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

Amir Manbachi, Tharindu De Silva, Ali Uneri, Matthew Jacobson, Joseph Goerres, Michael Ketcha, Runze Han, Nafi Aygun, David Thompson, Xiaobu Ye, Sebastian Vogt, Gerhard Kleinszig, Camilo Molina, Rajiv Iyer, Tomas Garzon-Muvdi, Michael R. Raber, Mari Groves, Jean Paul Wolinsky, Jeffrey H. Siewerdsen

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)1548-1557
Number of pages10
JournalAnnals of biomedical engineering
Issue number10
StatePublished - Oct 15 2018
Externally publishedYes


  • Clinical translation
  • Image-guided surgery
  • Intraoperative imaging
  • LevelCheck
  • Spine surgery
  • Surgical workflow

ASJC Scopus subject areas

  • Biomedical Engineering


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