SpineForge Planner: Free and Open-Source Software for Spinal Alignment Analysis and Surgical Planning

BACKGROUND AND OBJECTIVES: Precise measurement of sagittal spinopelvic parameters is fundamental to modern spine surgery planning, with established correlations to surgical outcomes. However, platforms such as Surgimap (Nemaris Inc.) have discontinued new-user registration, thereby restricting global access. Manual measurement introduces inefficiency and variability, while existing alternatives lack comprehensive functionality or remain closed-source. This study aimed to develop and validate SpineForge Planner, a free, open-source software for sagittal spinopelvic alignment analysis and surgical planning, addressing this critical accessibility gap. METHODS: Developed in Python 3, this software provides Digital Imaging and Communications in Medicine support and manual calibration for non-Digital Imaging and Communications in Medicine formats and integrates surgical planning modules, including screw trajectory planning, rod contouring with STereoLithography export, and osteotomy simulation. Validation was performed using 50 patients from the publicly available Pan et al lateral full-spine x-ray data set. Eight sagittal spinopelvic parameters were measured: C2-C7 lordosis, C2-C7 sagittal vertical axis (SVA), T1 slope, lumbar lordosis, sacral slope, pelvic tilt, pelvic incidence, and global SVA. Measurements were compared against Surgimap to establish reliability. Measurement efficiency was quantified by recording completion times. RESULTS: All 8 sagittal parameters showed good-to-excellent reliability (intraclass correlation coefficients [ICC] ≥0.89) relative to Surgimap, with 7 demonstrating excellent reliability (ICC ≥0.90). T1 slope showed good reliability (ICC = 0.891, 95% CI: 0.825-0.941). SVA measurements showed the highest agreement (ICC = 0.999, 95% CI: 0.998-0.999). Mean measurement differences were clinically negligible, ranging from -1.50° to +0.88 mm across all parameters. Measurement times were comparable between platforms (SpineForge: 70.0 ± 12.3 seconds vs Surgimap: 73.7 ± 17.2 seconds, P = .410). CONCLUSION: SpineForge Planner demonstrates measurement reliability that is noninferior to established commercial platforms and provides surgical planning capabilities within a permanently free, open-source framework. This software addresses the accessibility gap in sagittal alignment assessment, enabling universal access to precise measurement tools essential for modern spine surgery planning and outcomes optimization.