{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T02:50:36Z","timestamp":1787626236893,"version":"build-2736575974"},"reference-count":46,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2024,4,27]],"date-time":"2024-04-27T00:00:00Z","timestamp":1714176000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"CBP Non-Profit, Inc."}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: The biomechanical analysis of spine and postural misalignments is important for surgical and non-surgical treatment of spinal pain. We investigated the examiner reliability of sagittal cervical alignment variables compared to the reliability and concurrent validity of computer vision algorithms used in the PostureRay\u00ae software 2024. Methods: A retrospective database of 254 lateral cervical radiographs of patients between the ages of 11 and 86 is studied. The radiographs include clearly visualized C1\u2013C7 vertebrae that were evaluated by a human using the software. To evaluate examiner reliability and the concurrent validity of the trained CNN performance, two blinded trials of radiographic digitization were performed by an extensively trained expert user (US) clinician with a two-week interval between trials. Then, the same clinician used the trained CNN twice to reproduce the same measures within a 2-week interval on the same 254 radiographs. Measured variables included segmental angles as relative rotation angles (RRA) C1\u2013C7, Cobb angles C2\u2013C7, relative segmental translations (RT) C1\u2013C7, anterior translation C2\u2013C7, and absolute rotation angle (ARA) C2\u2013C7. Data were remotely extracted from the examiner\u2019s PostureRay\u00ae system for data collection and sorted based on gender and stratification of degenerative changes. Reliability was assessed via intra-class correlations (ICC), root mean squared error (RMSE), and R2 values. Results: In comparing repeated measures of the CNN network to itself, perfect reliability was found for the ICC (1.0), RMSE (0), and R2 (1). The reliability of the trained expert US was in the excellent range for all variables, where 12\/18 variables had ICCs \u2265 0.9 and 6\/18 variables were 0.84 \u2264 ICCs \u2264 0.89. Similarly, for the expert US, all R2 values were in the excellent range (R2 \u2265 0.7), and all RMSEs were small, being 0.42 \u2264 RMSEs \u2264 3.27. Construct validity between the expert US and the CNN network was found to be in the excellent range with 18\/18 ICCs in the excellent range (ICCs \u2265 0.8), 16\/18 R2 values in the strong to excellent range (R2 \u2265 0.7), and 2\/18 in the good to moderate range (R2 RT C6\/C7 = 0.57 and R2 Cobb C6\/C7 = 0.64. The RMSEs for expert US vs. the CNN network were small, being 0.37 \u2264 RMSEs \u2264 2.89. Conclusions: A comparison of repeated measures within the computer vision CNN network and expert human found exceptional reliability and excellent construct validity when comparing the computer vision to the human observer.<\/jats:p>","DOI":"10.3390\/jcm13092573","type":"journal-article","created":{"date-parts":[[2024,4,29]],"date-time":"2024-04-29T08:49:24Z","timestamp":1714380564000},"page":"2573","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":15,"title":["Intra-Examiner Reliability and Validity of Sagittal Cervical Spine Mensuration Methods Using Deep Convolutional Neural Networks"],"prefix":"10.3390","volume":"13","author":[{"given":"Mohammad Mehdi","family":"Hosseini","sequence":"first","affiliation":[{"name":"Ritchie School of Engineering and Computer Science, University of Denver, Denver, CO 80208, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammad H.","family":"Mahoor","sequence":"additional","affiliation":[{"name":"Ritchie School of Engineering and Computer Science, University of Denver, Denver, CO 80208, USA"},{"name":"Dreamface Technologies LLC, Centennial, CO 80111, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-0901-9608","authenticated-orcid":false,"given":"Jason W.","family":"Haas","sequence":"additional","affiliation":[{"name":"CBP Non-Profit, Inc., Eagle, ID 83616, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joseph R.","family":"Ferrantelli","sequence":"additional","affiliation":[{"name":"CBP Non-Profit, Inc., Eagle, ID 83616, USA"},{"name":"PostureCo, Inc., Trinity, FL 34655, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anne-Lise","family":"Dupuis","sequence":"additional","affiliation":[{"name":"PostureCo, Inc., Trinity, FL 34655, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jason O.","family":"Jaeger","sequence":"additional","affiliation":[{"name":"Community Based Internship Program, Associate Faculty, Southern California University of Health Sciences, Whittier, CA 90604, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6671-7106","authenticated-orcid":false,"given":"Deed E.","family":"Harrison","sequence":"additional","affiliation":[{"name":"CBP Non-Profit, Inc., Eagle, ID 83616, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,4,27]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1098100","DOI":"10.3389\/fpubh.2023.1098100","article-title":"Global and regional estimates of clinical and economic burden of low back pain in high-income countries: A systematic review and meta-analysis","volume":"11","author":"Fatoye","year":"2023","journal-title":"Front. Public Health"},{"key":"ref_2","unstructured":"Casiano, V.E., Sarwan, G., Dydyk, A.M., and Varacallo, M. (2023). Back Pain, StatPearls Publishing."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"e316","DOI":"10.1016\/S2665-9913(23)00098-X","article-title":"Global, regional, and national burden of low back pain, 1990\u20132020, its attributable risk factors, and projections to 2050: A systematic Analysis of the global burden of disease study 2021","volume":"5","author":"Ferreira","year":"2023","journal-title":"Lancet Rheumatol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"2012","DOI":"10.1097\/BRS.0b013e318133fb82","article-title":"Association of back pain frequency with mortality, coronary heart events, mobility, and quality of life in elderly women","volume":"32","author":"Zhu","year":"2007","journal-title":"Spine"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"90","DOI":"10.1007\/s11606-018-4680-7","article-title":"Association of back pain with all-cause and cause-specific mortality among older women: A cohort study","volume":"34","author":"Roseen","year":"2019","journal-title":"J. Gen. Intern. Med."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Williams, A., Kamper, S.J., Wiggers, J.H., O\u2019brien, K.M., Lee, H., Wolfenden, L., Yoong, S.L., Robson, E., McAuley, J.H., and Hartvigsen, J. (2018). Musculoskeletal conditions may increase the risk of chronic disease: A systematic review and meta-analysis of cohort studies. BMC Med., 16.","DOI":"10.1186\/s12916-018-1151-2"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"981","DOI":"10.1007\/s00586-005-0927-1","article-title":"Validation of and new clinical quantitative analysis software applicable in spine orthopedic studies","volume":"15","author":"Champain","year":"2006","journal-title":"Eur. Spine J."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"E671","DOI":"10.1097\/BRS.0000000000003830","article-title":"Deep learning automates measurement of spinopelvic parameters on lateral lumbar radiographs","volume":"46","author":"Schwartz","year":"2021","journal-title":"Spine"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1158712","DOI":"10.3389\/fnins.2023.1158712","article-title":"Research hotspots and trends on spinal cord stimulation for pain treatment: A two-decade bibliometric analysis","volume":"17","author":"Yang","year":"2023","journal-title":"Front. Neurosci."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"2215","DOI":"10.1097\/01.BRS.0000089525.59684.49","article-title":"Increased sagittal plane segmental motion in the lower cervical spine in women with chronic whiplash-associated disorders, grades I\u2013II: A case-control study using a new measurement protocol","volume":"28","author":"Kristjansson","year":"2003","journal-title":"Spine"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Yagi, M., Yamanouchi, K., Fujita, N., Funao, H., and Ebata, S. (2023). Revolutionizing spinal care: Current applications and future directions of artificail intelligence and machine learning. J. Clin. Med., 12.","DOI":"10.3390\/jcm12134188"},{"key":"ref_12","unstructured":"Orhurhu, V.J., Chu, R., and Gill, J. (2023). Failed Back Surgery Syndrome, StatPearls Publishing."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"56","DOI":"10.14245\/ns.2346226.113","article-title":"Complications and Management of Endoscopic Spinal Surgery","volume":"20","author":"Ju","year":"2023","journal-title":"Neurospine"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Tangsrivimol, J.A., Schonfeld, E., Zhang, M., Veeravagu, A., Smith, T.R., H\u00e4rtl, R., Lawton, M.T., El-Sherbini, A.H., Prevedello, D.M., and Glicksberg, B.S. (2023). Artificial intelligence in neurosurgery: A state-of-the-art review from past to future. Diagnostics, 13.","DOI":"10.3390\/diagnostics13142429"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1055\/s-0039-1677908","article-title":"AI in health: State of the art, challenges and future directions","volume":"28","author":"Wang","year":"2019","journal-title":"Yearb. Med. Inform."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"885599","DOI":"10.3389\/fsurg.2022.885599","article-title":"The application of artificial intelligence in spine surgery","volume":"9","author":"Zhou","year":"2022","journal-title":"Front. Surg."},{"key":"ref_17","first-page":"7618","article-title":"Sagittal cervical spine landmark point detection in x-ray using deep convoluted neural networks","volume":"11","author":"Fard","year":"2021","journal-title":"Sci. Rep."},{"key":"ref_18","unstructured":"Moore, D.S., Notz, W.I., and Flinger, M.A. (2013). The Basic Practice of Statistics, W. H. Freeman and Company. [6th ed.]."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"955367","DOI":"10.3389\/fneur.2022.955367","article-title":"Global, regional, and national neck pain burden in the general population, 1990\u20132019: An analysis of the global burden of disease study 2019","volume":"13","author":"Shin","year":"2022","journal-title":"Front Neurol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1532","DOI":"10.1007\/s00586-009-1011-z","article-title":"Individual, physical and psychological risk factors for neck pain in Australian office workers: A 1-year longitudinal study","volume":"18","author":"Hush","year":"2009","journal-title":"Eur. Spine J."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1007\/s00586-018-5462-y","article-title":"Which parameters are relevant in sagittal balance analysis of the cervical spine? A literature review","volume":"27","author":"Ling","year":"2018","journal-title":"Eur. Spine J."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"562","DOI":"10.1007\/s12178-019-09594-y","article-title":"The Relationship between Forward Head Posture and Neck Pain: A Systematic Review and Meta-Analysis","volume":"12","author":"Mahmoud","year":"2019","journal-title":"Curr. Rev. Musculoskelet. Med."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1007\/s43390-023-00735-5","article-title":"Adult cervical spine deformity: A state-of-the-art review","volume":"12","author":"Hockley","year":"2024","journal-title":"Spine Deform."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Saad, N., Moustafa, I.M., Ahbouch, A., Alsaafin, N.M., Oakley, P.A., and Harrison, D.E. (2023). Are Rotations and Translations of Head Posture Related to Gait and Jump Parameters?. J. Clin. Med., 12.","DOI":"10.20944\/preprints202307.0701.v1"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"3575","DOI":"10.2147\/JMDH.S437826","article-title":"Neck Health Metrics and Quality of Life: A Comparative Study in Bike Drivers with and without Neck Pain","volume":"16","author":"Aafreen","year":"2023","journal-title":"J. Multidiscip. Healthc."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"S26","DOI":"10.14444\/8507","article-title":"Potential Applications of Artificial Intelligence and Machine Learning in Spine Surgery Across the Continuum of Care","volume":"17","author":"Browd","year":"2023","journal-title":"Int. J. Spine Surg."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"2007","DOI":"10.1007\/s00586-021-07108-4","article-title":"Artificial intelligence and spine imaging: Limitations, regulatory issues and future direction","volume":"31","author":"Hornung","year":"2022","journal-title":"Eur. Spine J."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"e192","DOI":"10.1016\/j.wneu.2022.03.096","article-title":"Improving surgical triage in spine clinic: Predicting likelihood of surgery using machine learning","volume":"163","author":"Broida","year":"2022","journal-title":"World Neurosurg."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"915","DOI":"10.1097\/BRS.0000000000002974","article-title":"Artificial intelligence based hierarchical clustering of patient types and intervention categories in adult spinal deformity surgery: Towards a new classification scheme that predicts quality and value","volume":"44","author":"Ames","year":"2019","journal-title":"Spine"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"763","DOI":"10.1590\/S1807-59322008000600010","article-title":"Effect of global posture reeducation and of static stretching on pain, range of motion, and quality of life in women with chronic neck pain: A randomized clinical trial","volume":"63","author":"Cunha","year":"2008","journal-title":"Clinics"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"408","DOI":"10.2522\/ptj.20060009","article-title":"Effect of neck exercise on sitting posture in patients with chronic neck pain","volume":"87","author":"Falla","year":"2007","journal-title":"Phys. Ther."},{"key":"ref_32","first-page":"145","article-title":"Effectiveness of relaxation training in addition to stabilization exercises in chronic neck pain: A randomized clinical trial","volume":"30","author":"Toprak","year":"2019","journal-title":"Turk. J. Physiother. Rehabil."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Lwin, N.N., Myint, T., Oo, W.M., San, H.H., and Tun, M.T. (2021). Efficacy on pressure-biofeedback guided craniocervical flexion exercise in neck pain: A randomized controlled trial. J. Musculoskelet. Res.","DOI":"10.1142\/S0218957721500135"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"269","DOI":"10.1589\/jpts.28.269","article-title":"Clinical effects of deep cervical flexor muscle activation in patients with chronic neck pain","volume":"28","author":"Kim","year":"2016","journal-title":"J. Phys. Ther. Sci."},{"key":"ref_35","first-page":"102","article-title":"Effect of core stability exercise in patients with neck pain","volume":"14","author":"Shah","year":"2020","journal-title":"Indian. J. Physiother. Occup. Ther."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"784","DOI":"10.1589\/jpts.33.784","article-title":"Restoring cervical lordosis by cervical extension traction meth-ods in the treatment of cervical spine disorders: A systematic review of controlled trials","volume":"33","author":"Oakley","year":"2021","journal-title":"J. Phys. Ther. Sci."},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Katz, E.A., Katz, S.B., and Freeman, M.D. (2023). Non-surgical management of upper cervical instability via improved cervical lordosis: A case series of adult patients. J. Clin. Med., 12.","DOI":"10.3390\/jcm12051797"},{"key":"ref_38","first-page":"270","article-title":"Evidence-based protocol for structural rehabilitation of the spine and posture: Review of clinical biomechanics of posture (CBP) publications","volume":"49","author":"Oakley","year":"2005","journal-title":"J. Can. Chiropr. Assoc."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"108","DOI":"10.1589\/jpts.30.108","article-title":"Non-surgical improvement of cervical lordosis is possible in advanced spinal osteoarthritis: A CBP\u00ae case report","volume":"30","author":"Fortner","year":"2018","journal-title":"J. Phys. Ther. Sci."},{"key":"ref_40","first-page":"59","article-title":"Reducing thoracic hyperkyphosis subluxation deformity: A systematic review of chiropractic biophysics\u00ae methods employed in its structural improvement","volume":"1","author":"Oakley","year":"2018","journal-title":"J. Contemp. Chiropr."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"2485","DOI":"10.1097\/01.brs.0000144449.90741.7c","article-title":"Modeling of the sagittal cervical spine as a method to discriminate hypo-lordosis: Results of elliptical and circular modeling in 72 asymptomatic subjects, 52 acute neck pain subjects, and 70 chronic neck pain subjects","volume":"29","author":"Harrison","year":"2004","journal-title":"Spine"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1016\/j.gaitpost.2020.12.033","article-title":"Radiography and photogrammetry-based methods of assessing cervical spine posture in the sagittal plane: A systematic review with meta-analysis","volume":"84","author":"Pivotto","year":"2021","journal-title":"Gait Posture"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"392","DOI":"10.1016\/j.physio.2017.03.004","article-title":"Analysis of the cranio-cervical curvatures in subjects with migraine with and without neck pain","volume":"103","author":"Ferracini","year":"2017","journal-title":"Physiotherapy"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1067\/mmt.2002.121411","article-title":"Further reliability analysis of the Harrison radiographic line-drawing methods: Crossed ICCs for lateral posterior tangents and modified Risser-Ferguson method on AP views","volume":"25","author":"Harrison","year":"2002","journal-title":"J. Manip. Physiol. Ther."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"2072","DOI":"10.1097\/00007632-200008150-00011","article-title":"Cobb method or Harrison posterior tangent method: Which to choose for lateral cervical radiographic analysis","volume":"25","author":"Harrison","year":"2000","journal-title":"Spine"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1229","DOI":"10.1016\/j.spinee.2020.02.005","article-title":"The significance of cervical sagittal alignment for nonrecovery after whiplash injury","volume":"20","author":"Rydman","year":"2020","journal-title":"Spine J."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/9\/2573\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T14:34:32Z","timestamp":1760106872000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/9\/2573"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,4,27]]},"references-count":46,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2024,5]]}},"alternative-id":["jcm13092573"],"URL":"https:\/\/doi.org\/10.3390\/jcm13092573","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,4,27]]}}}