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Purpose: This study investigated the segmentation metrics of different segmentation networks trained on 730 manually annotated lateral lumbar spine X-rays to test the generalization ability and robustness which are the basis of clinical decision support algorithms. Methods: Instance segmentation networks were compared to semantic segmentation networks based on different metrics. The study cohort comprised diseased spines and postoperative images with metallic implants. Results: However, the pixel accuracies and intersection over union are similarly high for the best performing instance and semantic segmentation models; the observed vertebral recognition rates of the instance segmentation models statistically significantly outperform the semantic models' recognition rates. Conclusion: The results of the instance segmentation models on lumbar spine X-ray perform superior to semantic segmentation models in the recognition rates even by images of severe diseased spines by allowing the segmentation of overlapping vertebrae, in contrary to the semantic models where such differentiation cannot be performed due to the fused binary mask of the overlapping instances. These models can be incorporated into further clinical decision support pipelines.

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