Pelvic Incidence-Dependent Clustering of Sagittal Spinal Alignment in Asymptomatic Middle-Aged and Elderly Adults: A Machine Learning Approach

Study Design. A cross-sectional cohort study. Objective. This study aimed to refine the sagittal morphologic classification of the spine in asymptomatic middle-aged and elderly adult populations using the unsupervised machine learning (ML) techniques and, by leveraging these findings, to propose and validate a surgical correction reference for adult spinal deformity (ASD) patients across different morphologic subtypes. Summary of Background Data. Restoration of sagittal alignment is the key to preventing mechanical complications and achieving good clinical outcomes in ASD surgery. However, high variations in the reported incidence of mechanical complications and clinical outcomes under current ASD realignment strategies have severely impeded the decision-making process for the optimal surgical plan. Materials and Methods. This study cross-sectionally enrolled asymptomatic middle-aged and elderly Chinese adults. Sagittal spinal morphology clusters and pelvic incidence-based correction criteria for ASD realignment surgery were derived from whole spine radiographs using unsupervised ML algorithms. To externally validate the realignment strategy identified in asymptomatic adults, a consecutive cohort of ASD patients with sagittal deformity who underwent realignment surgery was examined for postoperative mechanical complications, unplanned reoperation, unplanned readmission, and clinical outcomes during follow-up. Results. A total of 635 asymptomatic adults were enrolled for morphologic stratification, and 103 ASD patients with sagittal deformity were included for validation. The unsupervised ML algorithm successfully stratified spinal morphology into four clusters. The pelvic incidence-based surgical correction criteria computed by the regression algorithm demonstrated plausible clinical relevance, evidenced by the significantly lower incidence of postoperative mechanical complications, unplanned reoperation, unplanned readmission, and superior patient-reported outcomes in the restored group (conforming to the correction criteria) during follow-up. Conclusion. In this study, unsupervised ML algorithm effectively partitioned asymptomatic sagittal spinal morphology into four distinct clusters. Using the pelvic incidence-based proportional correction criteria, ASD patients can anticipate a reduced incidence of mechanical complications and improved clinical outcomes following spinal realignment surgery. Level of Evidence. Level Ⅲ.