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The system focuses on spinal alignment calculation, leveraging B\u00e9zier curves and algorithm development to track vertebrae and estimate spinal curvature. Collaborative meetings with clinical experts identified challenges such as patient positioning complexities and limitations of minimal invasiveness. Thus, the method developed involves four algorithms: (1) tracking anatomical planes; (2) estimating the B\u00e9zier curve; (3) determining vertebrae positions; and (4) adjusting orientation. A proof of concept (PoC) using a porcine spinal segment validated\n                      <jats:italic>SpineAlign<\/jats:italic>\n                      \u2019s integrated algorithms and functionalities. The PoC demonstrated the system\u2019s accuracy and clinical applicability, successfully transitioning a spine without curvature to a lordotic spine. Quantitative evaluation of spinal alignment by the system showed high accuracy, with a maximum root mean squared error of 6\n                      <jats:inline-formula>\n                        <jats:alternatives>\n                          <jats:tex-math>$$^{\\circ }$$<\/jats:tex-math>\n                          <mml:math xmlns:mml=\"http:\/\/www.w3.org\/1998\/Math\/MathML\">\n                            <mml:mmultiscripts>\n                              <mml:mrow\/>\n                              <mml:mrow\/>\n                              <mml:mo>\u2218<\/mml:mo>\n                            <\/mml:mmultiscripts>\n                          <\/mml:math>\n                        <\/jats:alternatives>\n                      <\/jats:inline-formula>\n                      . The successful PoC marks an initial step towards developing a reliable CDSS for intraoperative spinal alignment assessment without medical image acquisition. Future steps will focus on enhancing system robustness and performing multi-surgeon serial studies to advance\n                      <jats:italic>SpineAlign<\/jats:italic>\n                      towards widespread clinical adoption.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Graphic abstract<\/jats:title>\n                  <\/jats:sec>","DOI":"10.1007\/s11517-025-03412-z","type":"journal-article","created":{"date-parts":[[2025,7,24]],"date-time":"2025-07-24T11:02:14Z","timestamp":1753354934000},"page":"3669-3694","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Towards a radiation-free clinical decision support system for intraoperative spinal alignment assessment"],"prefix":"10.1007","volume":"63","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7267-3106","authenticated-orcid":false,"given":"Luis","family":"Serrador","sequence":"first","affiliation":[]},{"given":"Pedro","family":"Varanda","sequence":"additional","affiliation":[]},{"given":"Bruno","family":"Direito-Santos","sequence":"additional","affiliation":[]},{"given":"Cristina P.","family":"Santos","sequence":"additional","affiliation":[]}],"member":"297","published-online":{"date-parts":[[2025,7,24]]},"reference":[{"issue":"3S","key":"3412_CR1","doi-asserted-by":"publisher","first-page":"S86","DOI":"10.1093\/neuros\/nyw077","volume":"80","author":"SC Overley","year":"2017","unstructured":"Overley SC, Cho SK, Mehta AI, Arnold PM (2017) Navigation and robotics in spinal surgery: where are we now? 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All applicable international, national, and\/or institutional guidelines for the care and use of animals were followed. All procedures performed in studies involving animals were in accordance with the ethical standards of the institution or practice at which the studies were conducted.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical Approval"}},{"value":"For this type of study, formal consent was not required.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Informed Consent"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of Interest"}}]}}