nnSAM2: nnUNet-Enhanced One-Prompt SAM2 for Few-shot Multi-Modality Segmentation and Composition Analysis of Lumbar Paraspinal Muscles

Purpose: To develop and validate No-New SAM2 (nnsam2) for few-shot segmentation of lumbar paraspinal muscles using only a single annotated slice per dataset, and to assess its statistical comparability with expert measurements across multi-sequence MRI and multi-protocol CT. Methods: We retrospectively analyzed 1,219 scans (19,439 slices) from 762 participants across six datasets. Six slices (one per dataset) served as labeled examples, while the remaining 19,433 slices were used for testing. In this minimal-supervision setting, nnsam2 used single-slice SAM2 prompts to generate pseudo-labels, which were pooled across datasets and refined through three sequential, independent nnU-Net models. Segmentation performance was evaluated using the Dice similarity coefficient (DSC), and automated measurements-including muscle volume, fat ratio, and CT attenuation-were assessed with two one-sided tests (TOST) and intraclass correlation coefficients (ICC). Results: nnsam2 outperformed vanilla SAM2, its medical variants, TotalSegmentator, and the leading few-shot method, achieving DSCs of 0.94-0.96 on MR images and 0.92-0.93 on CT. Automated and expert measurements were statistically equivalent for muscle volume (MRI/CT), CT attenuation, and Dixon fat ratio (TOST, P < 0.05), with consistently high ICCs (0.86-1.00). Conclusion: We developed nnsam2, a state-of-the-art few-shot framework for multi-modality LPM segmentation, producing muscle volume (MRI/CT), attenuation (CT), and fat ratio (Dixon MRI) measurements that were statistically comparable to expert references. Validated across multimodal, multicenter, and multinational cohorts, and released with open code and data, nnsam2 demonstrated high annotation efficiency, robust generalizability, and reproducibility.