STUDY DESIGN: This is a review of the literature about radiographic positioning for patients with sagittal imbalance. OBJECTIVES: We wanted to verify the optimal radiographic positioning for patients with sagittal imbalance. SUMMARY OF LITERATURE REVIEW: The standing lateral whole spine radiograph for identifying the sagittal alignment has a different value for the SVA according to the radiographic positioning. MATERIALS AND METHODS: This is a review of the literature. RESULTS: The fists-on-the clavicle position or the cross-arm position not only represents a functional standing position, but it also causes a less negative shift of the SVA in patients with sagittal imbalance. Both the extended hip and knee positions are necessary to exclude a compensation mechanism of the lower extremity. CONCLUSIONS: The optimal radiographic positioning is essential to examine the degrees of sagittal imbalance.