Clinical Translation of the LevelCheck Decision Support Algorithm for Target Localization in Spine Surgery

Ann Biomed Eng. 2018 Oct;46(10):1548-1557. doi: 10.1007/s10439-018-2099-2. Epub 2018 Jul 26.


Recent work has yielded a method for automatic labeling of vertebrae in intraoperative radiographs as an assistant to manual level counting. The method, called LevelCheck, previously demonstrated promise in phantom studies and retrospective studies. This study aims to: (#1) Analyze the effect of LevelCheck on accuracy and confidence of localization in two modes: (a) Independent Check (labels displayed after the surgeon's decision) and (b) Active Assistant (labels presented before the surgeon's decision). (#2) Assess the feasibility and utility of LevelCheck in the operating room. Two studies were conducted: a laboratory study investigating these two workflow implementations in a simulated operating environment with 5 surgeons, reviewing 62 cases selected from a dataset of radiographs exhibiting a challenge to vertebral localization; and a clinical study involving 20 patients undergoing spine surgery. In Study #1, the median localization error without assistance was 30.4% (IQR = 5.2%) due to the challenging nature of the cases. LevelCheck reduced the median error to 2.4% for both the Independent Check and Active Assistant modes (p < 0.01). Surgeons found LevelCheck to increase confidence in 91% of cases. Study #2 demonstrated accuracy in all cases. The algorithm runtime varied from 17 to 72 s in its current implementation. The algorithm was shown to be feasible, accurate, and to improve confidence during surgery.

Keywords: Clinical translation; Image-guided surgery; Intraoperative imaging; LevelCheck; Spine surgery; Surgical workflow.

MeSH terms

  • Algorithms*
  • Decision Making, Computer-Assisted*
  • Humans
  • Neurosurgical Procedures / instrumentation
  • Neurosurgical Procedures / methods*
  • Spinal Cord / diagnostic imaging*
  • Spinal Cord / surgery*
  • Translational Medical Research / instrumentation
  • Translational Medical Research / methods*