• Wesley M Durand, Renaud Lafage, D Kojo Hamilton, Peter G Passias, Han Jo Kim, Themistocles Protopsaltis, Virginie Lafage, Justin S Smith, Christopher Shaffrey, Munish Gupta, Michael P Kelly, Eric O Klineberg, Frank Schwab, Jeffrey L Gum, Gregory Mundis, Robert Eastlack, Khaled Kebaish, Alex Soroceanu, Richard A Hostin, Doug Burton, Shay Bess, Christopher Ames, Robert A Hart, Alan H Daniels, and International Spine Study Group (ISSG).
• 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.
• Eur Spine J. 2021 Aug 1; 30 (8): 2157-2166.

PurposeAI 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.MethodsThis 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.ResultsQualitatively, 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.ConclusionsThis 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 IvDiagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.

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