Artificial Intelligence Based Hierarchical Clustering of Patient Types and Intervention Categories in Adult Spinal Deformity Surgery

Abstract

Study Design. Retrospective review of prospectively-collected, multicenter adult spinal deformity (ASD) databases. Objective. To apply artificial intelligence (AI)-based hierarchical clustering as a step toward a classification scheme that optimizes overall quality, value, and safety for ASD surgery. Summary of Background Data. Prior ASD classifications have focused on radiographic parameters associated with patient reported outcomes. Recent work suggests there are many other impactful preoperative data points. However, the ability to segregate patient patterns manually based on hundreds of data points is beyond practical application for surgeons. Unsupervised machine-based clustering of patient types alongside surgical options may simplify analysis of ASD patient types, procedures, and outcomes. Methods. Two prospective cohorts were queried for surgical ASD patients with baseline, 1-year, and 2-year SRS-22/Oswestry Disability Index/SF-36v2 data. Two dendrograms were fitted, one with surgical features and one with patient characteristics. Both were built with Ward distances and optimized with the gap method. For each possible n patient cluster by m surgery, normalized 2-year improvement and major complication rates were computed. Results. Five hundred-seventy patients were included. Three optimal patient types were identified: young with coronal plane deformity (YC, n = 195), older with prior spine surgeries (ORev, n = 157), and older without prior spine surgeries (OPrim, n = 218). Osteotomy type, instrumentation and interbody fusion were combined to define four surgical clusters. The intersection of patient-based and surgery-based clusters yielded 12 subgroups, with major complication rates ranging from 0% to 51.8% and 2-year normalized improvement ranging from −0.1% for SF36v2 MCS in cluster [1,3] to 100.2% for SRS self-image score in cluster [2,1]. Conclusion. Unsupervised hierarchical clustering can identify data patterns that may augment preoperative decision-making through construction of a 2-year risk–benefit grid. In addition to creating a novel AI-based ASD classification, pattern identification may facilitate treatment optimization by educating surgeons on which treatment patterns yield optimal improvement with lowest risk. Level of Evidence: 4

Treatment of adult thoracolumbar spinal deformity: past, present, and future

“…Predictive models may facilitate surgeon decision making regarding operative versus nonoperative treatment and enable customized surgical planning to enhance durability and patient outcomes. 1 Payers and hospitals may benefit from enhanced prediction of treatment costs and ability to predict catastrophic cost outliers (C.P. Ames et al, unpublished data, 2018).…”

Artificial Intelligence for Adult Spinal Deformity

“…A more recent pioneering study was published by Ames et al 30 in which they demonstrated for the first time the use of unsupervised learning via hierarchical clustering to create a novel classification system for ASD. This monumental study showed how an unsupervised learning method, where there are no specific outputs corresponding to inputs within the dataset, can iteratively learn the inherent structure of the data, and investigate all available data to form representative models.…”

Applications of Machine Learning Using Electronic Medical Records in Spine Surgery

“…This could increase the study's generalizability and remove any potential bias that may have existed in the original prospective study. 26,48 Also, EMR data can be used to better identify highrisk patients and predict complications and prevent those complications. One recent study by Zhang et al 49 demonstrated the ability of quantitative CT ML algorithms to assess vertebral strength and predict vertebral fracture risk in elderly patients.…”

“…The integration of EMR data with ML algorithms also has huge ramifications on reimbursement processes, particularly in creating new classifications systems for bundled care models. 48,65 Moreover, all of the aforementioned impacts on risk stratification, personalized treatment algorithms, and clinical prognostication will allow for more accurate reimbursement models and financial optimization of clinical practice.…”