A Review on the Use of Artificial Intelligence in Spinal Diseases

Validating the Accuracy of a Patient-Facing Clinical Decision Support System in Predicting Lumbar Disc Herniation: Diagnostic Accuracy Study

BACKGROUND

Low back pain (LBP) is a major cause of disability globally, and the diagnosis of LBP is challenging for clinicians.

OBJECTIVE

Using new software called Therapha, this study aimed to assess the accuracy level of artificial intelligence as a Clinical Decision Support System (CDSS) compared to MRI in predicting lumbar disc herniated patients.

METHODS

One hundred low back pain patients aged ≥18 years old were included in the study. The study was conducted in three stages. Firstly, a case series was conducted by matching MRI and Therapha diagnosis for 10 patients. Subsequently, Delphi methodology was employed to establish a clinical consensus. Finally, to determine the accuracy of the newly developed software, a cross-sectional study was undertaken involving 100 patients.

RESULTS

The software showed a significant diagnostic accuracy with the area under the curve in the ROC analysis determined as 0.84 with a sensitivity of 88% and a specificity of 80%.

CONCLUSIONS

The study's findings revealed that CDSS using Therapha has a reasonable level of efficacy, and this can be utilized clinically to acquire a faster and more accurate screening of patients with lumbar disc herniation.

The Evolution of Risk Assessment in Spine Surgery: A Narrative Review

BACKGROUND

Risk assessment is critically important in elective and high-risk interventions, particularly spine surgery. This narrative review describes the evolution of risk assessment from the earliest instruments focused on general surgical risk stratification, to more accurate and spine-specific risk calculators that quantified risk, to the current era of big data.

METHODS

The PubMed and SCOPUS databases were queried on October 11, 2023 using search terms to identify risk assessment tools (RATs) in spine surgery. A total of 108 manuscripts were included after screening with full-text review using the following inclusion criteria: 1) study population of adult spine surgical patients, 2) studies describing validation and subsequent performance of preoperative RATs, and 3) studies published in English.

RESULTS

Early RATs provided stratified patients into broad categories and allowed for improved communication between physicians. Subsequent risk calculators attempted to quantify risk by estimating general outcomes such as mortality, but then evolved to estimate spine-specific surgical complications. The integration of novel concepts such as invasiveness, frailty, genetic biomarkers, and sarcopenia led to the development of more sophisticated predictive models that estimate the risk of spine-specific complications and long-term outcomes.

CONCLUSIONS

RATs have undergone a transformative shift from generalized risk stratification to quantitative predictive models. The next generation of tools will likely involve integration of radiographic and genetic biomarkers, machine learning, and artificial intelligence to improve the accuracy of these models and better inform patients, surgeons, and payers.

Deep learning-based quantitative morphological study of anteroposterior digital radiographs of the lumbar spine

Background

Morphological parameters of the lumbar spine are valuable in assessing lumbar spine diseases. However, manual measurement of lumbar morphological parameters is time-consuming. Deep learning has automatic quantitative and qualitative analysis capabilities. To develop a deep learning-based model for the automatic quantitative measurement of morphological parameters from anteroposterior digital radiographs of the lumbar spine and to evaluate its performance.

Methods

This study used 1,368 anteroposterior digital radiographs of the lumbar spine to train a deep learning model to measure the quantitative morphological indicators, including L1 to L5 vertebral body height (VBH) and L1-L2 to L4-L5 intervertebral disc height (IDH). The means of the manual measurements by three radiologists were used as the reference standard. The parameters predicted by the model were analyzed against the manual measurements using paired t-tests. Percentage of correct key points (PCK), intra-class correlation coefficient (ICC), Pearson correlation coefficient (r), mean absolute error (MAE), root mean square error (RMSE), and Bland-Altman plots were performed to assess the performance of the model.

Results

Within the 3-mm distance threshold, the model had a PCK range of 99.77-99.46% for the L1 to L4 vertebrae and 77.37% for the L5 vertebrae. Except for VBH-L5 and IDH_L3-L4, IDH_L4-L5 (P<0.05), the estimated values of the model in the remaining parameters were not statistically significant compared with the reference standard (P>0.05). Except for VBH-L5 and IDH_L4-L5, the model showed good correlation and consistency with the reference standard (ICC =0.84-0.96, r=0.85-0.97, MAE =0.5-0.66, RMSE =0.66-0.95). The model outperformed other models (EfficientDet + Unet, EfficientDet + DarkPose, HRNet, and Unet) in predicting landmarks within a distance threshold of 1.5 to 5 mm.

Conclusions

The model developed in this study can automatically measure the morphological parameters of the L1 to L4 vertebrae from anteroposterior digital radiographs of the lumbar spine. Its performance is close to the level of radiologists.

Clinical Decision Support System Used in Spinal Disorders: Scoping Review

BACKGROUND

Spinal disorders are highly prevalent worldwide with high socioeconomic costs. This cost is associated with the demand for treatment and productivity loss, prompting the exploration of technologies to improve patient outcomes. Clinical decision support systems (CDSSs) are computerized systems that are increasingly used to facilitate safe and efficient health care. Their applications range in depth and can be found across health care specialties.

OBJECTIVE

This scoping review aims to explore the use of CDSSs in patients with spinal disorders.

METHODS

We used the Joanna Briggs Institute methodological guidance for this scoping review and reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) statement. Databases, including PubMed, Embase, Cochrane, CINAHL, Web of Science, Scopus, ProQuest, and PsycINFO, were searched from inception until October 11, 2022. The included studies examined the use of digitalized CDSSs in patients with spinal disorders.

RESULTS

A total of 4 major CDSS functions were identified from 31 studies: preventing unnecessary imaging (n=8, 26%), aiding diagnosis (n=6, 19%), aiding prognosis (n=11, 35%), and recommending treatment options (n=6, 20%). Most studies used the knowledge-based system. Logistic regression was the most commonly used method, followed by decision tree algorithms. The use of CDSSs to aid in the management of spinal disorders was generally accepted over the threat to physicians' clinical decision-making autonomy.

CONCLUSIONS

Although the effectiveness was frequently evaluated by examining the agreement between the decisions made by the CDSSs and the health care providers, comparing the CDSS recommendations with actual clinical outcomes would be preferable. In addition, future studies on CDSS development should focus on system integration, considering end user's needs and preferences, and external validation and impact studies to assess effectiveness and generalizability.

TRIAL REGISTRATION

OSF Registries osf.io/dyz3f; https://osf.io/dyz3f.

Current Trends in Artificial Intelligence-Assisted Spine Surgery: A Systematic Review

This systematic review summarizes existing evidence and outlines the benefits of artificial intelligence-assisted spine surgery. The popularity of artificial intelligence has grown significantly, demonstrating its benefits in computer-assisted surgery and advancements in spinal treatment. This study adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), a set of reporting guidelines specifically designed for systematic reviews and meta-analyses. The search strategy used Medical Subject Headings (MeSH) terms, including "MeSH (Artificial intelligence)," "Spine" AND "Spinal" filters, in the last 10 years, and English- from January 1, 2013, to October 31, 2023. In total, 442 articles fulfilled the first screening criteria. A detailed analysis of those articles identified 220 that matched the criteria, of which 11 were considered appropriate for this analysis after applying the complete inclusion and exclusion criteria. In total, 11 studies met the eligibility criteria. Analysis of these studies revealed the types of artificial intelligence-assisted spine surgery. No evidence suggests the superiority of assisted spine surgery with or without artificial intelligence in terms of outcomes. In terms of feasibility, accuracy, safety, and facilitating lower patient radiation exposure compared with standard fluoroscopic guidance, artificial intelligence-assisted spine surgery produced satisfactory and superior outcomes. The incorporation of artificial intelligence with augmented and virtual reality appears promising, with the potential to enhance surgeon proficiency and overall surgical safety.

Predicting Survival in Glioblastoma Using Gene Expression Databases: A Neural Network Analysis

Glioblastoma (GBM) is the most aggressive and lethal brain tumor. Artificial neural networks (ANNs) have the potential to make accurate predictions and improve decision making. The aim of this study was to create an ANN model to predict 15-month survival in GBM patients according to gene expression databases. Genomic data of GBM were downloaded from the CGGA, TCGA, MYO, and CPTAC. Logistic regression (LR) and ANN model were used. Age, gender, IDH wild-type/mutant and the 31 most important genes from our previous study, were determined as input factors for the established ANN model. 15-month survival time was used to evaluate the results. The normalized importance scores of each covariate were calculated using the selected ANN model. The area under a receiver operating characteristic (ROC) curve (AUC), Hosmer-Lemeshow (H-L) statistic and accuracy of prediction were measured to evaluate the two models. SPSS 26 was utilized. A total of 551 patients (61% male, mean age 55.5 ± 13.3 years) patients were divided into training, testing, and validation datasets of 441, 55 and 55 patients, respectively. The main candidate genes found were: FN1, ICAM1, MYD88, IL10, and CCL2 with the ANN model; and MMP9, MYD88, and CDK4 with LR model. The AUCs were 0.71 for the LR and 0.81 for the ANN analysis. Compared to the LR model, the ANN model showed better results: Accuracy rate, 83.3 %; H-L statistic, 6.5 %; and AUC, 0.81 % of patients. The findings show that ANNs can accurately predict the 15-month survival in GBM patients and contribute to precise medical treatment.

An approach to the diagnosis of lumbar disc herniation using deep learning models

Background: In magnetic resonance imaging (MRI), lumbar disc herniation (LDH) detection is challenging due to the various shapes, sizes, angles, and regions associated with bulges, protrusions, extrusions, and sequestrations. Lumbar abnormalities in MRI can be detected automatically by using deep learning methods. As deep learning models gain recognition, they may assist in diagnosing LDH with MRI images and provide initial interpretation in clinical settings. YOU ONLY LOOK ONCE (YOLO) model series are often used to train deep learning algorithms for real-time biomedical image detection and prediction. This study aims to confirm which YOLO models (YOLOv5, YOLOv6, and YOLOv7) perform well in detecting LDH in different regions of the lumbar intervertebral disc. Materials and methods: The methodology involves several steps, including converting DICOM images to JPEG, reviewing and selecting MRI slices for labeling and augmentation using ROBOFLOW, and constructing YOLOv5x, YOLOv6, and YOLOv7 models based on the dataset. The training dataset was combined with the radiologist's labeling and annotation, and then the deep learning models were trained using the training/validation dataset. Results: Our result showed that the 550-dataset with augmentation (AUG) or without augmentation (non-AUG) in YOLOv5x generates satisfactory training performance in LDH detection. The AUG dataset overall performance provides slightly higher accuracy than the non-AUG. YOLOv5x showed the highest performance with 89.30% mAP compared to YOLOv6, and YOLOv7. Also, YOLOv5x in non-AUG dataset showed the balance LDH region detections in L2-L3, L3-L4, L4-L5, and L5-S1 with above 90%. And this illustrates the competitiveness of using non-AUG dataset to detect LDH. Conclusion: Using YOLOv5x and the 550 augmented dataset, LDH can be detected with promising both in non-AUG and AUG dataset. By utilizing the most appropriate YOLO model, clinicians have a greater chance of diagnosing LDH early and preventing adverse effects for their patients.

The use of deep learning in medical imaging to improve spine care: A scoping review of current literature and clinical applications

Background

Artificial intelligence is a revolutionary technology that promises to assist clinicians in improving patient care. In radiology, deep learning (DL) is widely used in clinical decision aids due to its ability to analyze complex patterns and images. It allows for rapid, enhanced data, and imaging analysis, from diagnosis to outcome prediction. The purpose of this study was to evaluate the current literature and clinical utilization of DL in spine imaging.

Methods

This study is a scoping review and utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology to review the scientific literature from 2012 to 2021. A search in PubMed, Web of Science, Embased, and IEEE Xplore databases with syntax specific for DL and medical imaging in spine care applications was conducted to collect all original publications on the subject. Specific data was extracted from the available literature, including algorithm application, algorithms tested, database type and size, algorithm training method, and outcome of interest.

Results

A total of 365 studies (total sample of 232,394 patients) were included and grouped into 4 general applications: diagnostic tools, clinical decision support tools, automated clinical/instrumentation assessment, and clinical outcome prediction. Notable disparities exist in the selected algorithms and the training across multiple disparate databases. The most frequently used algorithms were U-Net and ResNet. A DL model was developed and validated in 92% of included studies, while a pre-existing DL model was investigated in 8%. Of all developed models, only 15% of them have been externally validated.

Conclusions

Based on this scoping review, DL in spine imaging is used in a broad range of clinical applications, particularly for diagnosing spinal conditions. There is a wide variety of DL algorithms, database characteristics, and training methods. Future studies should focus on external validation of existing models before bringing them into clinical use.

Revolutionizing Spinal Care: Current Applications and Future Directions of Artificial Intelligence and Machine Learning

Artificial intelligence (AI) and machine learning (ML) are rapidly becoming integral components of modern healthcare, offering new avenues for diagnosis, treatment, and outcome prediction. This review explores their current applications and potential future in the field of spinal care. From enhancing imaging techniques to predicting patient outcomes, AI and ML are revolutionizing the way we approach spinal diseases. AI and ML have significantly improved spinal imaging by augmenting detection and classification capabilities, thereby boosting diagnostic accuracy. Predictive models have also been developed to guide treatment plans and foresee patient outcomes, driving a shift towards more personalized care. Looking towards the future, we envision AI and ML further ingraining themselves in spinal care with the development of algorithms capable of deciphering complex spinal pathologies to aid decision making. Despite the promise these technologies hold, their integration into clinical practice is not without challenges. Data quality, integration hurdles, data security, and ethical considerations are some of the key areas that need to be addressed for their successful and responsible implementation. In conclusion, AI and ML represent potent tools for transforming spinal care. Thoughtful and balanced integration of these technologies, guided by ethical considerations, can lead to significant advancements, ushering in an era of more personalized, effective, and efficient healthcare.

Comparison of Concordance between Chuna Manual Therapy Diagnostic Methods (Palpation, X-ray, Artificial Intelligence Program) in Lumbar Spine: An Exploratory, Cross-Sectional Clinical Study

Before Chuna manual therapy (CMT), a manual therapy applied in Korean medicine, CMT spinal diagnosis using palpation or X-ray is performed. However, studies on the inter-rater concordance of CMT diagnostic methods, concordance among diagnostic methods, and standard CMT diagnostic methods are scarce. Moreover, no clinical studies have used artificial intelligence (AI) programs for X-ray image-based CMT diagnosis. Therefore, this study sought a feasible and standard CMT spinal diagnostic method and explored the clinical applicability of the CMT-AI program. One hundred participants were recruited, and the concordance within and among different diagnostic modalities was analyzed by dividing them into manual diagnosis (MD), X-ray image-based diagnosis (XRD) by experts and non-experts, and XRD using a CMT-AI program by non-experts. Regarding intra-group concordance, XRD by experts showed the highest concordance (used as a gold standard when comparing inter-group concordance), followed by XRD using the AI program, XRD by non-experts, and then MD. Comparing diagnostic results between the groups, concordance with the gold standard was the highest for XRD using the AI program, followed by XRD by non-experts, and MD. Therefore, XRD is a more reasonable CMT diagnostic method than MD. Furthermore, the clinical applicability of the CMT-AI program is high.

Convolutional Neural Networks in Spinal Magnetic Resonance Imaging: A Systematic Review

OBJECTIVE

Convolutional neural networks (CNNs) are being increasingly used in the medical field, especially for image recognition in high-resolution, large-volume data sets. The study represents the current state of research on the application of CNNs in image segmentation and pathology detection in spine magnetic resonance imaging.

METHODS

For this systematic literature review, the authors performed a systematic initial search of the PubMed/Medline and Web of Science (Core collection) databases for eligible investigations. The authors limited the search to observational studies. Outcome parameters were analyzed according to the inclusion criteria and assigned to 3 groups: 1) segmentation of anatomical structures, 2) segmentation and evaluation of pathologic structures, and 3) specific implementation of CNNs.

RESULTS

Twenty-four retrospectively designed articles met the inclusion criteria. Publication dates ranged from 2017 to 2021. In total, 14,065 patients with 113,110 analyzed images were included. Most authors trained their network with a training-to-testing ratio of 80/20, while all but 2 articles used 5- to 10-fold cross-validation. Nine articles compared their performance results with other neural networks and algorithms, and all 24 articles described outcomes as positive.

CONCLUSIONS

State-of-the-art CNNs can detect and segment-specific anatomical landmarks and pathologies across a wide range, comparable to the skills of radiologists and experienced clinicians. With rapidly evolving network architectures and growing medical image databases, the future is likely to show growth in the development and refinement of these capable networks. However, the aid of automated segmentation and classification by neural networks cannot and should not be expected to replace clinical experts.

The value of quantitative magnetic resonance imaging signal intensity in distinguishing between spinal meningiomas and schwannomas

Background: Prior studies have suggested a number of the subjective visual characteristics that help distinguish between spinal meningiomas and schwannomas on magnetic resonance imaging and computed tomography; however, objective quantification of the signal intensity can be useful information. This study assessed whether quantitative magnetic resonance imaging (MRI) signal intensity (SI) measurements could distinguish intradural-extramedullary schwannomas from meningiomas. Methods: From July 2019 to September 2021, 54 patients with intradural-extramedullary tumors (37 meningiomas and 17 schwannomas) underwent surgery, and tumors were verified pathologically. Defined regions of interest were used to quantify SI values on T1- (T1W) and T2-weighted images (T2W). Receiver operating characteristic curve analysis was used to obtain cutoff values and calculate the area under the curve (AUC), sensitivity (SE), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV). Results: Both Maximum (T2max) and mean (T2mean) T2W SI values demonstrated outstanding (AUC: 0.91) abilities to differentiate meningiomas from schwannomas with Se, Sp, PPV, and NPV values of 94.6%, 70.6%, 87.5%, and 85.7%, respectively, for T2max and 81.1%, 88.2%, 93.8%, and 68.2% for T2mean. The maximum SI value on contrast-enhanced T1W (T1CEmax) and the T2W tumor: fat SI ratio (rTF) demonstrated acceptable abilities (AUC: 0.73 and 0.79, respectively) to differentiate meningiomas from schwannomas with Se, Sp, PPV, and NPV values of 94.6%, 70.6%, 87.5%, and 85.7%, respectively, for T1CEmax and 81.1%, 88.2%, 93.8%, and 68.2% for rTF. Conclusions: Quantitative SI values (T2max, T2mean, T2min, T1CEmax, rTF) can be used to differentiate intradural-extramedullary schwannomas from meningiomas.

Explainable AI (XAI) Applied in Machine Learning for Pain Modeling: A Review

Pain is a complex term that describes various sensations that create discomfort in various ways or types inside the human body. Generally, pain has consequences that range from mild to severe in different organs of the body and will depend on the way it is caused, which could be an injury, illness or medical procedures including testing, surgeries or therapies, etc. With recent advances in artificial-intelligence (AI) systems associated in biomedical and healthcare settings, the contiguity of physician, clinician and patient has shortened. AI, however, has more scope to interpret the pain associated in patients with various conditions by using any physiological or behavioral changes. Facial expressions are considered to give much information that relates with emotions and pain, so clinicians consider these changes with high importance for assessing pain. This has been achieved in recent times with different machine-learning and deep-learning models. To accentuate the future scope and importance of AI in medical field, this study reviews the explainable AI (XAI) as increased attention is given to an automatic assessment of pain. This review discusses how these approaches are applied for different pain types.

Novel Magnetic Resonance Imaging Tools for the Diagnosis of Degenerative Disc Disease: A Narrative Review

Low back pain (LBP) is one of the leading causes of disability worldwide, with a significant socioeconomic burden on healthcare systems. It is mainly caused by degenerative disc disease (DDD), a progressive, chronic, and age-related process. With its capacity to accurately characterize intervertebral disc (IVD) and spinal morphology, magnetic resonance imaging (MRI) has been established as one of the most valuable tools in diagnosing DDD. However, existing technology cannot detect subtle changes in IVD tissue composition and cell metabolism. In this review, we summarized the state of the art regarding innovative quantitative MRI modalities that have shown the capacity to discriminate and quantify changes in matrix composition and integrity, as well as biomechanical changes in the early stages of DDD. Validation and implementation of this new technology in the clinical setting will allow for an early diagnosis of DDD and ideally guide conservative and regenerative treatments that may prevent the progression of the degenerative process rather than intervene at the latest stages of the disease.

AI MSK clinical applications: spine imaging

Recent investigations have focused on the clinical application of artificial intelligence (AI) for tasks specifically addressing the musculoskeletal imaging routine. Several AI applications have been dedicated to optimizing the radiology value chain in spine imaging, independent from modality or specific application. This review aims to summarize the status quo and future perspective regarding utilization of AI for spine imaging. First, the basics of AI concepts are clarified. Second, the different tasks and use cases for AI applications in spine imaging are discussed and illustrated by examples. Finally, the authors of this review present their personal perception of AI in daily imaging and discuss future chances and challenges that come along with AI-based solutions.

Optimal machine learning methods for radiomic prediction models: Clinical application for preoperative T2*-weighted images of cervical spondylotic myelopathy

INTRODUCTION

Predicting the postoperative neurological function of cervical spondylotic myelopathy (CSM) patients is generally based on conventional magnetic resonance imaging (MRI) patterns, but this approach is not completely satisfactory. This study utilized radiomics, which produced advanced objective and quantitative indicators, and machine learning to develop, validate, test, and compare models for predicting the postoperative prognosis of CSM.

MATERIALS AND METHODS

In total, 151 CSM patients undergoing surgical treatment and preoperative MRI was retrospectively collected and divided into good/poor outcome groups based on postoperative modified Japanese Orthopedic Association (mJOA) scores. The datasets obtained from several scanners (an independent  scanner) for the training (testing) cohort were used for cross-validation (CV). Radiological models based on the intramedullary hyperintensity and compression ratio were constructed with 14 binary classifiers. Radiomic models based on 237 robust radiomic features were constructed with the same 14 binary classifiers in combination with 7 feature reduction methods, resulting in 98 models. The main outcome measures were the area under the receiver operating characteristic curve (AUROC) and accuracy.

RESULTS

Forty-one (11) radiomic models were superior to random guessing during CV (testing), with significant increased AUROC and/or accuracy (P AUROC < .05 and/or P accuracy < .05). One radiological model performed better than random guessing during CV (P accuracy < .05). In the testing cohort, the linear SVM preprocessor + SVM, the best radiomic model (AUROC: 0.74 ± 0.08, accuracy: 0.73 ± 0.07), overperformed the best radiological model (P AUROC = .048).

CONCLUSION

Radiomic features can predict postoperative spinal cord function in CSM patients. The linear SVM preprocessor + SVM has great application potential in building radiomic models.

Diagnosis and treatment of congenital scoliosis

Background: Congenital scoliosis is caused by anomalies of the vertebra, such as hemivertebra or unsegmented bar, which result in asymmetric growth of the spine. The disruption of vertebra development during embryogenesis may be accompanied by other congenital multi-organ anomalies. The progression of the scoliotic curve may also hinder the development of other organs.Current Concepts: Hemivertebra excision and short spinal fusion have demonstrated favorable outcomes. However, the need for spinal growth and lung development has led to new treatment modalities. Growth-friendly surgeries, such as with a growing rod or vertical expandable rib-based distraction device, have demonstrated good results with curve correction while maintaining spinal growth. Although the outcome of conservative treatment for congenital scoliosis is questionable, casting may be effective as a “time-buying strategy” to delay the need for surgery.Discussion and Conclusion: It is essential to decide on a treatment plan considering the progression of the curve and growth of the spine and lungs through an individualized approach.

Comparison of manual versus automated measurement of Cobb angle in idiopathic scoliosis based on a deep learning keypoint detection technology

PURPOSE

The present study compared manual and automated measurement of Cobb angle in idiopathic scoliosis based on deep learning keypoint detection technology.

METHODS

A total of 181 anterior-posterior spinal X-rays were included in this study, including 165 cases of idiopathic scoliosis and 16 normal adult cases without scoliosis. We labeled all images and randomly chose 145 as the training set and 36 as the test set. Two state-of-the-art deep learning object detection models based on convolutional neural networks were used in sequence to segment each vertebra and locate the vertebral corners. Cobb angles measured from the output of the models were compared to manual measurements performed by orthopedic experts.

RESULTS

The mean Cobb angle in test cases was 27.4° ± 19.2° (range 0.00-91.00°) with manual measurements and 26.4° ± 18.9° (range 0.00-88.00°) with automated measurements. The automated method needed 4.45 s on average to measure each radiograph. The intra-class correlation coefficient (ICC) for the reliability of the automated measurement of the Cobb angle was 0.994. The Pearson correlation coefficient and mean absolute error between automated positioning and expert annotation were 0.990 and 2.2° ± 2.0°, respectively. The analytical result for the Spearman rank-order correlation was 0.984 (p < 0.001).

CONCLUSION

The automated measurement results agreed with the experts' annotation and had a high degree of reliability when the Cobb angle did not exceed 90° and could locate multiple curves in the same scoliosis case simultaneously in a short period of time. Our results need to be verified in more cases in the future.

Artificial Intelligence and Computer Vision in Low Back Pain: A Systematic Review

Chronic Low Back Pain (LBP) is a symptom that may be caused by several diseases, and it is currently the leading cause of disability worldwide. The increased amount of digital images in orthopaedics has led to the development of methods related to artificial intelligence, and to computer vision in particular, which aim to improve diagnosis and treatment of LBP. In this manuscript, we have systematically reviewed the available literature on the use of computer vision in the diagnosis and treatment of LBP. A systematic research of PubMed electronic database was performed. The search strategy was set as the combinations of the following keywords: "Artificial Intelligence", "Feature Extraction", "Segmentation", "Computer Vision", "Machine Learning", "Deep Learning", "Neural Network", "Low Back Pain", "Lumbar". Results: The search returned a total of 558 articles. After careful evaluation of the abstracts, 358 were excluded, whereas 124 papers were excluded after full-text examination, taking the number of eligible articles to 76. The main applications of computer vision in LBP include feature extraction and segmentation, which are usually followed by further tasks. Most recent methods use deep learning models rather than digital image processing techniques. The best performing methods for segmentation of vertebrae, intervertebral discs, spinal canal and lumbar muscles achieve Sørensen-Dice scores greater than 90%, whereas studies focusing on localization and identification of structures collectively showed an accuracy greater than 80%. Future advances in artificial intelligence are expected to increase systems' autonomy and reliability, thus providing even more effective tools for the diagnosis and treatment of LBP.

Machine learning approaches applied in spinal pain research

The purpose of this narrative review is to provide a critical reflection of how analytical machine learning approaches could provide the platform to harness variability of patient presentation to enhance clinical prediction. The review includes a summary of current knowledge on the physiological adaptations present in people with spinal pain. We discuss how contemporary evidence highlights the importance of not relying on single features when characterizing patients given the variability of physiological adaptations present in people with spinal pain. The advantages and disadvantages of current analytical strategies in contemporary basic science and epidemiological research are reviewed and we consider how analytical machine learning approaches could provide the platform to harness the variability of patient presentations to enhance clinical prediction of pain persistence or recurrence. We propose that machine learning techniques can be leveraged to translate a potentially heterogeneous set of variables into clinically useful information with the potential to enhance patient management.

Lumbar Disc Herniation Automatic Detection in Magnetic Resonance Imaging Based on Deep Learning

Background: Lumbar disc herniation (LDH) is among the most common causes of lower back pain and sciatica. The causes of LDH have not been fully elucidated but most likely involve a complex combination of mechanical and biological processes. Magnetic resonance imaging (MRI) is a tool most frequently used for LDH because it can show abnormal soft tissue areas around the spine. Deep learning models may be trained to recognize images with high speed and accuracy to diagnose LDH. Although the deep learning model requires huge numbers of image datasets to train and establish the best model, this study processed enhanced medical image features for training the small-scale deep learning dataset. Methods: We propose automatic detection to assist the initial LDH exam for lower back pain. The subjects were between 20 and 65 years old with at least 6 months of work experience. The deep learning method employed the YOLOv3 model to train and detect small object changes such as LDH on MRI. The dataset images were processed and combined with labeling and annotation from the radiologist's diagnosis record. Results: Our method proves the possibility of using deep learning with a small-scale dataset with limited medical images. The highest mean average precision (mAP) was 92.4% at 550 images with data augmentation (550-aug), and the YOLOv3 LDH training was 100% with the best average precision at 550-aug among all datasets. This study used data augmentation to prevent under- or overfitting in an object detection model that was trained with the small-scale dataset. Conclusions: The data augmentation technique plays a crucial role in YOLOv3 training and detection results. This method displays a high possibility for rapid initial tests and auto-detection for a limited clinical dataset.

Multi-muscle deep learning segmentation to automate the quantification of muscle fat infiltration in cervical spine conditions

Muscle fat infiltration (MFI) has been widely reported across cervical spine disorders. The quantification of MFI requires time-consuming and rater-dependent manual segmentation techniques. A convolutional neural network (CNN) model was trained to segment seven cervical spine muscle groups (left and right muscles segmented separately, 14 muscles total) from Dixon MRI scans (n = 17, 17 scans < 2 weeks post motor vehicle collision (MVC), and 17 scans 12 months post MVC). The CNN MFI measures demonstrated high test reliability and accuracy in an independent testing dataset (n = 18, 9 scans < 2 weeks post MVC, and 9 scans 12 months post MVC). Using the CNN in 84 participants with scans < 2 weeks post MVC (61 females, 23 males, age = 34.2 ± 10.7 years) differences in MFI between the muscle groups and relationships between MFI and sex, age, and body mass index (BMI) were explored. Averaging across all muscles, females had significantly higher MFI than males (p = 0.026). The deep cervical muscles demonstrated significantly greater MFI than the more superficial muscles (p < 0.001), and only MFI within the deep cervical muscles was moderately correlated to age (r > 0.300, p ≤ 0.001). CNN's allow for the accurate and rapid, quantitative assessment of the composition of the architecturally complex muscles traversing the cervical spine. Acknowledging the wider reports of MFI in cervical spine disorders and the time required to manually segment the individual muscles, this CNN may have diagnostic, prognostic, and predictive value in disorders of the cervical spine.

The measurement of Cobb angle based on spine X-ray images using multi-scale convolutional neural network

Adolescent idiopathic scoliosis (AIS) is a structural spinal deformity mainly in the coronal plane and is among the most frequent deformities in children, adolescents, and young adults, with an overall prevalence of 0.47-5.2%. The Cobb angle is an objective measure to determine the progression of deformity and plays a critical role in the planning of surgical treatment. However, existing studies suggested that Cobb angle measurement is susceptible to inter- and intra-observer variability, as well as a high variability in the definition of the end vertebra. In this study, we proposed an automatic method for the spine vertebrae segmentation using Deeplab V3+, a powerful tool that has shown success in the image segmentation of other anatomical regions but spine, and Cobb angle measurement. The segmentation performance was compared to existing mainstay neural networks. Compared to U-Net, Residual U-Net and Dilated U-Net, our method using Deeplab V3+ showed the best performance in the Dice Similarity Coefficient (DSC), accuracy, sensitivity and Jaccard Index. An excellent correlation in the final Cobb angle calculation was achieved between the smallest distance point (SDP) method and two experts (> 0.95), with a small error in the angle estimation compared (MAE < 3°). The proposed method could provide a potential tool for the automatic estimation of the Cobb angle to improve the efficiency and accuracy of the treatment workflow for AIS.

Fatty infiltration in cervical flexors and extensors in patients with degenerative cervical myelopathy using a multi-muscle segmentation model

Background

In patients with degenerative cervical myelopathy (DCM) that have spinal cord compression and sensorimotor deficits, surgical decompression is often performed. However, there is heterogeneity in clinical presentation and post-surgical functional recovery.

Objectives

Primary: a) to assess differences in muscle fat infiltration (MFI) in patients with DCM versus controls, b) to assess association between MFI and clinical disability. Secondary: to assess association between MFI pre-surgery and post-surgical functional recovery.

Study design

Cross-sectional case control study.

Methods

Eighteen patients with DCM (58.6 ± 14.2 years, 10 M/8F) and 25 controls (52.6 ± 11.8 years, 13M/12 F) underwent 3D Dixon fat-water imaging. A convolutional neural network (CNN) was used to segment cervical muscles (MFSS- multifidus and semispinalis cervicis, LC- longus capitis/colli) and quantify MFI. Modified Japanese Orthopedic Association (mJOA) and Nurick were collected.

Results

Patients with DCM had significantly higher MFI in MFSS (20.63 ± 5.43 vs 17.04 ± 5.24, p = 0.043) and LC (18.74 ± 6.7 vs 13.66 ± 4.91, p = 0.021) than controls. Patients with increased MFI in LC and MFSS had higher disability (LC: Nurick (Spearman’s ρ = 0.436, p = 0.003) and mJOA (ρ = -0.399, p = 0.008)). Increased MFI in LC pre-surgery was associated with post-surgical improvement in Nurick (ρ = -0.664, p = 0.026) and mJOA (ρ = -0.603, p = 0.049).

Conclusion

In DCM, increased muscle adiposity is significantly associated with sensorimotor deficits, clinical disability, and functional recovery after surgery. Accurate and time efficient evaluation of fat infiltration in cervical muscles may be conducted through implementation of CNN models.

Nerve recognition in percutaneous transforaminal endoscopic discectomy using convolutional neural network

PURPOSE

Percutaneous transforaminal endoscopic discectomy (PTED) is one of the most common minimally invasive surgery methods used in clinic in recent years. In this study, we developed a computer-aided detection system (CADS) based on convolutional neural network (CNN) to automatically recognize nerve and dura mater images under PTED surgery.

METHODS

We collected surgical videos from 65 patients with lumbar disc herniation who underwent PTED; we then converted the videos into images, and randomly divided some images into a training dataset, a validation dataset, test dataset. The training dataset and validation dataset were composed of 10 454 images containing nerve and dura mater from 50 randomly selected patients; test dataset contained 12 000 images from the remaining 15 patients.

RESULTS

The results showed that sensitivity, specificity, and accuracy reached 90.90%, 93.68%, and 92.29%, respectively. CADS could recognize the nerve and dura mater with no significant difference (P > 0.05) between each patient in test dataset. In comparison with clinicians of different levels, the performance of CADS was lower than that of a spinal endoscopist, but significantly higher than that of general surgeons. With the assistance of CADS, the performance of the general surgeons approached that of the spinal endoscopist.

CONCLUSIONS

CNN can recognize well nerve and dura mater images in PTED surgery, and can help general surgeons to improve their ability to recognize tissues during the operation.

A narrative review of machine learning as promising revolution in clinical practice of scoliosis

Machine learning (ML), as an advanced domain of artificial intelligence (AI), is progressively changing our view of the world. By implementing its algorithms, our ability to detect previously undiscoverable patterns in data has the potential to revolutionize predictive analytics. Scoliosis, as a relatively specialized branch in the spine field, mainly covers the pediatric, adult and the elderly populations, and its diagnosis and treatment remain difficult. With recent efforts and interdisciplinary cooperation, ML has been widely applied to investigate issues related to scoliosis, and surprisingly augment a surgeon's ability in clinical practice related to scoliosis. Meanwhile, ML models penetrate in every stage of the clinical practice procedure of scoliosis. In this review, we first present a brief description of the application of ML in the clinical practice procedures regarding scoliosis, including screening, diagnosis and classification, surgical decision making, intraoperative manipulation, complication prediction, prognosis prediction and rehabilitation. Meanwhile, the ML models and specific applications adopted are presented. Additionally, current limitations and future directions are briefly discussed regarding its use in the field of scoliosis. We believe that the implementation of ML is a promising revolution to assist surgeons in all aspects of clinical practice related to scoliosis in the near future.