External validation of the deep learning system "SpineNet" for grading radiological features of degeneration on MRIs of the lumbar spine.

BACKGROUND: Magnetic resonance imaging (MRI) is used to detect degenerative changes of the lumbar spine. SpineNet (SN), a computer vision-based system, performs an automated analysis of degenerative features in MRI scans aiming to provide high accuracy, consistency and objectivity. This study evaluated SN's ratings compared with those of an expert radiologist. METHOD: MRIs of 882 patients (mean age, 72 ± 8.8 years) with degenerative spinal disorders from two previous trials carried out in our spine center between 2011 and 2019, were analyzed by an expert radiologist. Lumbar segments (L1/2-L5/S1) were graded for Pfirrmann Grades (PG), Spondylolisthesis (SL) and Central Canal Stenosis (CCS). SN's analysis for the equivalent parameters was generated. Agreement between methods was analyzed using kappa (κ), Spearman correlation (ρ) and Lin's concordance correlation (ρc) coefficients and class average accuracy (CAA). RESULTS: 4410 lumbar segments were analyzed. κ statistics showed moderate to substantial agreement in PG between the radiologist and SN depending on spinal level (range κ 0.63-0.77, all levels together 0.72; range CAA 45-68%, all levels 55%), slight to substantial agreement for SL (range κ 0.07-0.60, all levels 0.63; range CAA 47-57%, all levels 56%) and CCS (range κ 0.17-0.57, all levels 0.60; range CAA 35-41%, all levels 43%). SN tended to record more pathological features in PG than did the radiologist whereas the contrary was the case for CCS. SL showed an even distribution between methods. CONCLUSION: SN is a robust and reliable tool with the ability to grade degenerative features such as PG, SL or CCS in lumbar MRIs with moderate to substantial agreement compared to the current gold-standard, the radiologist. It is a valuable alternative for analyzing MRIs from large cohorts for diagnostic and research purposes.

Accurate prediction of lumbar microdecompression level with an automated MRI grading system.

OBJECTIVE: Lumbar spine MRI interpretations have high variability reducing utility for surgical planning. This study evaluated a convolutional neural network (CNN) framework that generates automated MRI grading for its ability to predict the level that was surgically decompressed. MATERIALS AND METHODS: Patients who had single-level decompression were retrospectively evaluated. Sagittal T2 images were processed by a CNN (SpineNet), which provided grading for the following: central canal stenosis, disc narrowing, disc degeneration, spondylolisthesis, upper/lower endplate morphologic changes, and upper/lower marrow changes. The grades were used to calculate an aggregate score. The variables and the aggregate score were analyzed for their ability to predict the surgical level. For each surgical level subgroup, the surgical level aggregate scores were compared with the non-surgical levels. RESULTS: A total of 141 patients met the inclusion criteria (82 women, 59 men; mean age 64 years; age range 28-89 years). SpineNet did not identify central canal stenosis in 32 patients. Of the remaining 109, 96 (88%) patients had a decompression at the level of greatest stenosis. The higher stenotic grade was present only at the surgical level in 82/96 (85%) patients. The level with the highest aggregate score matched the surgical level in 103/141 (73%) patients and was unique to the surgical level in 91/103 (88%) patients. Overall, the highest aggregate score identified the surgical level in 91/141 (65%) patients. The aggregate MRI score mean was significantly higher for the L3-S1 surgical levels. CONCLUSION: A previously developed CNN framework accurately predicts the level of microdecompression for degenerative spinal stenosis in most patients.

Correction to: Identifying Scoliosis in Population­Based Cohorts: Automation of a Validated Method Based on Total Body Dual Energy X­ray Absorptiometry Scans.

In the original version of the article, the co-author would like to add to the acknowledgements section to highlight their funding stream (EPSRC). The revised acknowledgements is given below.

Identifying Scoliosis in Population-Based Cohorts: Automation of a Validated Method Based on Total Body Dual Energy X-ray Absorptiometry Scans.

Scoliosis is a 3D-torsional rotation of the spine, but risk factors for initiation and progression are little understood. Research is hampered by lack of population-based research since radiographs cannot be performed on entire populations due to the relatively high levels of ionising radiation. Hence we have developed and validated a manual method for identifying scoliosis from total body dual energy X-ray absorptiometry (DXA) scans for research purposes. However, to allow full utilisation of population-based research cohorts, this needs to be automated. The purpose of this study was therefore to automate the identification of spinal curvature from total body DXA scans using machine learning techniques. To validate the automation, we assessed: (1) sensitivity, specificity and area under the receiver operator curve value (AUC) by comparison with 12,000 manually annotated images; (2) reliability by rerunning the automation on a subset of DXA scans repeated 2-6 weeks apart and calculating the kappa statistic; (3) validity by applying the automation to 5000 non-annotated images to assess associations with epidemiological variables. The final automated model had a sensitivity of 86.5%, specificity of 96.9% and an AUC of 0.80 (95%CI 0.74-0.87). There was almost perfect agreement of identification of those with scoliosis (kappa 0.90). Those with scoliosis identified by the automated model showed similar associations with gender, ethnicity, socioeconomic status, BMI and lean mass to previous literature. In conclusion, we have developed an accurate and valid automated method for identifying and quantifying spinal curvature from total body DXA scans.

Could automated machine-learned MRI grading aid epidemiological studies of lumbar spinal stenosis? Validation within the Wakayama spine study.

BACKGROUND: MRI scanning has revolutionized the clinical diagnosis of lumbar spinal stenosis (LSS). However, there is currently no consensus as to how best to classify MRI findings which has hampered the development of robust longitudinal epidemiological studies of the condition. We developed and tested an automated system for grading lumbar spine MRI scans for central LSS for use in epidemiological research. METHODS: Using MRI scans from the large population-based cohort study (the Wakayama Spine Study), all graded by a spinal surgeon, we trained an automated system to grade central LSS in four gradings of the bone and soft tissue margins: none, mild, moderate, severe. Subsequently, we tested the automated grading against the independent readings of our observer in a test set to investigate reliability and agreement. RESULTS: Complete axial views were available for 4855 lumbar intervertebral levels from 971 participants. The machine used 4365 axial views to learn (training set) and graded the remaining 490 axial views (testing set). The agreement rate for gradings was 65.7% (322/490) and the reliability (Lin's correlation coefficient) was 0.73. In 2.2% of scans (11/490) there was a difference in classification of 2 and in only 0.2% (1/490) was there a difference of 3. When classified into 2 groups as 'severe' vs 'no/mild/moderate'. The agreement rate was 94.1% (461/490) with a kappa of 0.75. CONCLUSIONS: This study showed that an automated system can "learn" to grade central LSS with excellent performance against the reference standard. Thus SpineNet offers potential to grade LSS in large-scale epidemiological studies involving a high volume of MRI spine data with a high level of consistency and objectivity.

ISSLS PRIZE IN BIOENGINEERING SCIENCE 2017: Automation of reading of radiological features from magnetic resonance images (MRIs) of the lumbar spine without human intervention is comparable with an expert radiologist.

STUDY DESIGN: Investigation of the automation of radiological features from magnetic resonance images (MRIs) of the lumbar spine. OBJECTIVE: To automate the process of grading lumbar intervertebral discs and vertebral bodies from MRIs. MR imaging is the most common imaging technique used in investigating low back pain (LBP). Various features of degradation, based on MRIs, are commonly recorded and graded, e.g., Modic change and Pfirrmann grading of intervertebral discs. Consistent scoring and grading is important for developing robust clinical systems and research. Automation facilitates this consistency and reduces the time of radiological analysis considerably and hence the expense. METHODS: 12,018 intervertebral discs, from 2009 patients, were graded by a radiologist and were then used to train: (1) a system to detect and label vertebrae and discs in a given scan, and (2) a convolutional neural network (CNN) model that predicts several radiological gradings. The performance of the model, in terms of class average accuracy, was compared with the intra-observer class average accuracy of the radiologist. RESULTS: The detection system achieved 95.6% accuracy in terms of disc detection and labeling. The model is able to produce predictions of multiple pathological gradings that consistently matched those of the radiologist. The model identifies 'Evidence Hotspots' that are the voxels that most contribute to the degradation scores. CONCLUSIONS: Automation of radiological grading is now on par with human performance. The system can be beneficial in aiding clinical diagnoses in terms of objectivity of gradings and the speed of analysis. It can also draw the attention of a radiologist to regions of degradation. This objectivity and speed is an important stepping stone in the investigation of the relationship between MRIs and clinical diagnoses of back pain in large cohorts. LEVEL OF EVIDENCE: Level 3.

Automated detection, labelling and radiological grading of clinical spinal MRIs.

Spinal magnetic resonance (MR) scans are a vital tool for diagnosing the cause of back pain for many diseases and conditions. However, interpreting clinically useful information from these scans can be challenging, time-consuming and hard to reproduce across different radiologists. In this paper, we alleviate these problems by introducing a multi-stage automated pipeline for analysing spinal MR scans. This pipeline first detects and labels vertebral bodies across several commonly used sequences (e.g. T1w, T2w and STIR) and fields of view (e.g. lumbar, cervical, whole spine). Using these detections it then performs automated diagnosis for several spinal disorders, including intervertebral disc degenerative changes in T1w and T2w lumbar scans, and spinal metastases, cord compression and vertebral fractures. To achieve this, we propose a new method of vertebrae detection and labelling, using vector fields to group together detected vertebral landmarks and a language-modelling inspired beam search to determine the corresponding levels of the detections. We also employ a new transformer-based architecture to perform radiological grading which incorporates context from multiple vertebrae and sequences, as a real radiologist would. The performance of each stage of the pipeline is tested in isolation on several clinical datasets, each consisting of 66 to 421 scans. The outputs are compared to manual annotations of expert radiologists, demonstrating accurate vertebrae detection across a range of scan parameters. Similarly, the model's grading predictions for various types of disc degeneration and detection of spinal metastases closely match those of an expert radiologist. To aid future research, our code and trained models are made publicly available.

Automated measurement of size of spinal curve in population-based cohorts: Validation of a method based on total body dual energy X-ray absorptiometry scans.

BACKGROUND: Scoliosis is spinal curvature that may progress to require surgical stabilisation. Risk factors for progression are little understood due to lack of population-based research, since radiographs cannot be performed on entire populations due to high levels of radiation. To help address this, we have previously developed and validated a method for quantification of spinal curvature from total body dual energy X-ray absorptiometry (DXA) scans. The purpose of this study was to automate this quantification of spinal curve size from DXA scans using machine learning techniques. METHODS: To develop the automation of curve size, we utilised manually annotated scans from 7298 participants from the Avon Longitudinal Study of Parents and Children (ALSPAC) at age 9 and 5122 at age 15. To validate the automation we assessed (1) agreement between manual vs automation using the Bland-Altman limits of agreement, (2) reliability by calculating the coefficient of variation, and (3) clinical validity by running the automation on 4969 non-annotated scans at age 18 to assess the associations with physical activity, body composition, adipocyte function and backpain compared to previous literature. RESULTS: The mean difference between manual vs automated readings was less than one degree, and 90.4 % of manual vs automated readings fell within 10°. The coefficient of variation was 25.4 %. Clinical validation showed the expected relationships between curve size and physical activity, adipocyte function, height and weight. CONCLUSION: We have developed a reasonably accurate and valid automated method for quantifying spinal curvature from DXA scans for research purposes.

External Validation of SpineNet, an Open-Source Deep Learning Model for Grading Lumbar Disk Degeneration MRI Features, Using the Northern Finland Birth Cohort 1966.

STUDY DESIGN: This is a retrospective observational study to externally validate a deep learning image classification model. OBJECTIVE: Deep learning models such as SpineNet offer the possibility of automating the process of disk degeneration (DD) classification from magnetic resonance imaging (MRI). External validation is an essential step to their development. The aim of this study was to externally validate SpineNet predictions for DD using Pfirrmann classification and Modic changes (MCs) on data from the Northern Finland Birth Cohort 1966 (NFBC1966). SUMMARY OF DATA: We validated SpineNet using data from 1331 NFBC1966 participants for whom both lumbar spine MRI data and consensus DD gradings were available. MATERIALS AND METHODS: SpineNet returned Pfirrmann grade and MC presence from T2-weighted sagittal lumbar MRI sequences from NFBC1966, a data set geographically and temporally separated from its training data set. A range of agreement and reliability metrics were used to compare predictions with expert radiologists. Subsets of data that match SpineNet training data more closely were also tested. RESULTS: Balanced accuracy for DD was 78% (77%-79%) and for MC 86% (85%-86%). Interrater reliability for Pfirrmann grading was Lin concordance correlation coefficient=0.86 (0.85-0.87) and Cohen κ=0.68 (0.67-0.69). In a low back pain subset, these reliability metrics remained largely unchanged. In total, 20.83% of disks were rated differently by SpineNet compared with the human raters, but only 0.85% of disks had a grade difference >1. Interrater reliability for MC detection was κ=0.74 (0.72-0.75). In the low back pain subset, this metric was almost unchanged at κ=0.76 (0.73-0.79). CONCLUSIONS: In this study, SpineNet has been benchmarked against expert human raters in the research setting. It has matched human reliability and demonstrates robust performance despite the multiple challenges facing model generalizability.

A deep learning approach to private data sharing of medical images using conditional generative adversarial networks (GANs).

Clinical data sharing can facilitate data-driven scientific research, allowing a broader range of questions to be addressed and thereby leading to greater understanding and innovation. However, sharing biomedical data can put sensitive personal information at risk. This is usually addressed by data anonymization, which is a slow and expensive process. An alternative to anonymization is construction of a synthetic dataset that behaves similar to the real clinical data but preserves patient privacy. As part of a collaboration between Novartis and the Oxford Big Data Institute, a synthetic dataset was generated based on images from COSENTYX® (secukinumab) ankylosing spondylitis (AS) clinical studies. An auxiliary classifier Generative Adversarial Network (ac-GAN) was trained to generate synthetic magnetic resonance images (MRIs) of vertebral units (VUs), conditioned on the VU location (cervical, thoracic and lumbar). Here, we present a method for generating a synthetic dataset and conduct an in-depth analysis on its properties along three key metrics: image fidelity, sample diversity and dataset privacy.

SpineNet: Automated classification and evidence visualization in spinal MRIs.

The objective of this work is to automatically produce radiological gradings of spinal lumbar MRIs and also localize the predicted pathologies. We show that this can be achieved via a Convolutional Neural Network (CNN) framework that takes intervertebral disc volumes as inputs and is trained only on disc-specific class labels. Our contributions are: (i) a CNN architecture that predicts multiple gradings at once, and we propose variants of the architecture including using 3D convolutions; (ii) showing that this architecture can be trained using a multi-task loss function without requiring segmentation level annotation; and (iii) a localization method that clearly shows pathological regions in the disc volumes. We compare three visualization methods for the localization. The network is applied to a large corpus of MRI T2 sagittal spinal MRIs (using a standard clinical scan protocol) acquired from multiple machines, and is used to automatically compute disk and vertebra gradings for each MRI. These are: Pfirrmann grading, disc narrowing, upper/lower endplate defects, upper/lower marrow changes, spondylolisthesis, and central canal stenosis. We report near human performances across the eight gradings, and also visualize the evidence for these gradings localized on the original scans.