MRI-to-CT Translation of Spinal Images via Anatomy-Guided Pseudo-Pairing and Adversarial Diffusion

Magnetic Resonance Imaging (MRI) is routinely used to diagnose spinal disorders, but surgical planning often requires Computed Tomography (CT) for better visualization of vertebral bone anatomy. Synthesizing CT from MRI could avoid additional radiation exposure and streamline preoperative assessment. We propose a three-stage framework for spine MRI-to-CT synthesis. First, an anatomy-guided vertebral matching system identifies similar sagittal MRI and CT slices using spine segmentations and aligns them through rigid registration, creating pseudo-paired data from unpaired scans. Second, these pairs train an adversarial diffusion model for MRI-to-CT translation. Third, synthesized slices are assembled into 3D volumes and refined by a network that improves inter-slice continuity and structural coherence. The framework was trained on over 10,000 unpaired sagittal MRI and CT slices and evaluated on 1,911 slices from 83 MRI volumes spanning all spinal regions. Assessment combined distribution-based measures with vertebral segmentation metrics. Compared with diffusion alone, the proposed approach increased binary 3D vertebral Dice from 0.666 to 0.739. Volumetric post-processing reduced visible discontinuities between stacked slices and improved vertebral coherence in axial and coronal views. Combining anatomy-guided pseudo-pairing, adversarial diffusion and 3D refinement improves spine MRI-to-CT synthesis. Vertebral matching primarily enhanced anatomical alignment and fidelity, while volumetric refinement improved 3D consistency. These findings support further development of MRI-derived CT-like visualization for preoperative planning, particularly to preserve fine intensity details while maintaining volumetric coherence.