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Figure 1. PRISMA flow chart. PRISMA: Preferred reporting items for systematic reviews and meta-analyses.

Quality assessment
The quality and risk of bias of included studies were assessed using the IJEMDI tool tailored specifically for
diagnostic accuracy studies. Studies were evaluated across four domains: (1) clarity in the description of the
research question, study objectives, and replicability of the study design; (2) availability of an open dataset
or detailed instructions for data access; (3) comprehensive documentation of methods, including software
details and statistical approaches, to facilitate replication; and (4) whether the results supported the
conclusions, limitations were discussed, and conflicts of interest were disclosed. Each domain was rated as
either present (2), absent (0), or unclear (1) .
[17]

RESULTS
A total of 14 studies published between 2018-2023 were included in this systematic review, encompassing
10,727 subjects [18-31] . The studies utilized various imaging modalities to develop and validate automated
methods for measuring spinal alignment, including lateral X-rays [18-31] , biplanar radiographs [30,31] , and CT
[26]
scans . Both preoperative and postoperative images were employed, with 6 studies incorporating cases
with spinal implants [19,20,23,24,28] to evaluate performance in surgically altered anatomy. The diversity of
imaging captures numerous clinically relevant scenarios, although multicenter external validation was