The purpose of this study is to evaluate the performance of a novel deep learning (DL) tool for fully automated measurements of the sagittal spinopelvic balance from X-ray images of the spine in comparison with manual measurements. Ninety-seven conventional upright sagittal X-ray images from 55 subjects were retrospectively included in this study. Measurements of the parameters of the sagittal spinopelvic balance, i.e., the sacral slope (SS), pelvic tilt (PT), spinal tilt (ST), pelvic incidence (PI) and spinosacral angle (SSA), were obtained manually by identifying specific anatomical landmarks using the SurgiMap Spine software and by the fully automated DL tool. Statistical analysis was performed in terms of the mean absolute difference (MAD), standard deviation (SD) and Pearson correlation, while the paired t test was used to search for statistically significant differences between manual and automated measurements. The differences between reference manual measurements and those obtained automatically by the DL tool were, respectively, for SS, PT, ST, PI and SSA, equal to 5.0 (3.4 ), 2.7 (2.5 ), 1.2 (1.2 ), 5.5 (4.2 ) and 5.0 (3.5 ) in terms of MAD (SD), with a statistically significant corresponding Pearson correlation of 0.73, 0.90, 0.95, 0.81 and 0.71. No statistically significant differences were observed between the two types of measurement (p value always above 0.05). The differences between measurements are in the range of the observer variability of manual measurements, indicating that the DL tool can provide clinically equivalent measurements in terms of accuracy but superior measurements in terms of cost-effectiveness, reliability and reproducibility.
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