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Artificial intelligence clustering of adult spinal deformity sagittal plane morphology predicts surgical characteristics, alignment, and outcomes

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Abstract

Purpose

AI algorithms have shown promise in medical image analysis. Previous studies of ASD clusters have analyzed alignment metrics—this study sought to complement these efforts by analyzing images of sagittal anatomical spinopelvic landmarks. We hypothesized that an AI algorithm would cluster preoperative lateral radiographs into groups with distinct morphology.

Methods

This was a retrospective review of a multicenter, prospectively collected database of adult spinal deformity. A total of 915 patients with adult spinal deformity and preoperative lateral radiographs were included. A 2 × 3, self-organizing map—a form of artificial neural network frequently employed in unsupervised classification tasks—was developed. The mean spine shape was plotted for each of the six clusters. Alignment, surgical characteristics, and outcomes were compared.

Results

Qualitatively, clusters C and D exhibited only mild sagittal plane deformity. Clusters B, E, and F, however, exhibited marked positive sagittal balance and loss of lumbar lordosis. Cluster A had mixed characteristics, likely representing compensated deformity. Patients in clusters B, E, and F disproportionately underwent 3-CO. PJK and PJF were particularly prevalent among clusters A and E. Among clusters B and F, patients who experienced PJK had significantly greater positive sagittal balance than those who did not.

Conclusions

This study clustered preoperative lateral radiographs of ASD patients into groups with highly distinct overall spinal morphology and association with sagittal alignment parameters, baseline HRQOL, and surgical characteristics. The relationship between SVA and PJK differed by cluster. This study represents significant progress toward incorporation of computer vision into clinically relevant classification systems in adult spinal deformity.

Level of Evidence IV

Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

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Data availability

The data from this study was obtained from the International Spine Study Group.

Code availability

Code for this study may be available upon request.

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Funding

This study was supported by the ISSG foundation.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Alpert Medical School, Providence, Rhode Island, 1 Kettle Point Avenue, East Providence, RI, 02914, USA

    Wesley M. Durand & Alan H. Daniels

  2. Hospital for Special Surgery, Newyork city, NY, USA

    Renaud Lafage, Han Jo Kim, Virginie Lafage & Frank Schwab

  3. University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    D. Kojo Hamilton

  4. Langone Medical Center, New York University, New York City, NY, USA

    Peter G. Passias & Themistocles Protopsaltis

  5. University of Virginia Health System, Charlottesville, VA, USA

    Justin S. Smith

  6. Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA

    Christopher Shaffrey

  7. Washington University, St. Louis, MO, USA

    Munish Gupta & Michael P. Kelly

  8. University of California, UC Davis Medical Center, Sacramento, CA, USA

    Eric O. Klineberg

  9. Leatherman Spine Center, Louisville, KY, USA

    Jeffrey L. Gum

  10. San Diego Spine, La Jolla, San Diego, CA, USA

    Gregory Mundis & Robert Eastlack

  11. Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Khaled Kebaish

  12. University of Calgary, Calgary, AB, Canada

    Alex Soroceanu

  13. Southwest Scoliosis Institute, Plano, TX, USA

    Richard A. Hostin

  14. Medical Center, University of Kansas, Kansas City, KS, USA

    Doug Burton

  15. Denver International Spine Center, Denver, CO, USA

    Shay Bess

  16. University of California, San Francisco, San Diego, CA, USA

    Christopher Ames

  17. Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA

    Robert A. Hart

Authors
  1. Wesley M. Durand
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  2. Renaud Lafage
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  7. Virginie Lafage
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  13. Frank Schwab
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  18. Alex Soroceanu
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  19. Richard A. Hostin
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  20. Doug Burton
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  24. Alan H. Daniels
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Consortia

International Spine Study Group (ISSG)

Corresponding author

Correspondence to Alan H. Daniels.

Ethics declarations

Conflict of interest

Wesley Durand has no potential conflicts of interest. Renaud Lafage has Stock ownership in Nemaris Inc. David K Hamilton has no potential conflicts of interest. Peter Passias has Consulting fees from Medicrea and SpineWave, Speaking/teaching arrangements from Zimmer Biomet, Scientific advisory board at Allosource, and Grants from Cervical Spine Research Society. Han Jo Kim has Fellowship support from AOSpine, Research support from CSRS and ISSGF, and Royalties from K2M and Zimmer Biomet. Themistocles Protopsaltis has Consulting fees from Globus, Medicrea, Innovasis, K2M, and NuVasive. Virginie Lafage has Stock ownership in Nemaris, Inc., Consulting fees for Globus, Speaking/teaching arrangements for DePuy Spine, K2M, and Board of directors for Nemaris, Inc. Justin S Smith has Grants from DePuy Synthes, Royalties from Zimmer Biomet, Stock ownership in Alphatec, Consulting fees from Zimmer Biomet, Nuvasive, Cerapedics and AllSource, and Fellowship support from AOSpine and NREF. Christopher Shaffrey has Royalties from Medtronic, Nuvasive and Zimmer Biomet, Stock ownership in Nuvasive, Consulting fees for Medtronic, and Fellowship support from NREF and AO. Munish Gupta has Royalties from DePuy and Innomed, Stock ownership in J&J, P&G and Perform Biologics, Consulting for DePuy and Medtronic, Trips/travel for Alphatec and Scoliosis Research Society, Scientific advisory board for DePuy and Medtronic, and Fellowship support from OMeGA and AOSpine. Michael P. Kelly has Fellowship support from AOSpine, and Research support from DePuy Synthes. Eric Klineberg has Consulting fees from DePuy Synthes, Stryker and Medicrea, Speaking/teaching arrangements from AOSpine and K2M, and Fellowship support from AOSpine. Frank Schwab has Royalties from MSD and K2M, Stock ownership in Nemaris, Inc., Consulting fees from Zimmer Biomet, Globus Medical, MSD, K2M and Medicrea, Speaking/teaching arrangements from Zimmer Biomet, MSD, Globus Medical and K2M, and Board of directors for Nemaris, Inc. Jeffrey Gum has Royalties from Acuity, Private Investments in Cingulate, Consulting from Medtronic, Acuity, K2M, NuVasive and Mazor, Speaking or teaching arrangements with Medtronic, Trips/Travel from Broadwater, Scientific Advisory Board with Medtronic and K2M, and Research Support from Pfizer, Intellirod, Texas Scottish Rite and SRS. Gregory Mundis has Royalties from Nuvasive and K2M, Stock Ownership in NuVasive and Viseon, Private Investments in Baker and Eastlack Venture, Consulting with NuVasive, K2M, Allosource, Viseon, SeaSpine, Speaking and teaching arrangements with Nuvasive, Board of Directors on Global Spine Outreach, Society of Lateral Access Surgery and San Diego Spine Foundation, Scientific Advisory Board with SeaSpine and AlloSource, Research Support with ISSGF, and Fellowship Support from NuVasive and SeaSpine. Robert Eastlack has Royalties from Globus Medical, NuTech, SeaSpine and Aesuculap, Stock Ownership from Nuvasive, Spine Innovations, Invuity, Alphatec and SeaSpine, Private Investments in Top Doctors Labs, SeaSpine and Nocimed, Consulting from K2M, Titan, SeaSpine, NuVasive, Aesculap, SI-BONE and Baxter, Board of Directors with SDSF, InjureFree, Nocimed, SOLAS, Spine Innovations and Matrisys, Scientific Advisory Board with ClearView, Top Doctors Labs and Aesculap, Research Support with NuVasive, Grants from Scripps Clinic Medical Grant, and Fellowship Support from SeaSpine and NuVasive. Khaled Kebaish has Royalties from DePuy Synthes, Consulting from SpineCraft, and Speaking or teaching arrangements from K2M. Alex Soroceanu has support from ISSGF. Richard Hostin has Consulting from DePuy. Doug Burton has Royalties from DePuy Spine, Consulting for DePuy Spine, and Board of directors for ISSGF, SRS, and University of Kansas Physicians, and Research support from DePuy Spine, Bioventus and Pfizer. Shay Bess has Grants from K2, DePuy Spine and Nuvasive, Royalties from K2M, Consulting for K2M, Scientific advisory board for EOS and MISONIX, and Grants from ISSGF. Christopher Ames has Royalties from Stryker, Zimmer Biomet, DePuy Synthes, Nuvasive, Next Orthosurgical, K2M and Medicrea, Consulting from DePuy Synthes, Medtronic, Medicrea and K2M, Research support from Titan Spine, DePuy Synthes and ISSG, and Grants from SRS. Robert Hart has Royalties from Seaspine and DSS, Consulting from Globus, and Grants from ISSGF. Alan H Daniels has Consulting fees from Stryker, Orthofix, Spineart and EOS, Research support from Southern Spine, and Fellowship support from Orthofix.

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Durand, W.M., Lafage, R., Hamilton, D.K. et al. Artificial intelligence clustering of adult spinal deformity sagittal plane morphology predicts surgical characteristics, alignment, and outcomes. Eur Spine J 30, 2157–2166 (2021). https://doi.org/10.1007/s00586-021-06799-z

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  • DOI: https://doi.org/10.1007/s00586-021-06799-z

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