to more than 50 mm Hg. ΔIMP did not correlate with segmental spinal canal diameter (stenosis). CONCLUSION: Thoracic kyphosis less than +51° resulted in no meaningful increase in IMP, whereas kyphosis measuring +51° to +63° resulted in minor increases in IMP. After the thoracic kyphosis exceeded +63°, IMP increased significantly. ΔIMP with spinal alignment may help explain the wide range of "normal" thoracic neutral upright sagittal alignment in studies of asymptomatic adult individuals and may help further define thoracic kyphotic deformity.