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Computational Methods and Clinical
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Proceedings of the Workshop held at
the 16th International Conference on
Medical Image Computing and
Computer Assisted Intervention
September 22 26 2013 Nagoya Japan
1st Edition Jianhua Yao
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Lecture Notes in Computational Vision and Biomechanics 17
Jianhua Yao
Tobias Klinder
Shuo Li Editors
Computational
Methods and
Clinical Applications
for Spine Imaging
Proceedings of the Workshop held
at the 16th International Conference
on Medical Image Computing and
Computer Assisted Intervention,
September 22–26, 2013, Nagoya, Japan
Lecture Notes in Computational Vision
and Biomechanics
Volume 17
Series editors
João Manuel R. S. Tavares, Porto, Portugal
R. M. Natal Jorge, Porto, Portugal
Editorial Advisory Board

Alejandro Frangi, Sheffield, UK
Chandrajit Bajaj, Austin, USA
Eugenio Oñate, Barcelona, Spain
Francisco Perales, Palma de Mallorca, Spain
Gerhard A. Holzapfel, Stockholm, Sweden
J. Paulo Vilas-Boas, Porto, Portugal
Jeffrey A. Weiss, Salt Lake City, USA
John Middleton, Cardiff, UK
Jose M. García Aznar, Zaragoza, Spain
Perumal Nithiarasu, Swansea, UK
Kumar K. Tamma, Minneapolis, USA
Laurent Cohen, Paris, France
Manuel Doblaré, Zaragoza, Spain
Patrick J. Prendergast, Dublin, Ireland
Rainald Löhner, Fairfax, USA
Roger Kamm, Cambridge, USA
Shuo Li, London, Canada
Thomas J. R. Hughes, Austin, USA
Yongjie Zhang, Pittsburgh, USA
For further volumes:

http://www.springer.com/series/8910
The research related to the analysis of living structures (Biomechanics) has been a source of
recent research in several distinct areas of science, for example, Mathematics, Mechanical
Engineering, Physics, Informatics, Medicine and Sport. However, for its successful
achievement, numerous research topics should be considered, such as image processing and
analysis, geometric and numerical modelling, biomechanics, experimental analysis,
mechanobiology and enhanced visualization, and their application to real cases must be
developed and more investigation is needed. Additionally, enhanced hardware solutions and
less invasive devices are demanded.
On the other hand, Image Analysis (Computational Vision) is used for the extraction of
high level information from static images or dynamic image sequences. Examples of
applications involving image analysis can be the study of motion of structures from image
sequences, shape reconstruction from images and medical diagnosis. As a multidisciplinary
area, Computational Vision considers techniques and methods from other disciplines, such
as Artificial Intelligence, Signal Processing, Mathematics, Physics and Informatics. Despite
the many research projects in this area, more robust and efficient methods of Computational
Imaging are still demanded in many application domains in Medicine, and their validation
in real scenarios is matter of urgency.
These two important and predominant branches of Science are increasingly considered
to be strongly connected and related. Hence, the main goal of the LNCV&B book series
consists of the provision of a comprehensive forum for discussion on the current state-of-
the-art in these fields by emphasizing their connection. The book series covers (but is not
limited to):
• Applications of Computational Vision and • Grid and High Performance Computing for
Biomechanics Computational Vision and Biomechanics
• Biometrics and Biomedical Pattern Analysis • Image-based Geometric Modeling and Mesh
• Cellular Imaging and Cellular Mechanics Generation
• Clinical Biomechanics • Image Processing and Analysis
• Computational Bioimaging and Visualization • Image Processing and Visualization in
• Computational Biology in Biomedical Imaging Biofluids
• Development of Biomechanical Devices • Image Understanding
• Device and Technique Development for Bio- • Material Models
medical Imaging • Mechanobiology
• Digital Geometry Algorithms for Computa- • Medical Image Analysis
tional Vision and Visualization • Molecular Mechanics
• Experimental Biomechanics • Multi-Modal Image Systems
• Gait & Posture Mechanics • Multiscale Biosensors in Biomedical Imaging
• Multiscale Analysis in Biomechanics • Multiscale Devices and Biomems for Bio-
• Neuromuscular Biomechanics medical Imaging
• Numerical Methods for Living Tissues • Musculoskeletal Biomechanics
• Numerical Simulation • Sport Biomechanics
• Software Development on Computational • Virtual Reality in Biomechanics
Vision and Biomechanics • Vision Systems
Jianhua Yao Tobias Klinder
•
Shuo Li
Editors
Computational Methods
and Clinical Applications
for Spine Imaging
Proceedings of the Workshop held at the 16th
International Conference on Medical Image
Computing and Computer Assisted
Intervention, September 22–26, 2013,
Nagoya, Japan
123
Editors
Jianhua Yao Shuo Li
Center Drive GE Healthcare and University of Western
National Institutes of Health Ontario
Bethesda, MA London, ON
USA Canada
Tobias Klinder
Innovative Technologies Research
Laboratories
Philips Research
Hamburg
Germany
ISSN 2212-9391 ISSN 2212-9413 (electronic)

ISBN 978-3-319-07268-5 ISBN 978-3-319-07269-2 (eBook)
DOI 10.1007/978-3-319-07269-2
Springer Cham Heidelberg New York Dordrecht London
Library of Congress Control Number: 2014943404
Springer International Publishing Switzerland 2014

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Preface
The spine represents both a vital central axis for the musculoskeletal system and a
flexible protective shell surrounding the most important neural pathway in the
body, the spinal cord. Spine-related diseases or conditions are common and cause a
huge burden of morbidity and cost to society. Examples include degenerative disk
disease, spinal stenosis, scoliosis, osteoporosis, herniated disks, fracture/liga-
mentous injury, infection, tumor, and spondyloarthropathy. Treatment varies with
the disease entity and the clinical scenario can be nonspecific. As a result, imaging
is often required to help make the diagnosis. Frequently obtained studies include
plain radiographs, DXA, bone scans, CT, MR, ultrasound, and nuclear medicine.
Computational methods play a steadily increasing role in improving speed, con-
fidence, and accuracy in reaching a final diagnosis. Although there has been great
progress in the development of computational methods for spine imaging over the
recent years, there are a number of significant challenges in both methodology and
clinical applications.
The goal of this workshop on ‘‘Computational Methods and Clinical Applica-
tions for Spine Imaging’’ was to bring together clinicians, computer scientists, and
industrial vendors in the field of spine imaging, for reviewing the state-of-art
techniques, sharing the novel and emerging analysis and visualization techniques,
and discussing the clinical challenges and open problems in this rapidly growing
field. We invited papers on all major aspects of problems related to spine imaging,
including clinical applications of spine imaging, computer-aided diagnosis of
spine conditions, computer Aided Detection of spine-related diseases, emerging
computational imaging techniques for spinal diseases, fast 3D reconstruction of
spine, feature extraction, multiscale analysis, pattern recognition, image
enhancement of spine imaging, image-guided spine intervention and treatment,
multimodal image registration and fusion for spine imaging, novel visualization
techniques, segmentation techniques for spine imaging, statistical and geometric
modeling for spine and vertebra, spine and vertebra localization.
Although being the first MICCAI workshop on this particular topic, we
received many high quality submissions addressing many of the above-mentioned
issues. All papers underwent a thorough double-blinded review with each paper
being reviewed by three members of the program committee including workshop
chairs. The program committee consisted of researchers who had actively con-
tributed to the field of spine imaging in the past. From all submissions, we finally
v
vi Preface
accepted 19 papers as oral presentations. The papers are organized into five parts
according to the topics. The parts are Segmentation I (CT), Computer Aided
Detection and Diagnosis, Quantitative Imaging, Segmentation II (MR) and Reg-
istration/Labeling.
In order to give deeper insights into the field and stimulate further ideas, we had
invited lectures held during the workshop. We are very thankful to Tokumi
Kanamura, Gabor Fichtinger, and Vipin Chaudhary for agreeing to give invited
talks on the topic of clinical indications, image guided intervention, and
commercialization.
We hope that with this workshop we have increased the attention toward this
important and interesting field of computational spine imaging and would like to
finally thank all contributors for their efforts in making this workshop possible. We
especially thank the following institutes for their sponsorship: Journal of Com-
puterized Medical Imaging and Graphics, GE Healthcare, Digital Imaging group
of London, Philips Research, and National Institutes of Health.
Jianhua Yao
Tobias Klinder
Aly A. Farag
Shuo Li
Workshop Organization
Organizing Committee
Jianhua Yao, National Institutes of Health, USA

Tobias Klinder, Philips Research, Germany
Aly A. Farag, University of Louisville, USA
Shuo Li, GE Healthcare and University of Western Ontario, Canada
Clinical Advisory
Gregory J. Garvin, St. Joseph’s Health Care, Canada

KengYeow Tay, Victoria Hospital, Canada
Joseph E. Burns, University of California, Irvine, USA
Ronald M. Summers, National Institutes of Health, USA
Program Committee
Ulas Bagci, National Institutes of Health, USA

Li Bai, University of Nottingham, UK
Jonathan Biosvert, National Research Council, Canada
Xinjian Chen, Soochow University, China
Ananda Chowdhury, Jadavpur University, India
Ben Glocker, Microsoft Research, UK
Seyed-Parsa Hojjat, GE Healthcare, Canada
Samuel Kadoury, Ecole Polytechnique de Montreal, Canada
Xiaofeng Liu, GE Healthcare, USA
Wai Kong Law Max, GE Healthcare and University of Western Ontario, Canada
Cristian Lorenz, Philips Research
Nikos Paragios, Ecole Centrale de Paris, France
Alberto Santamaria Pang, GE Global Research
vii
viii Workshop Organization
Jay Tian, Chinese Academy of Sciences, China

Tomaž Vrtovec, University of Ljubljana, Slovenia
Michael Ward, National Institutes of Health, USA
Yiqiang Zhan, Siemens Medical Solutions, USA
Scientific Review Committee
Ulas Bagci, National Institutes of Health, USA

Jonathan Biosvert, National Research Council, Canada
Xinjian Chen, Soochow University, China
Ananda Chowdhary, Jadavpur University, India
Daniel Forsberg, Linköping University, Sweden
Ben Glocker, Microsoft Research, UK
Bulat Ibragimov, University of Ljubljana, Slovenia
Samuel Kadoury, Ecole Polytechnique de Montreal, Canada
Poay Lim, University of Nottingham, UK
Jianfei Liu, National Institutes of Health, USA
Jiamin Liu, National Institutes of Health, USA
Yixun Liu, National Institutes of Health, USA
Xiaofeng Liu, GE Healthcare, USA
Meelis Lootus, Oxford University, UK
Le Lu, National Institutes of Health, USA
Wai Kong Law, GE Healthcare and University of Western Ontario, Canada
Ales Neubert, University of Queensland, Australia
Simon Pezold, University of Basel, Switzerland
Sovira Tan, National Institutes of Health, USA
Tomaž Vrtovec, University of Ljubljana, Slovenia
Qian Wang, University of North Carolina at Chapel Hill, USA
Shijun Wang, National Institutes of Health, USA
Tristan Whitmarsh, University of Cambridge, UK
Yiqiang Zhang, Siemens Medical Solutions, USA
Weidong Zhang, National Institutes of Health, USA
Proceedings Editors

Shuo Li, GE Healthcare and University of Western Ontario, Canada
Contents
Part I Segmentation I (CT)
Segmentation of Vertebrae from 3D Spine Images by Applying

Concepts from Transportation and Game Theories . . . . . . . . . . . . . . 3
Bulat Ibragimov, Boštjan Likar, Franjo Pernuš and Tomaž Vrtovec
Automatic and Reliable Segmentation of Spinal Canals

in Low-Resolution, Low-Contrast CT Images . . . . . . . . . . . . . . . . . . . 15
Qian Wang, Le Lu, Dijia Wu, Noha El-Zehiry, Dinggang Shen
and Kevin S. Zhou
A Robust Segmentation Framework for Spine Trauma Diagnosis . . . . 25

Poay Hoon Lim, Ulas Bagci and Li Bai
2D-PCA Based Tensor Level Set Framework for Vertebral

Body Segmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Ahmed Shalaby, Aly Farag and Melih Aslan
Part II Computer Aided Detection and Diagnosis
Computer Aided Detection of Spinal Degenerative Osteophytes

on Sodium Fluoride PET/CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Jianhua Yao, Hector Munoz, Joseph E. Burns, Le Lu
and Ronald M. Summers
Novel Morphological and Appearance Features for Predicting

Physical Disability from MR Images in Multiple Sclerosis Patients . . . 61
Jeremy Kawahara, Chris McIntosh, Roger Tam and Ghassan Hamarneh
Classification of Spinal Deformities Using a Parametric Torsion

Estimator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Jesse Shen, Stefan Parent and Samuel Kadoury
ix
x Contents
Lumbar Spine Disc Herniation Diagnosis

with a Joint Shape Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Raja S. Alomari, Jason J. Corso, Vipin Chaudhary and Gurmeet Dhillon
Epidural Masses Detection on Computed Tomography

Using Spatially-Constrained Gaussian Mixture Models . . . . . . . . . . . . 99
Sanket Pattanaik, Jiamin Liu, Jianhua Yao, Weidong Zhang,
Evrim Turkbey, Xiao Zhang and Ronald Summers
Part III Quantitative Imaging
Comparison of Manual and Computerized Measurements

of Sagittal Vertebral Inclination in MR Images . . . . . . . . . . . . . . . . . 111
Tomaž Vrtovec, Franjo Pernuš and Boštjan Likar
Eigenspine: Eigenvector Analysis of Spinal Deformities

in Idiopathic Scoliosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Daniel Forsberg, Claes Lundström, Mats Andersson and Hans Knutsson
Quantitative Monitoring of Syndesmophyte Growth in Ankylosing

Spondylitis Using Computed Tomography . . . . . . . . . . . . . . . . . . . . . 135
Sovira Tan, Jianhua Yao, Lawrence Yao and Michael M. Ward
A Semi-automatic Method for the Quantification of Spinal

Cord Atrophy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Simon Pezold, Michael Amann, Katrin Weier, Ketut Fundana,
Ernst W. Radue, Till Sprenger and Philippe C. Cattin
Part IV Segmentation II (MR)
Multi-modal Vertebra Segmentation from MR Dixon for Hybrid

Whole-Body PET/MR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Christian Buerger, Jochen Peters, Irina Waechter-Stehle,
Frank M. Weber, Tobias Klinder and Steffen Renisch
Segmentation of Lumbar Intervertebral Discs from

High-Resolution 3D MR Images Using Multi-level Statistical
Shape Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Aleš Neubert, Jurgen Fripp, Craig Engstrom and Stuart Crozier
Contents xi
A Supervised Approach Towards Segmentation of Clinical

MRI for Automatic Lumbar Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . 185
Subarna Ghosh, Manavender R. Malgireddy, Vipin Chaudhary
and Gurmeet Dhillon
Part V Registration/Labeling
Automatic Segmentation and Discrimination of Connected

Joint Bones from CT by Multi-atlas Registration . . . . . . . . . . . . . . . . 199
Tristan Whitmarsh, Graham M. Treece and Kenneth E. S. Poole
Registration of MR to Percutaneous Ultrasound of the Spine

for Image-Guided Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Lars Eirik Bø, Rafael Palomar, Tormod Selbekk and Ingerid Reinertsen
Vertebrae Detection and Labelling in Lumbar MR Images . . . . . . . . . 219

Meelis Lootus, Timor Kadir and Andrew Zisserman
Part I
Segmentation I (CT)
Segmentation of Vertebrae from 3D Spine
Images by Applying Concepts from
Transportation and Game Theories
Bulat Ibragimov, Boštjan Likar, Franjo Pernuš and Tomaž Vrtovec
Abstract We describe a landmark-based three-dimensional (3D) segmentation

framework, in which the shape representation of the object of interest is based on
concepts from transportation theory. Landmark-based shape representation relies on
a premise that considering spatial relationships for every pair of landmarks is redun-
dant, therefore landmarks are first separated into clusters. Landmarks within each
cluster form a complete graph of connections, while landmarks within any two clus-
ters are connected in a one-to-one manner by applying a concept from transportation
theory called the optimal assignment. The resulting optimal assignment-based shape
representation captures the most descriptive shape properties and therefore repre-
sents an adequate balance among rigidity, elasticity and computational complexity,
and is combined with a 3D landmark detection algorithm that is based on concepts
from game theory. The framework was applied to segment 50 lumbar vertebrae from
3D computed tomography images, and the resulting symmetric surface distance of
0.76 ± 0.10 mm and Dice coefficient of 93.5 ± 1.0 % indicate that accurate segmen-
tation can be obtained by the described framework. Moreover, when compared to the
complete graph, the computational time was reduced by a factor of approximately
nine in the case of optimal assignment-based shape representation.
B. Ibragimov (B) · B. Likar · F. Pernuš · T. Vrtovec

Faculty of Electrical Engineering, University of Ljubljana, Tržaška cesta 25,
SI-1000 Ljubljana, Slovenia
e-mail: bulat.ibragimov@fe.uni-lj.si
B. Likar
e-mail: bostjan.likar@fe.uni-lj.si
F. Pernuš
e-mail: franjo.pernus@fe.uni-lj.si
T. Vrtovec
e-mail: tomaz.vrtovec@fe.uni-lj.si
J. Yao et al. (eds.), Computational Methods and Clinical Applications 3

for Spine Imaging, Lecture Notes in Computational Vision and Biomechanics 17,
DOI: 10.1007/978-3-319-07269-2_1, © Springer International Publishing Switzerland 2014
4 B. Ibragimov et al.
1 Introduction
Segmentation of vertebrae is among the most challenging segmentation problems, as

vertebrae are highly articulated structures, consisting of the vertebral body, pedicles
and processes. As a result, the application of unsupervised segmentation approaches
is limited, however, supervised segmentation approaches that require prior modeling
of vertebral structures were already successfully applied, especially in the case of
three-dimensional (3D) spine images [1–7]. For the segmentation of vertebral and
also other anatomical structures, shape modeling has been mostly driven by active
shape models (ASM) [8] and active appearance models (AAM) [9]. However, if
the distance between the initial model and the object of interest is too large, model
optimization may lead to an incorrect solution that is locally but not globally optimal.
Moreover, intensities and shapes are generally treated separately and independently.
To overcome these shortcomings, landmark-based segmentation methods, where
the object of interest is described by intensity and shape properties of landmarks
and connections among these landmarks, have been proposed [10–12]. However,
methods that were originally developed for two-dimensional (2D) images cannot be
directly applied to 3D images, because a considerably larger number of landmarks
is required to accurately capture the shape of the object of interest in 3D. If the
number of landmarks increases linearly, the number of connections among landmarks
exhibits a quadratic growth, which is reflected in the computational complexity. In
the case the shape is represented by a complete set of connections among landmarks
(i.e. a complete graph), the resulting shape representation is strong and prevents
non-plausible shape deformations in 2D, but may at the same time limit the shape
elasticity in 3D. A balance among computational complexity, rigidity and elasticity
may be obtained by reducing the complete set of connections [13], and the more
recent approaches combined statistical properties of individual connections, defining
local shape properties, and of the complete set of connections, defining global shape
properties [11, 14]. Despite considerable improvements, existing approaches often
result in a discriminative degree of connections for different landmarks, i.e. the
number of connections established for different landmarks varies. In practice, this
usually reflects in a high degree of connections for few landmarks and a low degree
for most landmarks, which may lead to errors in landmark detection and formation
of non-plausible shapes.
In this paper, we combine a non-discriminative landmark-based shape repre-
sentation [15] with a landmark-based segmentation framework [12] and extend its
application from 2D to 3D image segmentation (Fig. 1). The introduced 3D shape
representation is based on concepts from transportation theory [16], and is integrated
with a landmark-based detection in 3D that relies on concepts from game theory [17].
The resulting framework was validated for segmentation of lumbar vertebrae from
3D computed tomography (CT) spine images.
Segmentation of Vertebrae from 3D Spine Images 5
Fig. 1 An overview of the proposed segmentation framework. The 3D shape representation of the
object of interest is determined by connections among landmarks that are established according to
the optimal assignment, a special case of transportation theory. The shape and intensity likelihood
maps are also computed for landmarks in images from the training set, and together with the shape
representation used to guide landmark detection in the target image, which is based on concepts
from game theory. The resulting landmarks in the target image are combined with an atlas-based
image registration that combines landmarks and pre-segmented surfaces of the object of interest
in the training set of images with landmarks in the target image to generate the final segmentation
results in 3D
2 Methodology
2.1 Transportation Theory
Transportation theory [16], originally developed in the field of applied economy, is

focused on solving problems related to transporting goods and allocating resources
between sources and destinations, and provides globally optimal solutions for a vari-
ety of applications based on graph theory. In the field of image analysis, transporta-
tion theory has already been applied to solve various problems related to information
matching and comparison. In this paper, we apply transportation theory to determine
the optimal landmark-based shape representation of the object of interest. In the case
the object of interest is described by landmarks p ∈ P, its landmark-based shape
representation can be defined by connections among pairs of landmarks ∀p, q ∈ P;
p ∇= q. The most straightforward approach is to establish connections for every pair
of landmarks, which results in the complete graph of 21 |P| (|P| − 1) connections,
where |P| is the number of landmarks. As the complete graph-based shape repre-
sentation is relatively rigid, its application in segmentation will in general not result
in non-plausible shapes, but some shapes that are plausible may not be detected due
to its limited elasticity. Because a connection is established for every pair of land-
marks, the resulting shape representation is also relatively complex. Although these
limitations may not be of utmost importance in the case of 2D shapes, they may be
emphasized in the case of 3D shapes, where the number of landmarks and corre-
sponding connections can be considerably larger. To balance the rigidity, elasticity
and complexity of the shape representation, connections among landmarks can be
selectively established by various approaches [13]. However, existing approaches
may result in unequal degrees of connections among landmarks (Fig. 2a), which
may lead to non-plausible shapes. We therefore propose a novel non-discriminative
statistical shape representation, where we selectively establish connections and, at
the same time, enforce equal degrees of connections among landmarks. The process
of establishing optimal connections is guided by statistical properties of landmarks,
learned from the training set of images and then applied to the target image, and is
observed from the perspective of transportation theory. For our purpose, we exploit
a special case of allocating sources to destinations in a one-to-one manner called
the optimal assignment, because it has several computationally effective solutions,
e.g. the Hungarian algorithm [18].
2.2 Game Theory
Game theory [17] is a discipline that studies the behavior of decision makers, who
play a game by making decisions that impact one another. A game is a set of rules
for playing, and a play is a specific combination of these rules that occurs when each
player (i.e. the decision maker) chooses a strategy (i.e. a decision as an admissible
behavior of the decision maker) so that it maximizes his payoff (i.e. the benefit gained
Fig. 2 a A shape representation consisting of 13 landmarks with unequal degrees of connections.

b Separation of landmarks into two clusters of 6 and 7 landmarks (note that the cardinality of clusters
is equalized by a pseudo-landmark). Intra-cluster connections are established as complete graphs.
c Optimal assignment-based shape representation, consisting of intra-cluster and also inter-cluster
connections (in green), established by optimal assignment among landmarks in the two clusters
according to the behavior of other players). In non-cooperative games, each player

acts independently and aims to maximize his payoff regardless of payoffs gained by
other players, while in cooperative games, players can join into coalitions (the grand
coalition joins all players) and aim to maximize their joint payoff. In this paper,
we apply game theory to detect the optimal position of landmarks that describe the
object of interest. Landmark detection is considered as a game where landmarks
are players, landmark candidate points are strategies, and likelihoods that each can-
didate point represents a landmark are payoffs [12]. As players (i.e. landmarks)
can simultaneously participate in maximizing their joint payoffs (i.e. cumulative
likelihoods) through the corresponding strategies (i.e. landmark candidate points),
landmark detection in the target image can be represented as a cooperative game
with the grand coalition and solved by maximizing the joint payoff ϑ ∗ :
⎛ ⎞
⎨
ϑ ∗ (P, S, W) = arg max ⎝ wp ⎠ , (1)
ω
p∈P
where P and S = Sp ∪ Sq ∪ . . . are, respectively, sets of landmarks and landmark

candidate points, wp is the payoff for landmark p ∈ P, ω = {wp , wq , . . .} is an
admissible combination of payoffs, and W = {Wp,q ; ∀p, q ∈ P, p ∇= q} is the payoff
matrix that consists of matrices Wp,q of partial payoffs for each pair of landmarks
p, q ∈ P. The element of Wp,q at location (sp , sq ) represents the partial payoff of
landmark p if landmarks p and q are represented by, respectively, candidate points
sp ∈ Sp and sq ∈ Sq .
2.3 Optimal Assignment-Based 3D Shape Representation
Let the object of interest be in each image from the training set T annotated by corre-
sponding landmarks p ∈ P. The application of optimal assignment to all landmarks
would result in a weak shape representation, because every landmark would be con-
nected to only one other landmark (i.e. the degree of connections would be equal to
one). To avoid such situation, we first divide landmarks into L clusters, each with the
same number of landmarks |C|, so that |P| ≈ L |C| (if the same cardinality cannot be
achieved for every cluster, it is equalized by introducing pseudo-landmarks). Land-
marks within each ith cluster are connected by a complete graph Gi∗ , resulting in
intra-cluster connections (Fig. 2b). For all clusters, the total number of intra-cluster
connections is therefore 21 L |C| (|C| − 1). Moreover, each landmark from ith clus-
ter is connected to exactly one landmark from every other jth cluster, resulting in
inter-cluster connections (Fig. 2c). For all clusters, the total number of inter-cluster
connections is therefore 21 |P| (L − 1). The inter-cluster connections are defined by
the optimal assignment A∗i,j that corresponds to the maximal total benefit of a shape
representation [18]:
⎛ ⎞
⎨ ⎟ i, j = 1, . . . , L;
A∗i,j = arg max ⎝ u Dp,a(p) , Φp,a(p) , Θp,a(p) ⎠ ; (2)
a∈Ai,j i ∇= j,
p∈Ci
where Ai,j is the set of all possible one-to-one assignments among landmarks
between ith and jth cluster in the form of bijections i → j, a(p) is the landmark
from jth cluster that is assigned to landmark p from ith cluster by bijection a ∈ Ai,j ,
and u(·) is a linear function that is composed of probability distributions of distances
Dp,a(p) , azimuth angles Φp,a(p) and polar angles Θp,a(p) . These probability distri-
butions describe the 3D spatial relationships, observed in the spherical coordinate
system, between any two landmarks p, q ∈ P that occur in images from the training
set and are computed as:
⎟ 2 ⎡
⎟ ⎨ 1 xp,q (n) − x
X p,q xp,q , σ X , x = exp − , (3)
σX 2σ X2
n∈T
where xp,q (n) is the feature value for landmarks p and q in the nth image from the
training set T , x is an arbitrary feature value (0 ≤ x ≤ xmax ), and σ X is a predefined
constant that tunes the sensitivity of the distribution to feature value variations. The
resulting distance, azimuth angle and polar angle distributions are therefore, respec-
tively, Dp,q (d) = X p,q (dp,q , σ D , d), Φp,q (ϕ) = X p,q (ϕp,q , σΦ , ϕ) and Θp,q (θ ) = X p,q
(θp,q , σΘ , θ ), where dp,q is the distance, ϕp,q is the azimuth angle, and θp,q is the polar
angle between landmarks p and q.
The resulting optimal assignment A∗i,j between ith and jth cluster defines the
set {1p,q } of indicator functions for landmarks p from ith cluster and landmarks q
from jth cluster. Each indicator function 1p,q equals 1 if the inter-cluster connection
between landmarks p and q was established, and 0 otherwise. On the other hand, for
intra-cluster connections in ith cluster that result from Gi∗ , the indicator function 1p,q
always equals 1, as the connections form a complete graph.
2.4 Landmark-Based 3D Image Segmentation
Landmark-based image segmentation is the problem of finding landmarks that define

the object of interest in an unknown target image, and one of the options is to exploit
the statistical information of shape representations in the annotated training set of
images. We first extract the statistical information from the training set of images
in the form of intensity and shape likelihood maps, then use the intensity likelihood
maps to identify landmark candidate points, and finally use both intensity and shape
likelihood maps to detect the combination of optimal candidate points that represents
landmarks in the target image.
For each corresponding landmark p ∈ P we first compute the mean image inten-
sity μp at every point in its neighborhood across the images in the training set T .
At location v in the target image, which is a candidate for landmark p, the inten-
sity likelihood map fp (v) is computed as a cross-correlation between μp and image
intensities at every point in the neighborhood of v. The set Sp of M candidate points
for landmark p in the target image is obtained by selecting points at locations of
M largest maxima of fp (Fig. 3a). The shape likelihood map gp,q is defined as a lin-
ear combination of the distance (Dp,q ), azimuth angle (Φp,q ) and polar angle (Θp,q )
probability distributions (Eq. 3):
gp,q (d, ϕ, θ, Δ, Υ, Ω) = λ1 Dp,q (Δ · d) + λ2 Φp,q (ϕ + Υ ) + λ3 Θp,q (θ + Ω) (4)
and therefore represents the shape variations for landmarks p and q in images from
the training set T . The parameters R = {Δ, Υ, Ω} serve to additionally scale and
rotate the system of landmarks p and q, and therefore compensate for an eventual
global scaling and rotation of the object of interest.⎢The parameters λi weight the
contribution of individual probability distributions; 3i=1 λi = 1, ∀i: λi ≥ 0.
The resulting intensity (fp ) and shape (gp,q ) likelihood maps, and the optimal
assignment-based shape representation (G ∗ ∪ A∗ ) are combined with an existing
landmark-based image segmentation framework [12] that relies on concepts from
game theory [17]. The partial payoff (Eq. 1) of landmark p if landmarks p and q are
represented by, respectively, candidate points sp ∈ Sp and sq ∈ Sq is defined as:
⎟
Wp,q (sp , sq , R) = (1 − τ ) fp (vsp ) + τ gp,q dsp ,sq , ϕsp ,sq , θsp ,sq , R , (5)
where vsp is the location of sp in the target image, dsp ,sq , ϕsp ,sq and θsp ,sq are, respec-
tively, the distance, azimuth angle and polar angle between sp and sq in the target
image, R = {Δ, Υ, Ω} are the parameters that compensate for the global scaling
and rotation of the object of interest (Eq. 4), and τ weights the contribution of the
intensity and shape likelihood maps; 0 ≤ τ ≤ 1.
The cooperative game with the grand coalition is, in terms of combinatorial opti-
mization, a relatively complex problem. However, a locally optimal combination
of candidate points σ ∗ = {sp∗ , sq∗ , . . .} can be obtained by an iterative optimiza-
Fig. 3 The proposed landmark-based segmentation of the L1 vertebra, shown in an axial CT cross-
section. a Candidate points for landmarks p and q form the corresponding sets Sp and Sq . b The
optimal candidate points sp∗ and sq∗ are found by the game-theoretic landmark detection. c The set of
optimal candidate points σ ∗ represents landmarks that define the boundary of the object of interest
tion algorithm [12]. According to Eqs. 1 and 5, and by considering the optimal
assignment-based shape representation, we define the total payoff ψ as:
⎨ ⎨
ψ(q, sq ,k P,k S, W, R) = 1i,j Wi,j (si , sj , R) (6)
i∈k P j∈k P
j∇=i
⎨
+ 1i,q Wi,q (si , sq , R)
i∈k P
⎨
+ 1q,j Wq,j (sq , sj , R),
j∈k P
where k P is an observed subset of landmarks without landmark q; k P ⊂ P\{q}, k S

is the combination of optimal candidate points that correspond to landmarks in k P
(each landmark is associated with exactly one optimal candidate point), 1p,q is the
indicator function obtained from the optimal assignment G ∗ ∪ A∗ , and k denotes
the current configuration of sets k P and k S that are associated with the iteration
of the optimization algorithm. By maximizing the above described total payoff ψ,
the optimal combination of candidate points σ ∗ = {sp∗ , sq∗ , . . .} can be detected in
polynomial time.
The obtained combination of optimal candidate points σ ∗ = {sp∗ , sq∗ , . . .} repre-
sents landmarks in the target image that correspond to P = {p, q, . . .}. In the case the
object of interest is, in each image from the training set, segmented in the form of a
binary mask, its 3D segmentation in the target image can be achieved by atlasing these
binary masks from images in the training set to the target image. For each image in the
training set, landmarks are first non-rigidly registered to the obtained combination
of optimal candidate points σ ∗ , and the resulting transformation is used to propagate
the corresponding binary mask to the target image. The propagated and transformed
binary masks of all images in the training set are accumulated in the target image,
and voxels for which the overlap in accumulated binary masks exceeds a predefined
threshold are selected as the final 3D segmentation of the object of interest.
3 Experiments and Results
The proposed framework was applied to segment 50 vertebrae that were obtained
from 10 CT lumbar spine images with in-plane voxel size of 0.282–0.791 mm
and slice thickness of 0.725–1.530 mm. Vertebrae at each segment (i.e. L1 to L5)
were first manually segmented, and the resulting 10 binary masks were non-rigidly
registered [19] to obtain surface correspondences. The obtained transformation fields
were then used to propagate |P| = 300 landmarks, which were evenly distributed
on the surface of one binary mask, to the remaining nine binary masks, resulting
in sets of corresponding landmarks. By applying the√k-means algorithm, landmarks
were divided into L = 18 clusters, each with |C| ≈ |P| = 17 landmarks (pseudo-
landmarks were added to corresponding
⎣ ⎣ clusters to equalize the number of landmarks
in each cluster, therefore |P| → ⎣P ⎣ = L |C| = 306). Within each cluster, connec-
tions were established as complete graphs, amounting to 21 L |C| (|C| − 1) = 2,448
intra-cluster connections. Between any pair⎣ of
⎣ clusters, connections were established
by optimal assignment, amounting to 21 ⎣P ⎣ (L − 1) = 2,601 inter-cluster connec-
tions. The total number of connections in the resulting optimal assignment-based
representation was therefore 2,448 + 2601 = 5,049, which is approximately nine
times less than in the case of the complete graph-based shape representation with
2 |P| (|P| − 1) = 44,850
1
connections. The remaining parameters of the framework
1 ⎢
were set to u(·) = |T | n∈T dp,q (n) (the linear function in Eq. 2), σ D = 15 mm and
σΦ = σΘ = 15◦ (parameters of probability distributions in Eq. 3), M = 30 (the num-
ber of candidate points for each landmark, obtained on the basis of 11 × 11 × 11 mm
large neighborhoods), λ1 = 0.7, λ2 = 0.2 and λ3 = 0.1 (weights of the contribution
of probability distributions in Eq. 4), τ = 0.9 (weight of the contribution of the inten-
sity and shape likelihood map in Eq. 5), and 50 % threshold for the overlap in the
binary mask accumulation. These parameter values were determined experimentally
by observing their impact on the final segmentation, however, they may be further
tuned for a specific application.
The proposed framework was implemented in C++ without any code optimization,
and executed on a personal computer with Intel Core i7 processor at 2.8 GHz and 8 GB
of memory without any hardware-assisted acceleration. The segmentation perfor-
mance was validated by leave-one-out experiments, one for each vertebral segment,
i.e. the framework was iteratively trained on nine vertebrae and applied to segment
the remaining vertebra of the same segment. The results are for individual vertebral
segments presented in Table 1 in terms of symmetric surface distance δ and Dice
coefficient κ, measured against reference binary masks that were obtained by man-
ual segmentation, and in terms of computational time t. For all vertebral segments,
Table 1 Lumbar vertebra segmentation results in terms of symmetric surface distance δ, Dice coef-
ficient κ and computational time t, reported as mean ± standard deviation (generation of intensity
likelihood maps requires 4–6 min per vertebra and is not included)
Vertebral segment Optimal assignment-based Complete graph-based
shape representation shape representation
(5,049 connections) (44,850 connections)
δ (mm) κ (%) t (s) δ (mm) κ (%) t (s)
L1 0.71 ± 0.07 93.9 ± 0.6 81 ± 5 0.78 ± 0.11 93.5 ± 0.7 709 ± 28
L2 0.73 ± 0.07 94.1 ± 0.5 66 ± 4 0.75 ± 0.08 93.6 ± 0.5 596 ± 17
L3 0.76 ± 0.08 93.8 ± 0.5 68 ± 4 0.81 ± 0.10 93.2 ± 0.7 612 ± 18
L4 0.81 ± 0.15 92.8 ± 1.4 90 ± 2 0.86 ± 0.15 92.1 ± 1.4 804 ± 10
L5 0.78 ± 0.11 92.9 ± 1.6 92 ± 3 0.82 ± 0.16 91.9 ± 2.0 811 ± 12
Fig. 4 Segmentation results for two selected images of lumbar vertebrae (a, b), obtained by applying
the complete graph-based (left) and optimal assignment-based (right) shape representation (the
colormap encodes the symmetric surface distance δ against the corresponding reference binary
masks)
the mean values were δ = 0.76 ± 0.10 mm, κ = 93.5 ± 1.0 % and t = 79 ± 4 s
for the optimal assignment-based shape representation, and δ = 0.80 ± 0.12 mm,
κ = 92.9 ± 1.2 % and t = 706 ± 18 s for the complete graph-based shape repre-
sentation. The results show that accurate segmentation can be obtained both by the
optimal assignment-based and complete graph-based shape representation (Fig. 4).
However, as the number of connections was considerably lower in the case of the opti-
mal assignment-based shape representation, the computational time was reduced by
a factor of approximately nine, i.e. proportionally to the number of established con-
nections. At the same time, the segmentation accuracy was improved when compared
to the complete graph-based shape representation, which indicates that an adequate
balance among rigidity, elasticity and complexity was achieved by introducing the
optimal assignment-based shape representation.
4 Discussion and Conclusion
In this paper, we presented a framework for landmark-based 3D image segmentation

that combines a landmark-based 3D shape representation with a reduced number of
connections among landmarks, determined by using concepts from transportation
theory, and a landmark detection algorithm, which relies on concepts from game
theory. The process of landmark detection results in a set of optimal candidate points
for landmarks that define the shape of the object of interest, and were obtained by
simultaneously considering the intensity likelihood maps of individual landmarks
and the shape likelihood maps of selected connections among landmarks with the
largest shape representativeness. The landmarks were divided into clusters, and for
every cluster, connections among landmarks were established in the form of com-
plete graphs, while for every pair of clusters, connections among landmarks were
established by optimally assigning landmarks between clusters in a one-to-one man-
ner. The resulting optimal assignment-based shape representation was a combination
of intra-cluster connections that captured the shape of local regions, and inter-cluster
connections that captured the global shape of the object of interest. By replacing the
complete graph-based shape representation with the optimal assignment-based shape
representation, segmentation became less prone to non-plausible deformations, the
elasticity of the shape was enabled, and the computational complexity was consider-
ably reduced. The proposed framework does not depend on any initialization and all
possible combinations of candidate points were simultaneously taken into account,
therefore it was more likely to converge to the globally optimal solution. The perfor-
mance of the framework was evaluated for segmentation of lumbar vertebrae from
CT images. The obtained mean symmetric surface distance of δ = 0.76 mm is equal
to the lowest value presented in the literature that can be found in the work of Klinder
et al. [3], while the obtained Dice coefficient of κ = 93.5 % is comparable to the
lowest value presented in the literature, which equals 92.5 % in the work of Kadoury
et al. [6, 7]. The performance of the proposed framework is therefore similar to
the existing approaches, however, they were validated on different databases and, as
such, segmentation results cannot be directly compared.
Nevertheless, for a thorough evaluation of the segmentation performance, the pro-
posed framework needs to be validated on a larger training set of images, which has
to include also images of diseased or pathological vertebrae, e.g. wedged vertebrae
that may occur in the case of scoliosis or fractured vertebrae that may occur due to
osteoporosis. On the other hand, the described framework is formulated in a general
form, and is therefore not limited to segmentation of vertebrae from CT images, but
may be easily adapted to other anatomical structures and imaging modalities. As
such, it can be applied to a variety of segmentation problems where it is possible to
effectively describe the shape of the object of interest by landmarks.
Acknowledgments This work has been supported by the Slovenian Research Agency under grants
P2-0232, J7-2264, L2-7381, and L2-2023.
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Automatic and Reliable Segmentation
of Spinal Canals in Low-Resolution,
Low-Contrast CT Images
Qian Wang, Le Lu, Dijia Wu, Noha El-Zehiry, Dinggang Shen

and Kevin S. Zhou
Abstract Accurate segmentation of spinal canals in Computed Tomography (CT)

images is an important task in many related studies. In this paper, we propose an
automatic segmentation method and apply it to our highly challenging 110 datasets
from the CT channel of PET-CT scans. We adapt the interactive random-walks (RW)
segmentation algorithm to be fully automatic which is initialized with robust vox-
elwise classification using Haar features and probabilistic boosting tree. One-shot
RW is able to estimate yet imperfect segmentation. We then refine the topology
of the segmented spinal canal leading to improved seeds or boundary conditions
of RW. Therefore, by iteratively optimizing the spinal canal topology and running
RW segmentation, satisfactory segmentation results can be acquired within only a
few iterations. Our experiments validate the capability of the proposed method with
promising segmentation performance, even though the resolution and the contrast of
our datasets are low.
Q. Wang (B)
Department of Computer Science, Department of Radiology and BRIC, University of North
Carolina at Chapel Hill, Chapel Hill, NC, USA
e-mail: qianwang@cs.unc.edu
L. Lu
Radiology and Imaging Science, National Institutes of Health (NIH) Clinical Center,
Bethesda, MD, USA
e-mail: le.lu@nih.gov
D. Wu · N. El-Zehiry · K. S. Zhou
Siemens Corporate Research, Princeton, NJ, USA
e-mail: dijia.wu@siemens.con
D. Shen
Department of Radiology and BRIC, University of North Carolina at Chapel Hill, Chapel
Hill, NC, USA
e-mail: dgshen@med.unc.edu
J. Yao et al. (eds.), Computational Methods and Clinical Applications 15

for Spine Imaging, Lecture Notes in Computational Vision and Biomechanics 17,
DOI: 10.1007/978-3-319-07269-2_2, © Springer International Publishing Switzerland 2014
16 Q. Wang et al.
Fig. 1 Examples of datasets in our studies: a Sagittal view of restricted FOV near the chest area
only; b Coronal view of disease-affected spine; c Sagittal view of full-body scan. Two additional
transverse planes show that the spinal canal is not always contoured by bones
1 Introduction
To segment spinal canals is desirable in many studies because it facilitates analysis,

diagnosis, and therapy planning related to spines. Segmentation of spinal canal pro-
vides helpful references to parcellate other anatomical structures and contributes to
the understandings of full-body scans essentially [1]. Given spinal canal, it is much
easier to delineate spinal cord, which is vulnerable to dosage tolerance and crucial
for radiotherapy [2]. More previous works on spinal canal/cord focus on MR images,
partly due to the better capability of MRI in rendering soft tissues. However, in this
paper, we present an automatic method to segment spinal canals in low-resolution,
low-contrast CT images. In particular, our highly diverse datasets are acquired from
the CT channel in PET-CT and on pathological subjects. They are collected from
eight different sites and vary significantly in Field-of-View (FOV), resolution, SNR,
pathology, etc. Sagittal views of two typical datasets with different FOVs are shown
in Fig. 1a, c, respectively. The coronal plane of another patient, whose spine twists
due to diseases, is also provided in Fig. 1b. High variation and limited quality of the
datasets have incurred additional difficulty in segmenting spinal canals.
Most spinal canal segmentation methods in the literature are semi-automatic
[3–5], which require manual initializations or interactions. Archip et al. [2] present a
fully automatic pipeline by parsing objects in a recursive manner. Specifically, body
con-tour and bones are extracted first. Then region growing is employed to segment
spinal canal on each slice independently. When the boundary of spinal canal is rela-
tively weak as shown in top-right of Fig. 1c, this approach does not suffice and thus
Snakes [6] is used to incorporate segmentation results from neighboring slices. Fol-
lowing similar top-down parcellation strategy, [7] uses watershed and graph search
to segment spinal canals. However, this top-down parcellation depends on locating
the spine column first to provide rough but important spatial reference, which can be
nevertheless non-trivial.
Automatic and Reliable Segmentation of Spinal Canals 17
Interactive segmentation has also developed rapidly and drawn many successes in
past decades. By allowing users to define initial seeds, the interactive mechanism is
able to understand image content better and generate improved segmentation results
in the end. We refer readers to [8] for a comprehensive survey of interactive seg-
mentation methods. Among them, random walks (RW) [9] has been widely applied
in various studies. RW asks users to specify seeding voxels of different labels, and
then assigns labels to non-seeding voxels by embedding the image into a graph and
utilizing intensity similarity between voxels. Users can edit the placement of seeds
in order to acquire more satisfactory results.
In this paper, we adapt the idea of interactive segmentation to form a fully auto-
matic approach that segments spinal canals from CT images. Different from manually
editing seeds in the interactive mode, our method refines the topology of the spinal
canal and improves segmentation in the automatic and iterative manner. To start the
automatic pipeline, we identify voxels that are inside the spinal canal according to
their appearance features [10]. For convenience, we will denote the voxels inside
the spinal canal as foreground, and background otherwise. Then the detected seeds
are input to RW and produce the segmentation of foreground/background. Based on
the tentative segmentation, we extract and further refine the topology of the spinal
canal by considering both geometry and appearance constraints. Seeds are adjusted
accordingly and fed back to RW for better segmentation. By iteratively applying this
scheme, we are able to cascade several RW solvers and build a highly reliable method
to segment spinal canals from CT images, even under challenging conditions.
Our method and its bottom-up design, significantly different from the top-down
parcellation in other solutions, utilize both population-based appearance information
and subject-specific geometry model. With limited training subjects, we are able to
locate enough seeding voxels to initialize segmentation and iteratively improve the
results by learning spinal canal topologies that vary significantly across patients. We
will detail our method in Sect. 2, and show experimental results in Sect. 3.
2 Method
We treat segmenting spinal canal as a binary segmentation problem. Let px denote

the probability of the voxel x being foreground (inside spinal canal) after voxel clas-
sification and p̄x for background, respectively. In general, we have px + p̄x = 1 after
normalization. The binary segmentation can be acquired by applying a threshold to
px . Although shapes of spinal canals can vary significantly across the population,
they are tubular structures in general. We start from a small set of foreground voxels
with very high classification confidences. These voxels act as positive seeds in RW
to generate conservative segmentation with relatively low sensitivity but also low
false positives (FP). All foreground voxels are assumed to form a continuous and
smooth anatomic topology, which refines the seed points in order to better approxi-
mate the structure of the spinal canal. Hence the sensitivity of the RW segmentation
increases with the new seeds. By iteratively feeding the improved seeds to RW, we
18 Q. Wang et al.
have successfully formed an automatic pipeline that yields satisfactory segmentation

of spinal canals.
2.1 Voxelwise Classification
In order to identify highly reliable foreground voxels as positive seeds, we turn to

voxelwise classification via supervised learning. We have manually annotated the
medial lines of spinal canals on 20 CT datasets. Voxels exactly along the medial
lines are sampled as foreground, while background candidates are obtained from
a constant distance away to the medial lines. We further use 3D Haar features as
voxel descriptors. With varying sizes of detection windows, an abundant collection
of Haar features is efficiently computed for each voxel. The probabilistic boosting
tree (PBT) classifiers are then trained with AdaBoost nodes [11]. We have cascaded
multiple PBT classifiers that work in coarse-to-fine resolutions. In this way, we not
only speed up the detection in early stage by reducing the number of samples, but also
exploit features benefiting from higher scales of Haar wavelets in coarse resolution.
Note that similar strategy is also successfully applied in other studies [10]. The well-
performing foreground voxel confidence map (as well as the measuring color map)
with respect to a training subject is displayed in Fig. 2a. However, when applied
to a new testing dataset (e.g., Fig. 2c–d), the classifiers may suffer from both false
negative (FN) and FP errors. For instance, an FP artifact is highlighted in Fig. 2b.
Figure 2c shows discontinuity of foreground confidence due to FN errors. Since the
purpose here is to preserve highly reliable foreground voxels only (i.e., Fig. 2d), we
have adopted a high confidence threshold (>0.9) empirically to suppress most FP
errors. The detection sensitivity will be subsequently improved as follows.
2.2 Random Walks
Similar to PBT-based classification, RW also produces voxelwise likelihoods of

being foreground/background [9]. After users have specified foreground/background
seeds, RW departs from a certain non-seeding voxel and calculates its probabilities
to reach foreground and background seeds, as px and p̄x , respectively. Usually the
non-seeding voxel x is assigned to foreground if px > p̄x . In the context of RW, the
image is embedded into a graph where vertices correspond to individual voxels and
edges link neighboring voxels. The weight wx y of the edge ex y , which measures the
similarity between two neighboring voxels x and y, is defined as
wx y = exp(−β(I x − I y )2 ), (1)
where I x and I y represent intensities at two locations; β a positive constant. Assum-

ing segmentation boundaries to be coincident with intensity changes, RW aims to
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craft of war; and hath not the Prophet himself said, What is war but a
game of deception?’[497] ‘That is true,’ responded Aly, ‘but I will have
none of the aid that cometh from Muâvia.’ ‘Then,’ said Ibn Abbâs,
‘thou hadst better depart to thy property at Yenbó, and close the
gates of thy stronghold behind thee; for everywhere the Bedouins
are hounding along; and if thou makest the rest of the people thine
enemies, these will find thee alone, and will surely lay the blood of
Othmân at thy door.’ ‘Come,’ said Aly, trying another line, ‘thou shalt
go forth thyself to Syria. See, now, I have appointed thee.’ ‘That,’
replied Ibn Abbâs, ‘can never be. Muâvia would surely behead me or
cast me into prison because of Othmân’s death, and my being akin
to thee. Hearken to me, and make terms with him ere it be too late.’
But Aly turned a deaf ear to his appeal.[498] .
Acting on these wayward impulses, Aly
sent men of his own to replace the existing Aly appoints new governors
governors in the chief commands throughout the empire.
Moharram, a.h. XXXVI. July,
throughout the empire. In most places they a.d. 656.
met with but a sorry reception. At
Bussorah, Ibn Aámir, unwilling to provoke hostilities, retired, and his
successor, Othmân ibn Honeif, entered unopposed; but the faction
which clung to the memory of the late Caliph was as strong at
Bussorah as that which favoured Aly, while a third party waited to
see how the tide of public opinion might run at Medîna. In Egypt it
was much the same. Cays, appointed to the command, was a
singularly wise and able ruler; but he only succeeded in passing the
frontier garrison by feigning attachment to the cause of Othmân;
while a strong and aggressive faction occupied the district of
Kharanba, swearing that they would not submit until the regicides
were brought to justice. In Yemen, the new governor obtained
possession, but only after Yála, his predecessor, had carried off to
Mecca all the treasure. The governors-elect of Aly who attempted to
enter Kûfa and the province of Syria, met with a rough reception on
the border, and were fortunate in escaping with their lives back again
to Medîna.
Dispirited by these reports, Aly again took counsel with Talha and
Zobeir. The sedition, he said, which he had apprehended, was
already kindled, and would spread like
wildfire, catching whatever came in its way. Aly sends letters to Muâvia
‘Then,’ replied they, ‘let us depart, that we and Abu Mûsa.
may do thee service in the field.’ ‘Wait,’ answered Aly; ‘the cautery
must be the last resort.’ So he resolved, in the first instance, to
address letters to Muâvia, and also to Abu Mûsa at Kûfa, demanding
their allegiance. Abu Mûsa replied in loyal terms, but at the same
time bade the Caliph beware of the spirit of disaffection which in
Kûfa was rife around him. With Syria, all communication was cut off;
weeks elapsed, and there was no reply. In truth, a strange scene
was being enacted there.
Muâvia had no sooner received the
emblems of his Master’s murder—the gory Emblems of vengeance
shirt and Nâila’s mangled fingers—than he suspended
Damascus.
on the pulpit at
hung them up on the pulpit of the Great

Mosque at Damascus. There suspended, they remained a spectacle
maddening the Syrians to a bloody revenge.[499] Still they took no
immediate action. Biding their time, they waited to see what the new
Caliph might do. Aly, had he been wise, would have used such allies
to take vengeance at once on the conspirators, and at the same time
crush the rising democracy and disaffection of the Arab tribes. In this
work Syria would have been his strongest stand-by; for it never
suffered from the Bedouin turbulence which kept Irâc and Egypt in
continual turmoil. In the early campaigns, Syria was the favourite
field of the Coreish, who, settling there in larger proportion than
elsewhere, found their influence, in consequence, better recognised.
Moreover, the conquering race inhabited the ancient Syrian cities in
common with the Christian population, which had surrendered, for
the most part, on favourable terms. Society was thus throughout all
classes of the community orderly and loyal, whereas on the banks of
the Euphrates the settlements of Bussorah and Kûfa were filled with
wild and headstrong Arab tribes who regarded the vanquished lands
as their patrimony. Law prevailed in Syria; in Irâc and Egypt, the
pride and petulance of arms. Syria was, moreover, attached to its
Coreishite governors of the Omeyyad stock, and remained thus
faithful to the end.
The Syrians had not long to wait for the outcome of Aly’s plans.
The abortive attempt to supersede Muâvia, and the refusal to arraign
the regicides, gave colour to the charge of collusion; and, with the
bloody shirt before their eyes, the Syrians soon raised that cry
against the Caliph. The majesty of
outraged law must be vindicated; and if the Muâvia sends defiant answer
assassins were not pursued to justice, then to Aly’s letter, Safar, a.h.
XXXVI. August, a.d. 656.
who but Aly was responsible for the
failure? Damascus was in this excited temper when Aly’s letter was
handed to Muâvia. At the first no answer was vouchsafed. The
envoy was kept in waiting from day to day to witness the gathering
storm. At last Muâvia sent a despatch; and a stranger document,
perhaps, was never seen. It bore, as was usual, the seal of state
outside upon the cover, which was superscribed with this address—
From Muâvia to Aly. It contained no other word, but was all blank
within. The despatch was carried by Cabîsa, a chief of the Beni Abs,
and with him the envoy was given permission to depart. Arriving at
Medîna just three months after Othmân’s death, Cabîsa presented
the letter to Aly, who read the address, and, breaking open the seal,
found the despatch all blank within. ‘What meaneth this?’ cried Aly,
starting at the unwonted sight;—‘let the enigma be explained.’
Cabîsa, instructed by his Master, inquired whether his life was safe.
‘It is safe,’ answered Aly; ‘the person of an ambassador is sacred.
Speak on.’ ‘Know then,’ proceeded the envoy, ‘that but now I left
behind me, weeping under the blood-stained shirt of Othmân, by the
pulpit of the Great Mosque at Damascus, sixty thousand warriors, all
bent on revenging the Caliph’s death—and revenging it on thee!’
‘What!’ exclaimed Aly, aghast, ‘on me! Seest thou not that I am
powerless to pursue the murderers? Oh, Lord! I take Thee to witness
that I am guiltless of Othmân’s blood. Begone! See, thy life is safe.’
As the Absite chief withdrew, the petulant slaves and rabble shouted
after him, ‘Slay the dog; slay the envoy of dogs!’ He turned, and,
apostrophising the Coreish, cried at the pitch of his voice, ‘Children
of Modhar! Children of Cays! The horse and the bow! Four thousand
picked warriors are close at hand. See to your camels and your
horses!’
Medîna was startled by the envoy’s cry,
only as Mecca had been startled by the Aly resolves to attack Muâvia
voice of Dham-dham at the battle of Bedr, and invade Syria.
four-and-thirty years before. The time was come when Aly could no
longer put his decision off. Hasan, ever poor in spirit, counselled his
father to wait; but Aly saw too plainly that the hour for action was
now or never. He gave vent to his troubled soul in martial lines which
were soon in everyone’s mouth, and from which the people first
learned his resolve to make the sword the arbiter betwixt Muâvia and
himself. An expedition against Syria was proclaimed. Captains were
appointed to command the various companies of the expected
levies, and banners were presented to them by Aly; but he was
careful to name no one who had taken any part in the attack on
Othmân.[500] Orders were also sent to Kûfa, Bussorah, and Egypt, to
raise troops for the war. Having made these preparations, Aly
mounted the pulpit and harangued the citizens of Medîna. If they
failed to fight now, he told them, the power would pass away from
them, never more to be regained. ‘Fight, then, against the cursed
schismatics, who would destroy the unity of Islam and rend in twain
the body of the Faithful. Haply the Lord will set that right which the
nations of the earth are setting wrong.’ But the people did not
respond to the appeal, and the ranks were slow of filling.
Talha and Zobeir, when they saw how
affairs were drifting, again asked that they Talha and Zobeir depart to
might be allowed to quit Medîna. With Aly’s Mecca.
leave, they now set out for Mecca, on pretext of performing the
Lesser Pilgrimage.
CHAPTER XXXVI.
REBELLION AT BUSSORAH.
A.H. XXXVI. A.D. 656.
But, before crossing arms with Muâvia,

heavy work was still in store for Aly. Work nearer home.
On her way back from the pilgrimage at

Mecca, Ayesha was met by the tidings of Ayesha retires to Mecca.
Othmân’s murder and of Aly’s accession to
the Caliphate. ‘Carry me back,’ forthwith cried the incensed and
impetuous lady; ‘carry me back to Mecca. They have murdered the
Caliph. I will avenge his blood.’
In the early period of Othmân’s
troubles, Ayesha, like the rest of the world, And propagates sedition
there.
is said to have contributed her share
towards fomenting public discontent. We are told that she even
abetted the conspirators, among whom (as we have seen) her
brother Mohammed son of Abu Bekr was a chief leader. But however
this may have been, she certainly was no party to the factious
proceedings so soon as they began to be pressed to cruel
extremities; and she had, in fact, sought to detach her brother from
them by carrying him off with her to Mecca. Vain and factious, she
had never forgiven the cold and unhandsome conduct towards her of
Aly when, on the occasion of the misadventure with Safwân, her
virtue had been doubted by the Prophet;[501] and now she would
gladly have seen Zobeir Caliph in the place of Aly. Instead, therefore,
of proceeding onwards to her home at Medîna, she returned
straightway to Mecca. There the disaffected (who ever gravitated for
safety to the Sanctuary) gathered around her, while from her veiled
retreat she plotted the revenge of Othmân, and with shrill voice
loudly harangued her audience on the enormous crime that had
desecrated the Prophet’s home and resting-place.[502]
Thus when Zobeir and Talha reached
Mecca, they found sedition well in the Zobeir and Talha, with
ascendant. The numerous members of the Ayesha, march on Bussorah,
Rabi II. a.h. XXXVI. a.d. 656.
Omeyyad family, who had fled on the
Caliph’s death from Medîna, and the adherents of that powerful
House still residing at Mecca, as well as the factious and
discontented population at large, listened eagerly to the tale of their
distinguished visitors. ‘They had left the men of Medîna,’ they said,
‘plunged in perplexity. Right and wrong had been so confounded that
the people knew not which way to go. It was therefore for the citizens
of Mecca now to lead, and to punish the traitors who had slain their
Caliph.’ The standard of rebellion was raised, and many flocked to
join it. Bussorah was chosen as the first object of attack. It was a city
which had always favoured the claims of Talha; and Ibn Aámir, the
late governor, had an influential following there. The treasure which
he had brought away with him, as well as that carried off by Alâ from
Yemen, was now expended in equipping the force, and providing
carriage for the more needy followers. Ayesha, spurning the
restraints of her sex, prepared to join the campaign and to stir up the
people of Bussorah, as she had stirred up those of Mecca. Haphsa,
daughter of Omar, another of ‘the Mothers of the Faithful,’ was with
difficulty restrained by her brother (who had just fled from Medîna,
and held aloof from either side) from accompanying her sister-widow.
At length, some four months after Othmân’s death, the rebel army
set out 3,000 strong, of whom a thousand were men of Mecca and
Medîna. Ayesha travelled in her litter on a camel, which was
destined to give its name to the first engagement in the civil war.[503]
The other widows of Mahomet residing at Mecca accompanied her a
little way, and then returned. As they parted, the whole company,
men and women, gave vent to their feelings, and wept bitterly at the
louring fortunes of Islam; ‘there was no such weeping, before or
after, as then; so that it was called The Day of Tears.’[504]
Questions even now began to arise as
to which of the two, Talha or Zobeir, would Ambition mingled with cry for
revenge.
in event of victory be the Caliph; but
Ayesha, staying the strife, as premature, desired that Abdallah son
of Zobeir should lead the prayers; and it was given out that, if
success should crown their efforts, the choice of the future Caliph
would be left, as heretofore, in the hands of the men of Medîna.[505]
Saîd, with a body of the rebel troops, distrusting the motives of the
leaders, turned aside at the last moment, and went back to Mecca.
As the cavalcade swept by him, shouting that they were on their way
to destroy the murderers of Othmân root and branch, Saîd cried out
to Merwân: ‘Whither away? the proper objects of your vengeance
are on the humps of their camels before your eyes.[506] Slay these,
and return to your homes!’ It is not improbable that with many of the
party, and notably with Talha and Zobeir, ambition, the ruling motive,
was mistaken for the desire of a just revenge. In the whirl of passion
and intrigue, party-cry too often takes the place of reason; and we
need not doubt that both leaders and followers had wrought
themselves up into the belief that punishment of the high treason
enacted at Medîna was their real object.
Yet, notwithstanding all this parade of
justice, the conscience of Ayesha was ill at Ayesha’s qualms of
ease. As they journeyed through the conscience.
desert, her camel-driver beguiled the tedium of the long autumn
nights by calling out the names of the hills and vales along which
they passed. Approaching a Bedouin settlement the dogs as usual
began to howl;—‘The Valley of Hawâb!’ cried the guide. Ayesha
started and screamed. Something dreadful which Mahomet had
spoken, about those at whom the dogs of Hawâb should bark,
flashed across her memory or imagination. ‘Carry me back,’ she
cried; and, making her camel kneel, she hastily alighted from her
litter. ‘Alas and alas!’ she continued, ‘for I heard the Prophet say,
reproaching us, as he sat surrounded by his wives one day: “O that I
knew which amongst you it is at whom the dogs of Hawâb will bark!”
It is me! I am the wretched Woman of Hawâb. I declare that I will not
take another step on this ill-omened expedition.’ They sought to
persuade her that the guide had mistaken the name; but she refused
to stir, and the army halted for her a whole day. In despair, they
bethought them of a stratagem. The following night, they raised the
cry that Aly was upon them. The greater terror prevailing, Ayesha
hastened to her camel, and the march was resumed.
The alarm, feigned for the purpose,
was not, however, altogether groundless. Aly fails to intercept the
rebels.
When rumours of the defection first
reached Medîna, Aly declared that he would not move against
malcontents at Mecca, so long as no overt act of rebellion
threatened the unity of Islam. But shortly after, a message arrived
from the widow of Abbâs[507] at Mecca, with news of the design
against Bussorah. At the first, Aly was disposed to congratulate
himself that the conspirators had not made Kûfa, with its greater
Bedouin population, their object. The son of Abbâs, however, pointed
out that Bussorah was really the more dangerous of the two,
because fewer of the leading chiefs were there, able as at Kûfa, if
they chose, to curb the people and repress rebellion. Aly admitted
the truth of this; and, now thoroughly alarmed, gave orders that the
Syrian column should march instead to Nejd, hoping thereby to
intercept the rebels on their way to Bussorah. But the people still
hung back. Finding that Abdallah son of Omar had disappeared, Aly,
in alarm lest he too should have gone to join the rebels, sent scouts
in all directions after him. Meanwhile his own daughter, Omm
Kolthûm, widow of Omar, sent to assure her father that Abdallah had
really gone on pilgrimage to Mecca, and was altogether neutral;
whereupon Aly, ashamed of his apprehensions, recalled the scouts.
[508] At last a column of 900 men was got together, at the head of
which Aly himself marched to Nejd.[509] But, although they used all
expedition on the road, they found on reaching Rabadza that the
insurgents had already passed. Not being equipped for further
advance, Aly halted at Dzu Câr. Messengers were sent to Kûfa,
Egypt, and elsewhere, demanding reinforcements; and for these the
Caliph waited, in his camp, before he ventured forwards.
To return to Ayesha. The insurgent
army, having resumed its march, reached The rebels attack Bussorah.
Bussorah, and encamped close by.
Messages were exchanged, and immediately on Ibn Honeif, the
governor, becoming aware that the cry of vengeance on the
regicides covered designs against his Master, he called together an
assembly to try the temper of the people. Finding from the uproar
that the strangers had a strong party in the city, he put on his armour,
and, followed by the larger portion of the citizens, went forth to meet
Ayesha, who, on her side, was joined from the town by the insurgent
faction. A parley ensued. Talha, the favourite at Bussorah, Zobeir,
and even Ayesha, with her shrill and powerful voice, declaimed
against the murderers of Othmân, and demanded justice. The other
side were equally loud in their protestations against the expedition. It
was a shame, they said, and a slight on the memory of the Prophet,
for Ayesha to forego the sanctity of the Veil, and the proprieties of
‘the Motherhood of the Faithful.’ Aly had been duly elected, and
saluted Caliph; and now Talha and Zobeir were treacherously
violating the allegiance which they had been the first to swear. These
both protested that the oath had been forced upon them. On this
point the controversy turned; and from words they fell to blows. Night
interposed; but fighting was resumed the following day, and with so
serious a loss to the loyalists that a truce was called, and an
agreement come to, on the understanding that the facts should be
ascertained from Medîna. If it were shown
that force had been put upon the two Reference to Medîna on
leaders to take the oath, then Ibn Honeif question of compulsion.
would retire leave the city in their hands. An envoy accredited by
either side was accordingly deputed to Medîna. He arrived while Aly
was absent in his camp, and forthwith proclaimed the commission he
was charged with, before the assembled city. The people at first
were silent. At last Osâma ibn Zeid, a Companion of the highest
rank,[510] declared that both Talha and Zobeir had done homage
under compulsion, whereupon a great tumult arose; and the envoy,
having seen and heard enough to prove diversity of opinion on the
subject, took his leave.
When tidings of these things reached
Aly, who was with his army in Nejd, he Fighting at Bussorah. City
addressed a letter to Ibn Honeif: ‘There occupied
Talha.
by Zobeir and
was no compulsion,’ he wrote; ‘neither of

these my adversaries was constrained otherwise than by the will of
the majority. By the Lord! if their object be to make me abdicate, hey
are without excuse; if it be any other thing, I am ready to consider it.’
So when the envoy returned, and upon his report the insurgents
called on Ibn Honeif to evacuate the city according to agreement, he
produced the Caliph’s letter, and refused. But the rebels had already
obtained the footing they desired within the city. Arming themselves,
they repaired to the Mosque for evening service, and, the night being
dark and stormy, were not perceived until they had overpowered the
body-guard, entered the adjoining palace, and made Ibn Honeif a
prisoner. On the following day, a severe conflict raged throughout the
city, which ended in the complete discomfiture with heavy loss of
Aly’s party, and so the government passed into the hands of Talha
and Zobeir. True to their ostensible object, these now made
proclamation that every citizen who had engaged in the attack on
Othmân should be brought forth and executed. The order was
carried rigorously out, and great numbers were put to death.[511] The
life of Ibn Honeif was, after some hesitation, spared. He was set at
liberty, his head and beard shaven, and his eyelashes and
moustaches clipped; and in this sorry plight the ousted governor
made the best of his way to Aly.
The insurgents communicated tidings
of their success to Syria. And Ayesha Ayesha’s messages to Kûfa,
wrote letters to Kûfa, Medîna, and Yemen, &c.
seeking to detach the people from their allegiance to Aly, and stir
them up to avenge the death of Othmân.
Meanwhile the citizens of Bussorah
swore allegiance to Talha and Zobeir Apathy of Bussorah towards
conjointly. To avoid all appearance of Talha and Zobeir.
rivalry, the public prayers were conducted alternately by a son of
each. Little active sympathy was evoked by the usurpers. Talha
proclaimed an expedition to proceed against Aly. But no one
responded to the call, and his spirit fell. Thus some weeks passed
uneasily, till the city was aroused by the announcement that Aly with
a great army was in full march upon it.
CHAPTER XXXVII.
BATTLE OF THE CAMEL.
Jumad II., A.H. XXXVI. December, A.D. 656.
Finding that the insurgent troops, with

Ayesha, Zobeir, and Talha, had already Aly, strengthened by
passed, Aly, as we have seen, halted for a contingent from Kûfa,
advances on Bussorah,
while at Dzu Câr in Nejd, with the view of Jumâd II. a.h. XXXVI. Nov.
strengthening his army; for, although joined a.d. 656.
on his march by the Beni Tay and some
other loyal tribes, he still felt too weak for an offensive step. To Kûfa
he addressed a special summons, inhabited as it was by many
veteran Companions on whose loyalty to the Caliphate he might
reasonably depend; and he added force to the call by holding out the
prospect that their city should be the seat of his government. ‘See,’
he wrote to them, ‘have I not chosen Kûfa before all the cities for
mine own? Unto you do I look, in these hard times, for succour, if
haply peace and unity again prevail as it behoveth among brethren
in the Faith.’ But the summons was at the first unheeded. The
overgrown city was made up of many factions; and from some of
these the message of Ayesha, demanding revenge for Othmân’s
blood, had already found response. Abu Mûsa was altogether
unequal to the emergency. Loyal to the memory of the murdered
Caliph, he yet sought to allay the ferment by a neutral course, and
urged the citizens to join neither party, but remain at home. A second
deputation meeting with no better success, the Caliph bethought him
of sending his eldest son, in company with Ammâr, the former
Governor of Kûfa, to urge his cause. The personal appeal of Hasan,
the grandson of the Prophet (albeit a spiritless creature devoted only
to his harem), had the desired effect.[512] The chord of loyalty in the
fickle city’s heart was touched; a tumult arose, and Abu Mûsa,
unable to maintain his weak neutrality, was deposed. The Arab tribes
rallied, and for the moment heartily, around such noted leaders as
Cacâa, and Adî the son of Hâtim. And soon ten thousand men, partly
by land, partly embarking on the river, set out to join the Caliph, who,
advancing slowly from Dzu Câr, awaited their arrival. Thus
reinforced, Aly was able to take the field effectively, and to march on
the rebellious city with an imposing force.
Bussorah itself was not wholly hostile.
A considerable portion of the Beni Bekr Aly opens negotiations with
and Abd al Cays went forth and joined the Talha and Zobeir.
camp of Aly. The Beni Temîm, another tribe inhabiting the city,
perplexed by conflicting obligations, stood aloof, and encamped,
under their leader Ahnaf, within a few miles of the city, watched what
the result might be. Still the numbers bound to the insurgent cause
nearly equalled the Caliph’s army; and on its approach they marched
forth with Talha and Zobeir at their head, and Ayesha in a well-
fenced litter on her camel. But Aly’s thoughts were for peace, if it
were possible. He was a man of compromise; and here he was
ready, in the interests of Islam, magnanimously to forget the insult
offered to his throne. Apart, indeed, from personal jealousies, there
was no disagreement sufficient to bar the hope of reconciliation. The
cry of Talha and Zobeir was for vengeance against the murderers of
Othmân. As yet, Aly did not deny that justice should be dealt out
against them. But he was obliged to temporise. He had in his army
great numbers of these very men, and he felt that to inflict
punishment on them, as his adversaries required, would be, for the
present at least, impossible. Holding these views, he halted while still
some little way from Bussorah, and sent forward Cacâa to
expostulate with Talha and Zobeir. ‘Ye have slain six hundred men of
Bussorah,’ said Cacâa to them, ‘for the blood of Othmân; and lo! to
avenge their blood, six thousand more have started up. Where in this
internecine work are ye to stop? It is peace and repose that Islam
needeth. Give that, and again the majesty of law shall be set up, and
the guilty brought to justice.’ As he spoke, the truth flashed on the
minds of Zobeir and Talha, and even of Ayesha; and they returned
word that if these really were the sentiments of Aly, they were ready
to submit. After several days were spent in such negotiations, Aly,
rejoicing at the prospect of a bloodless compromise, advanced.
But as we have seen, Aly’s army,
recruited at random from the Bedouin Tactics of the regicide.
settlements, comprised a great number of
notorious regicides. Afraid of bringing these into contact with the
heated army of his opponents, which was still breathing out fire and
slaughter against them, Aly gave command that none who had
shared in the attack on Othmân should for the present accompany
him in his advance.[513] These in their turn, with Ashtar and Ibn
Sawda at their head, became alarmed. Talha’s adherents, sworn to
their destruction, were double their number. If peace, then, were
patched up, as was now proposed, what were they all but doomed
men? Reasoning thus, they held a secret conclave, and came to the
conclusion that their only safety lay in precipitating hostilities, and
thus forcing Aly’s hand to crush their enemies. Accordingly, when the
Caliph marched, they remained behind, but with the resolve that,
when the right moment came, they would advance and throw
themselves upon the enemy.
The army of Bussorah, numbering from
twenty to thirty thousand men, remained Continued peaceful
encamped on the outskirts of the city. Aly’s negotiations.
force, advancing unopposed, halted within sight of them. The
citizens, as well as Talha and Zobeir, sent deputations to the Caliph;
and negotiations for peace went on, evidently of a sincere and
substantial character. Aly himself approached on horseback, and
Talha with Zobeir rode forth to confer with him. ‘Wherefore came ye
out?’ asked Aly; ‘did ye not swear homage to me?’ ‘Yea,’ replied
Talha, ‘but with the sword over our necks; and now our demand is
that justice be executed against the regicides.’ Thereupon Aly said
that he too held them guilty; and in no measured terms exclaimed,
‘The Lord blast the murderers of Othmân!’ But they must bide their
time. Zobeir on his side was softened by a passage from some
conversation of the Prophet recalled by Aly to his mind; and he
bound himself by an oath that he would not fight.[514] Then they all
retired. And both armies, understanding that pacific negotiations
were in progress between their leaders, went to rest that night in
such security as they had not felt for many weeks.
But the spell was rudely broken.
Towards morning, a sudden shock Armies both surprised by
changed the scene. The regicides, finding regicides.
that the time for action was fully come, had, during the night, carried
their design into execution. Squadron upon squadron of Bedouin
lances bore down, while it was yet dark, upon the Bussorah tents,
and in a moment all was confusion. Each camp believed that it was
being treacherously attacked by the other; and the dawn found both
armies drawn up, just as the conspirators desired, in mortal combat
one against the other. In vain Aly, perceiving the cause, endeavoured
to hold back his men. The sense of treachery embittered the conflict.
It was a strange engagement, and the first occasion on which
Moslems crossed swords with Moslems. It resembled one of the
deadly battles of old Arab times, only that for tribal rivalry were now
substituted other passions. The clans were broken up, and it became
rather a contest between the two rival settlements: ‘The Beni Rabia
of Kûfa fought against the Beni Rabia of Bussorah, the Beni Modhar
of the one against the Beni Modhar of the other;’ and so on, we are
told, with the various tribes of the Peninsula, and even with families,
one part arrayed against the other. The Kûfa ranks were urged on by
the regicides, who felt that, unless Aly conquered, they were
altogether lost. The field was contested with an obstinacy and
sanguinary issue which can be only thus accounted for. An eye-
witness tells us that ‘when the opposing sides came breast to breast,
it was with a furious shock, the noise whereof was like that of
washermen at the ghaut.’[515] The attitude of the leaders was in
marked contrast with the bitter struggle of the ranks. Zobeir, half-
hearted since his interview with Aly, had left the battle-field according
to his promise, and was killed in an adjoining valley by a soldier of
Ahnaf’s neutral company. Talha, disabled
by an arrow in the leg, was carried into Zobeir and Talha killed.
Bussorah, where he died. Bereft of their
leaders, the insurgent troops gave way. They were falling back upon
the city, when they passed by the camel of Ayesha, stationed in the
rear. Attacked fiercely all round, she was screaming unceasingly,
with fruitless energy, from within her litter, the old cry, ‘Slay the
murderers of Othmân.’ The word ran through the retiring ranks, that
‘the Mother of the Faithful was in peril,’ and they gallantly stayed
their flight to rescue her. Long and cruelly the renewed conflict raged
around the fated camel. One after another, brave warriors rushed to
seize the standard by its side, and one after another they were cut
down. Of the Coreish, seventy perished by the bridle. At last, Aly,
perceiving that the camel was the rallying point of his enemy, sent
one of his captains to hamstring and disable it. With a loud scream,
the animal fell to the ground.[516] The
struggle ceased and the insurgents retired The insurgents defeated.
Ayesha escapes unhurt.
into the city. The litter, bristling all round
with arrows like a hedgehog, was taken down, and, by desire of Aly,
placed in a retired spot, where Ayesha’s brother, Mohammed,
pitched a tent for her. As he drew aside the curtain of the litter, she
screamed at the unknown intrusion;—‘Are thine own people, then,’
he said, ‘become strange unto thee?’ ‘It is my brother!’ she
exclaimed, and suffered herself to be led into the tent. The brave but
wayward lady had escaped without a wound.
The carnage in this ill-starred battle
was very great. The field was covered with Losses in the battle.
ten thousand bodies in equal proportion
from either side;[517] and this, notwithstanding that there was no
pursuit. For Aly had given stringent orders that no fugitive should be
followed, nor any wounded soldier slain, nor plunder seized, nor the
privacy of any house invaded. A great trench was dug, and in it the
dead were buried, friends and foes together. Aly, who encamped for
three days without the city, himself performed the funeral service. It
was a new experience to bury the dead slain in battle not against the
infidel, but believer fighting against believer. Instead of cursing the
memory of his enemies (as became too soon the fashion in these
civil wars), Aly on this occasion spoke hopefully of the future state of
those who had entered the field, on whichever side, with an honest
heart. When they brought him the sword of Zobeir, he cursed the
man who had taken his life; and, calling to mind the feats of the
deceased warrior in the early battles of Islam, he exclaimed: ‘Many a
time hath this sword driven away care and sorrow from the Prophet’s
brow.’ The Moslems might well mourn over the memory both of Talha
and Zobeir, when they remembered how on the field of Ohod the
former had saved the life of Mahomet at the peril of his own; and
how often the latter, conspicuous from afar in his saffron turban,
carried confusion into the ranks of the idolaters while they yet held
possession of Mecca. Their fall, and that of many amongst the
Companions, was a loss to the empire itself, because seriously
weakening the Coreish in the struggle that yet remained to be fought
out betwixt them and the Arab tribes. In fact, this victory of Aly was
virtually the victory of these latter—that is to say, of the regicides,
and of the factious citizens of Kûfa. Thenceforward Aly himself was
almost wholly dependent on them. If, instead, he had succeeded in
effecting a strong and lasting compromise with Talha and Zobeir, his
position would have been incomparably strengthened.
The bearing of Aly after the victory was
generous towards the fallen foe. Having Aly’s magnanimity towards
entered the city, he divided the contents of the enemy.
the treasury amongst the troops which had fought on his side,
promising them a still larger reward when the Lord should have
delivered Syria into his hands. But otherwise he treated friends and
foes alike, and buried in oblivion the animosities of the past. Merwân
and the immediate adherents of the house of Omeyya fled back into
the Hejâz, or found refuge in Syria. All that remained in the city
swore fealty to Aly. The only class dissatisfied was that of the slaves
and rabble, who murmured at having no share in the treasure, nor
any chance of plunder. These, gathering into marauding bands,
occasioned much disquietude to the Caliph, and indeed hastened his
departure with the view of checking the mischief they were bent on.
[518]
Ayesha was treated by Aly with the

honour and reverence due to ‘the Spouse Ayesha retires to Medîna.
of the Prophet both in this life and in the
life to come.’ She was now five-and-forty years of age, but had lost
little of the fire and vivacity of her early days. After the battle, the
Caliph visited her tent, and expressed his satisfaction at finding her
unhurt; adding mildly, but half reproachfully: ‘The Lord pardon thee
for what hath passed, and have mercy upon thee.’ ‘And upon thee!’
was her ready answer. The best house in Bussorah was given up to
her; and there she was waited on by her own adherents. Not many
days after, she was dismissed, with a retinue of forty handmaids, and
attended by her brother. Aly himself accompanied her for a mile or
two on foot; and a large party went as far as the first stage, to bid her
farewell. At Mecca she performed the Lesser Pilgrimage; and then
retiring to Medîna, no more attempted to interfere with the affairs of
State. Her nephew Abdallah son of Zobeir (and of her sister
Asma[519]) retired with her. He is famous as the nearly successful
usurper of the Caliphate; but that was not till Ayesha had passed
away. She spent the remainder of her days at Medîna. There crowds
of pilgrims visiting the Prophet’s tomb (her own apartment) gazed
wonderingly at her as the once beautiful and favourite wife of
Mahomet; while she, becoming the garrulous and fertile source of
tradition, entertained them with stories of the Prophet, ascending as
far back as the earliest memories of her childhood. She died in the
fifty-eighth year of the Hegira, aged about sixty-six, having passed
forty-seven years in widowhood.[520]
Aly did not stay long in Bussorah.
Having appointed his cousin, Abdallah son Ibn Abbâs governor of
of Abbâs, as governor of the city, with Ziâd, Bussorah.
the able administrator, to aid him, as in charge of the treasury, he set
out for Kûfa.

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Computational Methods and Clinical

Applications for Spine Imaging

Machine Learning in Medical Imaging 4th International

Clinical Image Based Procedures Translational Research

Medical Computer Vision Large Data in Medical Imaging

Computational Methods and Clinical Applications for

Medical Image Computing and Computer Assisted

Medical Image Computing and Computer Assisted

Medical Image Computing and Computer Assisted

Medical Image Computing and Computer Assisted

Editorial Advisory Board

For further volumes:

ISSN 2212-9391 ISSN 2212-9413 (electronic)

Library of Congress Control Number: 2014943404

Springer International Publishing Switzerland 2014

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

Jianhua Yao, National Institutes of Health, USA

Gregory J. Garvin, St. Joseph’s Health Care, Canada

Ulas Bagci, National Institutes of Health, USA

Jay Tian, Chinese Academy of Sciences, China

Scientific Review Committee

Ulas Bagci, National Institutes of Health, USA

Jianhua Yao, National Institutes of Health, USA

Part I Segmentation I (CT)

Segmentation of Vertebrae from 3D Spine Images by Applying

Automatic and Reliable Segmentation of Spinal Canals

A Robust Segmentation Framework for Spine Trauma Diagnosis . . . . 25

2D-PCA Based Tensor Level Set Framework for Vertebral

Part II Computer Aided Detection and Diagnosis

Computer Aided Detection of Spinal Degenerative Osteophytes

Novel Morphological and Appearance Features for Predicting

Classification of Spinal Deformities Using a Parametric Torsion

Lumbar Spine Disc Herniation Diagnosis

Epidural Masses Detection on Computed Tomography

Part III Quantitative Imaging

Comparison of Manual and Computerized Measurements

Eigenspine: Eigenvector Analysis of Spinal Deformities

Quantitative Monitoring of Syndesmophyte Growth in Ankylosing

A Semi-automatic Method for the Quantification of Spinal

Part IV Segmentation II (MR)

Multi-modal Vertebra Segmentation from MR Dixon for Hybrid

Segmentation of Lumbar Intervertebral Discs from

A Supervised Approach Towards Segmentation of Clinical

Automatic Segmentation and Discrimination of Connected

Registration of MR to Percutaneous Ultrasound of the Spine

Vertebrae Detection and Labelling in Lumbar MR Images . . . . . . . . . 219

Bulat Ibragimov, Boštjan Likar, Franjo Pernuš and Tomaž Vrtovec

Abstract We describe a landmark-based three-dimensional (3D) segmentation

B. Ibragimov (B) · B. Likar · F. Pernuš · T. Vrtovec

J. Yao et al. (eds.), Computational Methods and Clinical Applications 3

Segmentation of vertebrae is among the most challenging segmentation problems, as

2.1 Transportation Theory

Transportation theory [16], originally developed in the field of applied economy, is

2.2 Game Theory

Fig. 2 a A shape representation consisting of 13 landmarks with unequal degrees of connections.

according to the behavior of other players). In non-cooperative games, each player

where P and S = Sp ∪ Sq ∪ . . . are, respectively, sets of landmarks and landmark

2.3 Optimal Assignment-Based 3D Shape Representation

2.4 Landmark-Based 3D Image Segmentation

Landmark-based image segmentation is the problem of finding landmarks that define

gp,q (d, ϕ, θ, Δ, Υ, Ω) = λ1 Dp,q (Δ · d) + λ2 Φp,q (ϕ + Υ ) + λ3 Θp,q (θ + Ω) (4)

where k P is an observed subset of landmarks without landmark q; k P ⊂ P\{q}, k S

3 Experiments and Results