Expert Validation of Synthetic Cervical Spine Radiographs Generated with a Denoising Diffusion Probabilistic Model

Machine learning in neurosurgery is limited by challenges in assembling large, high-quality imaging datasets. Synthetic data offers a scalable, privacy-preserving solution. We evaluated the feasibility of generating realistic lateral cervical spine radiographs using a denoising diffusion probabilistic model (DDPM) trained on 4,963 images from the Cervical Spine X-ray Atlas. Model performance was monitored via training/validation loss and Frechet inception distance, and synthetic image quality was assessed in a blinded "clinical Turing test" with six neuroradiologists and two spine-fellowship trained neurosurgeons. Experts reviewed 50 quartets containing one real and three synthetic images, identifying the real image and rating realism on a 4-point Likert scale. Experts correctly identified the real image in 29% of trials (Fleiss' kappa=0.061). Mean realism scores were comparable between real (3.323) and synthetic images (3.228, 3.258, and 3.320; p=0.383, 0.471, 1.000). Nearest-neighbor analysis found no evidence of memorization. We also provide a dataset of 20,063 synthetic radiographs. These results demonstrate that DDPM-generated cervical spine X-rays are statistically indistinguishable in realism and quality from real clinical images, offering a novel approach to creating large-scale neuroimaging datasets for ML applications in landmarking, segmentation, and classification.