• Renaud Lafage, Bryan Ang, Basel Sheikh Alshabab, Jonathan Elysee, Francis Lovecchio, Karen Weissman, Han Jo Kim, Frank Schwab, and Virginie Lafage.
• Department of Spine Surgery, Hospital for Special Surgery, Department of Spine Surgery, New York, New York, USA.
• World Neurosurg. 2021 Feb 1; 146: e225-e232.

ObjectiveTo train and validate an algorithm mimicking decision making of experienced surgeons regarding upper instrumented vertebra (UIV) selection in surgical correction of thoracolumbar adult spinal deformity.MethodsA retrospective review was conducted of patients with adult spinal deformity who underwent fusion of at least the lumbar spine (UIV > L1 to pelvis) during 2013-2018. Demographic and radiographic data were collected. The sample was stratified into 3 groups: training (70%), validation (15%) and performance testing (15%). Using a deep learning algorithm, a neural network model was trained to select between upper thoracic (T1-T6) and lower thoracic (T7-T12) UIV. Parameters used in the deep learning algorithm included demographics, coronal and sagittal preoperative alignment, and postoperative pelvic incidence-lumbar lordosis mismatch.ResultsThe study included 143 patients (mean age 63.3 ± 10.6 years, 81.8% women) with moderate to severe deformity (maximum Cobb angle: 43° ± 22°; T1 pelvic angle: 27° ± 14°; pelvic incidence-lumbar lordosis mismatch: 22° ± 21°). Patients underwent a significant change in lumbar alignment (Δpelvic incidence-lumbar lordosis mismatch: 21° ± 16°, P < 0.001); 35.0% had UIV in the upper thoracic region, and 65.0% had UIV in the lower thoracic region. At 1 year, revision rate was 11.9%, and rate of radiographic proximal junctional kyphosis was 29.4%. Neural network comprised 8 inputs, 10 hidden neurons, and 1 output (upper thoracic or lower thoracic). After training, results demonstrated an accuracy of 81.0%, precision of 87.5%, and recall of 87.5% on testing.ConclusionsAn artificial neural network successfully mimicked 2 lead surgeons' decision making in the selection of UIV for adult spinal deformity correction. Future models integrating surgical outcomes should be developed.Copyright © 2020 Elsevier Inc. All rights reserved.

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