AI measures spinopelvic angles accurately on standing spine radiographs, but performance drops after fusion surgery.

A commercial AI algorithm measured spinopelvic parameters on full-spine X-rays with good-to-excellent reliability (ICC 0.79-0.99) compared with ground truth, closely matching radiologists. Accuracy worsened in patients with prior spinal fusion surgery.

• Mean absolute error for coronal Cobb angle was 4.6° (95% CI 3.6–5.5°); for lumbar lordosis, 8.1° (95% CI 6.9–9.3°).
• AI agreement with ground truth was good to excellent (ICC 0.79–0.99), except moderate for lumbar lordosis (ICC 0.68).
• Performance declined in patients with prior spinal instrumentation, with lower correlation and higher measurement deviations.

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