Rene Louis devoted his life to the spine surgery and forged himself in this speciality an international reputation. This fame is the fruit of a keen work and an early comprehension of what must be the complete training of a surgeon of the rachis.

 

. : How did you come to the spine surgery?

. : During my studies of medicine and to the boarding school I did not have a quite precise idea on the guideline which I was going to take. It is my instructor of anatomy, the Instructor who by giving me my first work of anatomy in 1956, at the time of my first year of boarding school, finally directed me. He had asked me to make a study of the topography of the roots and of skull base until the in order to know exactly that they were their projections and their variations. It wished that my work bring a better precision to the vertebral surgery. By excavating the literature I realized that nervous topography compared to the osseous elements of the rachis depended on a single work. It was that of which at the beginning of the century starting from 9 corpses had issued “laws” of projection of the compared to the thorny ones. Indeed for its time topography was intended to the clinicians who identified themselves by palpating the thorny ones. When one asked me to do the work it started to have not badly spine surgery there, i.e. much of laminectomies and a beginning of former surgery and he was thus good to know at the time of the posterior accesses which was radicular topography compared to the blades and either with the thorny ones. In addition at the time of the former accesses it was necessary to know the topography of the compared to the discs and to the vertebral body.

. : How had you undertaken this study?

. : Laboriously since I had dissected at the time 30 corpses, which does not make far from 2000 roots that I dissected and that I reproduced on plans with the millimetre with their projection compared to the blades, with the vertebral body and the discs. While determining an average topography and some variations I arrived at certain conclusions. When a hernia is located like usually, the conventional laws are faithful but when the hernia is median it touches a root whose territory is located low; you can thus have a whereas compression is on a higher level for example in median . Contrary, if the hernia is located in the foramen, it will touch a root which starts from a higher stage for example in foramen instead of having a compression of the root, one will have a topography. Currently with scanning it this does not have any more utility because it is known where the hernia is and thus the correspondence radio-private clinic is easy to establish.

. : You had already chosen the surgery?

. : Yes I had already chosen the surgery. I had realized by attending the various services which I had a frame of mind which approached more of the surgeon than the doctor. After a few months of radicular dissection I noted serious discordances between what I noted on the corpse and what my Masters taught in front of a with the . I felt upon the departure there was something to develop. I was convinced that the anatomy of the rachis was not very thorough in the works because the surgeons had not made precise requests with the anatomists and that finally anatomical search on the rachis had not been directed the needs of the surgeons. I felt that very early and as from this moment there I decided to specialize me in the rachis. I continued to do many work on the spinal column and I wondered what it was necessary to do to be effective in this surgery. I compared the surgery of the members with that of the rachis and I realized that there was a very great discordance between vertebral operational logic and the operational logic of the members. My Masters during the consultations proposed therapeutic logics and direct when it was about pathology of the hip or the knee, whereas for the rachis they generally proposed a laminectomy and sometimes a merger but without direct mechanical stress on the lesions. I thus thought that it was necessary to do work to make it possible to the surgeon to act directly on the rachis on any level. As I noted that in my area one never practiced former channel, I thought that a surgeon of the rachis was to be able to make former channels to act directly on the lesions. Following the example long rivers which cross several countries, the rachis pass through many anatomical areas. That starts with the mouth and that continues by the neck, the thorax, the diaphragm, the abdomen to finish in the . Consequently, to become a surgeon of the rachis it was necessary that I learn all these disciplines contrary to the banal course which did not make it possible to make a complete vertebral specialist. Upon the departure I asserted myself this multiple formation. I made neurosurgery, csotcina.comedy, general surgery, vascular surgery and ENT.

. : Thus as of had the beginning, you thought your formation as surgeon of the rachis?

. : Yes as of 56, my first year of boarding school. Taking into account the scientific literature of the time, I had really the feeling which it was possible to make of useful work on the rachis. When I realized that internationally recognized principles of vertebral rested on the study of nine corpses… I finally undertook my study to 100 corpses and there I could measure at which point the anatomy was variable and which the anatomy of the books unfortunately is not always the most frequent anatomy. When an large group is studied one realizes that the average should be changed. But when one is surgeon one cannot operate averages, one operates individuals and it is necessary to know the variations, it is what pushed me to do many work of anatomy before practicing surgical acts a little more logical than before. I took again many old work, I took again all former topography with the distribution of the vessels, their branches, anastomoses and I reorientated the techniques of the initially former channel because they were not adapted to the rachis. The approach of the thoracic surgeon is done according to a side surgery of opening of a space but thus one reaches the rachis only laterally whereas the surgeon of the rachis, for certain former lesions, needs to go more close possible of the median sagittal plan in order to reaching directly through the vertebral body the vertebral canal, to unpack it, and make rebuildings which are symmetrical. To operate nearest possible to the line of centers it was difficult because of the vascular reports but as from the moment when one could control these large vessels one was in front of rachis on which one could have a mechanical share as rational as on a femur.

. : You contributed in anatomy?

. : As soon as I passed the boarding school I reached all the stages of the course in anatomy. I was monitor then as soon as my seniority allowed it to me I was . I continued to do work of anatomy the afternoon at the laboratory, but as at the time we did not have enough corpses at the laboratory I were obliged to work during the night in the mortuaries. With the result that three nights per week up to three hours of the morning I worked in the mortuaries to conclude my work. I did that during 15 years and that enabled me to know all the anatomy around the rachis. I also resumed old work which generally did nothing but confirm what was established but which from time to time made me discover variations. I could develop ideas in particular on the biodynamics of the rachis and the which were completely original and which were useful to me much in my practice.

. : How is held your ?

. : Before making my , I was and as finally my instructors had noticed my heat with work, very quickly I became chief of work in anatomy. I.e. I had already a titular post in the civil service before to have begun my . My university statute was thus advances some on my hospital statute. I was at the period of the institution of hospital full-time under the impulse of Robert , and at this time difficulties of equivalence between the post of faculty and the hospital post arose. I wanted to be a surgeon of the rachis and it was necessary thus that I would be an csotcina.comedist in addition to being an anatomist. As of the publication of the first texts over full-time it appeared that there was only one possibility: to be an anatomist and general surgeon. He had not been provided for of other speciality and I was one of the first to be postulated for this dual function. I had to prolong my two year old boarding school because one could not allow me to be at the same time assistant of surgery and chief of work of anatomy. Then one needed after one year of waiting that I go directly to the Minister of education Main road and that I meet a Mr who was called Mr Solomon, with which I exposed my problem. “I am a chief of work of anatomy, I tell him, and I would like to be assistant in surgery but the regulation does not allow it and my faculty tells me that I can be assistant-assistant or senior registrar but which I cannot be an at the same time chief of work of anatomy and assisting in surgery”. He answered me: “But it is myself which made the regulations and nobody had posed this problem to me. You can return quietly on your premise; on the following day I make publish an additive in the official journal and you will have your post”. I thus became assistant with two years of delay compared to my colleagues but my two additional years of boarding school enabled me to make the turn of all the specialities. Moreover, as I was very advances some on the university level one forwarded to me to the aggregation which I made a success of whereas I had only three months of assistantship. It was into 66. I left immediately to Senegal because the post that I had aspired to was a post of aggregation at the medical college of Dakar.

. : What a exquisite time! It was enough to announce to the Ministry which a law was imperfect so that it is amended; it was enough to be a keen worker so that an aggregation is proposed to you…

. : It was one transitional period. In addition on the one hand there was no age limit and on the other hand an obligatory time ago to carry out, to be able to pass to the higher grade. It was enough to make a success of the proofs of the contest and to have a sufficient proof of bonds. I could pass the boarding school in fourth year of medicine and I could be a chief of work about the sixth year. I was obviously not only in this case there. Thus, 10 years after my success with the boarding school I could be an instructor, which was frequent at the time.

. : At this period you had published a work on the anatomy of the central nervous system…

. : With Paul . which was our excellent instructor of . He had noticed my facilities of drawing in the board at the time of my various contests in anatomy and he had come to see me to transform his exchange rate into a work. I was to occupy to me to make all the plates of drawings and he was to make the text starting from the plates. I made all the drawings, I recomputed the plates and I amended them while trying to put a unity in the colors and made him all the text.

. : This chalk blow, it is a gift?

. : When I was child I could already draw; without lessons, quite naturally. In addition, I often drew when I was all alone. At the time of my secondary studies I was often first during drawing. That was thus not a problem to put itself at the anatomical drawing but it was necessary for me despite everything work because all is not innate. I learned how to draw all my anatomy of has to Z by repeating many times the drawings and by forging me of the reference marks. So that still currently one can ask me for any diagram, than it is on the nervous system, urology or the vascular one, I can draw it in the board.

. : Why do you go to Senegal?

. : I had a proof of bonds which enabled me by its volume to be forwarded to an aggregation, but I was too young compared to my Marseilles colleagues who contributed. It was told me that there could not be of post for me in Marseilles before a few years but which I could forward to me elsewhere and return then to Marseilles. There was at this time of the posts for the co-operation and I thus forwarded myself to the bond of the co-operation with the of Dakar. The post corresponded well so that I wished, i.e. at the same time anatomy and surgery. There were nevertheless 5 or 6 competitors for the same post but finally I carried it and I was very happy to go to Senegal. When I arrived I was the assistant of a remarkable man who was the Instructor but who died three or four months after my arrival of an traffic accident. I thus was very young person in the obligation to ensure the of service. It was a service of 100 beds and during five years I made function of departmental manager.

. : How did the local work conditions arise?

. : To the beginning of the co-operation, France provided the appropriations and the personnel necessary so that we can exert our mission which consisted in forming new executives for Africa and of new instructors for faculty. At the beginning the material conditions were satisfactory but we had an enormous sphere of activity. We had also much freedom and somebody who wanted really to develop his ideas and to make good work had all the possibilities of doing it. Pathology was very varied but we were confronted with affections at difficult stages because very advanced. Vertebral tuberculoses that we had to discuss destroyed three or four vertebrae and involved important , which one did not see almost any more in Europe. That posed difficult problems to us but it was also one demolished surgical for each one among us and that obliged us to improve our techniques considerably. In spite of means as a whole satisfactory, we did not have sufficient blood for the transfusions so that I had to improve me with excess in the hemostasis. One did not have to make lose blood unnecessarily and be able to make vertebral osteotomies which take three to four hours with simply 500 DC of blood. These qualities acquired by these circumstances were very useful to me and currently taking into account the transfusional problems my anesthetists appreciate much the fact that there does not need to make large transfusions with my operated.

. : It was not question of hypotension controlled in Dakar?

. : Not… I had a neurosurgical formation however and it should well be recognized that the hemostasis of a neurosurgeon is not the same one as that of an csotcina.comedist. I had thus adopted for the haemostasis the neurosurgical method with electrocoagulation with the bipolar grip and not with the hemostatic grip. I had learned electrocoagulation plan by plan and I never passed in the following plan as long as there were one drops of blood in the preceding plan.

. : But did the local structures enable you to practice heavy spinal surgery?

. : Yes, there were goods , there were sufficient beds and what missed was the services of readjustment. So that the patients operated for evils of turned over in hospitals of bush after only 15 days or 3 weeks of hospitalization. Them their antibiotics were provided but I was obliged to develop ambulatory methods because I could not keep them with the bed. Thus I developed collars in depreciation and lordosis to allow them to walk without the chamber being forwarded to major stresses in pressure. Thanks to that I could avoid the common method of the centers photogravure-sailors where the patients were to be lengthily confined to bed.

. : Did the processing of the evil of constitute the essence of the spine surgery which you practice in Dakar?

. : There was especially that but there was also all the usual . When I arrived it was told me that in Senegal the slipped disc and the scoliosis did not exist. Finally at the end of a year I realized that I found all the pathology which I had known in Europe.

. : What did you make on the evils of ?

. : For the evils of I prolonged the share of the surgeons which had preceded me like by Hong-Kong or by Algiers. These authors practiced a very advanced surgery for the time by approaching the chamber for directly the lesions and to rectify the deformations. rectified them while embedding in the chamber of the fragments of coast. For my part I had realized before leaving to Dakar the reductions evils or fracture the rachis while operating under traction. The patients were tractor drawn by the two poles and a strong exerted pressure perpendicular to the opened as a book the chamber. I found myself thus in front of enormous losses of substance and this is why I was brought to place fragments of fibula in the chamber in spite of the bad name of the peroneal graft. But finally the experiment proved that in the situation where I used these grafts i.e. between healthy and revived plates vertebral, on the line of centers and in compression there was no problem and which one obtained in nths of very good mergers of the chamber with re-establishment of the straightness of the rachis without osteosynthesis.

. : Did the reanimation follow?

. : The reanimation existed but obviously not under its current form. I had a doctor who was able to follow the patients and as I previously said it by minimizing breakdowns of blood, I had very little post-operative shock so that the things happened rather well. It was necessary that the surgery is very rigorous in its methods and its indications. It is certain that with the least counter-indication of general order I did not operate. It should not be forgotten that the average age was rather young and my patients reached of Evil of had between 6 years and 45 years. I operated only some people of about sixty. Moreover I had a population which was of an extraordinary physical resistance and whose psychism was not undermined of concern with respect to the surgery. They trusted me much and the reputation helping they realized that the things were well. These young, very trustful and very motivated patients contributed certainly to the very satisfactory results as a whole.

. : You were not confronted with complications?

. : If, at the beginning. I had to solve major problems of infection and post-operative. As of my first interventions I had cicatrizations which were done with two or three small surface and one told me: “It is the climate, it is the conjunctive way of African to heal, it is inevitable”. Well quickly I realized that they were errors of asepsis. Moreover, my first attempts at plates screwed on the vertebral body were intricate of suppuration and I had been obliged to withdraw the hardware. I could not continue any more under these conditions. I thus took again all the asepsis as an operating room while being rigorous for clothing, the edge strips, the stone-blocks and I instituted something very again in Dakar, ammonium disinfection with formol. I did not have modern equipment so that I made put to the personnel gas masks to make disseminate the every day the products with manual pumps with insecticide. Both or the first three years one injected initially into the room of formol and 4 hours after ammonia to neutralize. Of course at the beginning I had to face general reprobation but I showed the example the first times and everyone followed me. Then I took again at the basis the way of doing the bandages. In a few months my cicatrizations became what they were in Europe and I did not have a post-operative problem of infection any more.

. : Did you can continue your work of anatomy in Dakar?

. : Yes absolutely. I was besides responsible for the laboratory of anatomy to faculty. I resumed on African subjects all my work completed in Marseilles on “Caucasian” subjects. That enabled me to note some differences in the proportions of such or such variation. It was essential because I had the ambition to know, before operating, all the possible variations. That enabled me to make a book which understands the anatomical variations of Europeans and African. For the Asian ones I was obliged to refer to me to work of the others.

. : Did you note differences in rachidian curvatures between African and the Caucasian?

. : What I noted they are especially differences in proportions in the variations. For example the termination of the spinal-cord at the Caucasian is projected in more than 75% on the level of disc and in 10% of the cases in the middle of the body of . At African I found this termination of the cone in the middle of in 45% of the cases. With regard to the rachidian curvatures, I was interested in lumbar lordosis because the “hollow of the back” of the African women strikes the glance of any European and can, for a medical eye, to refer to a . I made this error of appreciation at the beginning and I resumed work which I had made on lumbosacral lordoses to study in particular the incurvation of the posterior arch and the incurvation of the lumbosacral isthmus on the level of which I had shown that between the birth and the adulthood it occurred a of 23°. By remaking the studies of angle I had the surprise to see that the was only one appearance and that angles, except for some variations, were the same ones as at European. In fact, what varied, be the relief of the buttocks. The distribution of greases is completely specific at African and it makes cover the buttock what gives an impression of accentuated lumbar lordosis. The conclusion of this work published was thus which lumbar lordosis was practically the same one at the African woman but that the relief gluteus was different.

. : How does your return to France occur?

R.L.: On my return I find myself with the Hospital of Marseilles as assistant of the Instructor who then operated very little, so that I had the technical responsibility for the service. I continued to develop my vertebral surgery in all the managements and in particular towards osteosynthesis. Very quickly I appreciated the items, work of fire my friend Raymond and in particular his technique of vertebral osteosynthesis. Thus, I became faithful of Raymond and I adopted his technique. Progressively of the months I realized that there were modifications to be made to its hardware so that it corresponds to my techniques. On the plate, I brought closer the holes and I added oblique holes for the . On the technique of Clerc's Office I developed the intra-articular merger of the posterior breakages. This option initially enabled me to decrease the time of intervention since I did not have a Clerc's Office to take by using the thorny ones in small cortico-spongy matches, placed in intra-articular spaces. Then and especially I did not have to dissect the rachis beyond the articular breakages and thus not to cut the neuro-vascular pedicles of the muscles as obligatorily the many surgeons do it who practice the intertransverse Clerc's Office.

. : Which were, in 1975, your indications of merger?

. : At the time one did not speak about instability such as one currently conceives it. I grafted all the times that I had to rectify a or deformation; it was then necessary to maintain the correction by means of an osteosynthesis and of a posterior merger. When the reduction of a kyphosis involved a loss of former substance that imposed a Clerc's Office and an osteosynthesis by former channel. When I made a I created a loss of overall substance automatically and I was obliged to repair the three columns.

. : Had you thought of the inter-somatic Clerc's Office by posterior channel?

. : I thought of it. Before even leaving to Dakar I had tested one or twice a technique of arthrodesis per posterior channel which was not called at the time the technique of but the technique of : I had been struck by the fact that to introduce large grafts by posterior channel it in a major way the cauda equina and that in addition was needed was necessary really to mobilize not badly the breakages. As an anatomist that did not rain me much. I acknowledge that I gave up very quickly and I preferred to launch out in the former channels not to be obliged to touch with the nervous system.

. : What do you think of the current debates on the rigidity of osteosyntheses?

. : When it with the experiment of the study of the hinges on the fresh corpse one is known that the hinges of the man are not like the hinges created by the man for his machines: they are not rigid. There exists always a little play and that seems to be a fundamental biological law. It is easy to be reported some for example, on the level of the knee. The knee in light bending is not stable and is not rigid. For my part I made the same observation on the level of all the hinges. Another example, he is easy to prove that the hinge which is very specialized in axial rotation also has 10° of movement of bending-extension and which the tooth of the axis is capable of movements of oscillation behind the former arc of the Atlas authorizing a small sector of bending. There is incontestably a difference between the biological gaskets and the mechanical gaskets. If one is too mechanist and if one does not have this experience of alive one is likely to require for the human body same rigidity that one can require in an engine. An axis around whose a wheel turns must be absolutely rigid because it is known that if there is a little play, very quickly that will wear, cause an abnormal movement, etc… And well in the human body there are no perfect movements around an axis, it has there coupled phenomena of update and voltage . This is why semi-rigid osteosyntheses of the rachis lead to a good percentage of merger. Of course this semi-rigidity should not confine with an excessive flexibility source of pseudarthrosis. That can appear tempting to be able to say to a patient that thanks to the rigidity of an assembly it does not need any external support, and that with the rigor it can do what it wants. Only I warn against this reasoning because if the hardware is very rigid then the movements will occur between the ends of the hardware and the bone tissues and it will be created obligatorily with long room of mobility, source of pains.

. : Once the arthrodesis obtained, which importance that the hardware is rigid or not?

. : It should not especially be forgotten that even an osseous arthrodesis has a certain flexibility; even the enormous ones scrapes-ciels are able to oscillate on the level of their summit. Nature did not do anything of rigid completion. The tibia of the ski champion requires a certain flexibility being given the stresses to which it is forwarded at the time of a descent high speed so that all the ski champions years know since that one should not preserve of hardware of osteosynthesis. It is not necessary that the young csotcina.comedists forget these natural biologic phenomena. The body is not metal rigidity, the body is of a biological rigidity i.e. quite relative. Then if metals that we establish are too rigid and which there are disproportion between physical qualities bone and physical qualities of metal, it will occur problems with the interface. In practice nature is able to support mechanical deviation enormously and finally the complications occur only in one small proportion.

. : What do you think of the artificial intervertebral disc?

. : When my service is visited one realizes that I make put artificial disc, neither of cage nor of artificial ligament. One could of course think that I or that I age do not like the new methods because it is not me which imagined them. At all, I am very open, I created techniques and I was quite happy that one allows me to implement them. And I give ideas to the young people so that they continue to innovate. I think that the current trends are sometimes good but that they should be improved. What grains me a little it is that the first materials, that it was proposed to materialize these ideas, are not adapted yet to biomechanics of the rachis. For example the artificial disc has for him that it restores the height of the intervertebral discs and at the same time the height of the foramens; it abolishes a certain dynamic side coarctation thus. But especially since it interposes an inert hardware between the vertebral plates , it abolishes one of the mechanisms of the pain. I thus conceive very although the immediate results are very satisfactory. But the problem it is that one manufactured a hardware which has a center of rotation located at equidistance of the plates higher and lower and when one knows a little biomechanics of the rachis one knows that the center of rotation is close to the lower plate. So that the two posterior hinges cannot function in a synchronous way with the disc. The artificial disc imposes a movement whose center is at equal distance from the two plates thus three-four time millimetres higher than normally and then you have breakages which cannot slip in a uniform way one any more on the other. Rotations are excentric. At the beginning and as long as there will be a little cartilage the patient will not suffer but quickly that will cause posterior osteoarthritides and a wear of the hardware, it is automatic. Thus it is a short-term, elegant surgery but in the short run. Those which practices it know that they will be able to later on make a merger whose they delayed the realization, but on the other hand they imposed two operations.

. : Did you already observe complications?

. : Yes, at the beginning when the first operators did not can place the artificial discs well. I saw discs placed too ahead, the center of rotation was then aberrant and moreover there was not retention of this prosthesis by the banks of the vertebral plate. As they were behind the aorta or the vena cava that made fear of seeing these protuberant prostheses. Contrary when one wanted to place them too behind one created artificial hernias in the vertebral canal. Currently the majority of the authors place them relatively well and it does not remain in my opinion that the problems of this wear and center of rotation. Nevertheless, the installations are made by former access and it is certain that it will be very difficult to go back there because adherences with a vena cava or an aorta are not negotiated like usual adherences. It should be warned the patients that the operation was made by front and that one will not be able to go back probably there any more by this channel. One cut a bridge and the future will tell us if that has many consequences.

. : And cages?

. : I already removed some from them. Those which did not understand the problem well think of thus replacing the conventional arthrodesis. It is to ignore biology completely because without posterior merger or unless you do not impose to the patient a nths immobility, all the unfavourable mailmen are joined together. Indeed there are , the plates are not very quite vascularized and the grafts have evil to pass by the narrow windows of the cages. All that led to the painful nonunion and indeed I have patients and to regraft them by front after having removed the cages. On the other hand if the cage is proposed to abolish on the former column whereas the back was amalgamated, I am of agreement because in this case the cage has nothing any more but one small role mechanical. Because of the posterior merger there will not be too many microcomputer-movements and that will give time to this Clerc's Office badly placed so that gradually it takes. The cage accompanied by a posterior osteosynthesis-merger is theoretically acceptable because it with the advantage of restoring a height of the intervertebral discs. But my experiment proved that it was seldom useful and that by a posterior technique of radicular release without noting the vertebral plate one had also excellent results. It is necessary to warn the young people against the error to take the rachis for a face and to make vertebral face lift with all people who as me exceeded about sixty. It is not necessary to want to rectify all intervertebral spaces for esthetic considerations because by making decompressions with or without merger and raising the disc one obtains very good performances.

. : What do you think of the ligaments?

. : The problem here is the following: one proposes to us to put artificial ligaments to discuss a instability because degenerative instability is well a instability. To understand the phenomenon, let us transpose it to the level of the knee. After a for or genu valgum it occurs a loss of substance of bone surfaces which involves a relaxation of the ligaments and an instability. Will you under these conditions propose to the patient to retighten the hinges by artificial ligaments when you know that at the end of some time the artificial ligament will not resist and when you know that the processing of a osteoarthritis is not to restore ligaments but to restore surfaces. Then with the rachis, since there are 23 discs, if you put ligaments on one or two mobile segments you have the others to compensate for the technical error and the things are seen less than if you made the same silly thing on the level of a knee. But philosophically the silly thing is the same one. In addition, if one with the claim to want to restore a stability only by one share between two vertebrae then nature should be imitated because nature put between two vertebrae a ligament which is enormous and which is largest of all the human body: it is the fibrous ring. This intervertebral ligament is in 6 cm in transverse diameter and 3-4 cm in antéro-posterior diameter what makes about 20 cm2 of section. It is a ligament which is circular i.e. it can face all the managements of movements. You have then other ligaments which supplement the circumferential aspect of stability between two vertebrae, they are the intertransverse ligaments, the ligaments or #E8FFFF ligament, interspinous ligaments etc… If you want to replace the nature which made such circumferential such solid things by two or three artificial axes posterior, if you want to twice replace 20 cm2 of section by 1/2 cm2 you are really bold as regards vertebral biomechanics. It is still in my opinion an immediate brilliant surgery but in the short run. I put the question with the young people: do we have to make evolve/move our surgery with part of our techniques which is short-term and with the risk to have in a few years enormously patients to begin again? How long we will keep the confidence of our patients in their saying “your operation did not last a long time but we have another operation which can go”. I think that if we evolve/move in this feel and that we do not make a long-term surgery we are likely to demolish the reputation of our speciality.

. : There is a current clear trend to solve all the problems surgically…

. : An important thing that I learned while advancing in the speciality, a thing of which everyone speaks but which in my opinion is not rather well done it is the psychological interpretation of the pathology of the patients. For 15 years, I have taken at my sides a psychiatrist and now I am able to question myself the patients. Without speaking about heavy psychiatry, one frequently finds among our patients of small disturbances which concern the stress. The stress is able to create a painful pathology starting from a minor organic primitive lesion which of itself would not have given large thing but which exaggerated because of chemical modifications in the nervous transmission due to the stress becomes intolerable for the patient. In front of failure of therapy medical, such a patient can have to consult a surgeon. If it is that on its radiographies minor anomalies like a small protrusion of the intervertebral discs or a degenerated disc appear, an erroneous relation of cause and effect can be established and the patient will be operated. It will be then the catastrophe because the condition of the patient far from being improved will be often worsened.

. : Which are the elements which make you suppose that the pain is raised for an existential reason?

. : I know about a dozen signs which in a few minutes make it possible to determine the problem.
Their search is really not a waste of time. The first of the signs is announced by the patients who tell you that they saw many doctors and that nobody was able to relieve them; the usual processing i.e. the anti-inflammatory drugs and analgesics did not have of influence, except perhaps cortisone; rehabilitation often worsened them. Start by their asking whether they often awake the night between 4:00 and 5:00 of the morning and if they have evil . The answer will be 9 times out of 10 positive. Then you ask to them whether the morning they have the feeling to be very tired whereas they should be rested. Then you ask to them whether they feel nervous in their relation with the others, and when it is a couple which is present, the spouse makes you a sign which means “yes it is very nervous”. Often at the ladies you will find the concept of the morning. Here are for the general phenomena.
Then there are the local phenomena, i.e. the small internal injury excited by the neurochemical disordered state of the nervous transmission. These patients show pains which have a false mechanical aspect because they are often muscle pains, which naturally are raised with the effort and decrease at rest. That misleads everyone because one thinks of a mechanical phenomenon. But the pain persists the night, even at rest. This pain is often with type of burn and its characteristics are variable in time and space. I.e. sometimes more intense the morning and sometimes more the evening; the pain is sometimes localized during a few days then it changes side, it changes level. Then a remote symptomatology is discovered. There are other pains about which the patients do not speak spontaneously because they chose to come to see you for a precise pain, lumbar or cervical. If you put the question they will say you that from time to time they have pains with the foot or elsewhere. Moreover they often forward phenomena vascular, vasomotor, numbnesses and ants in the upper extremities, of the areas which fall asleep on the level of the members and who make fear because interpreted by the patients and by some doctors as of the paralyzes which settle. One will speak to you about paralyzing sciatica even if it is a temporary numbness which does not have anatomical topography.
Finally you will find the origin of the stress: a divorce, an unemployment, a child invalidates that it is necessary to discuss since years, etc… and when you have this context you can confirm your guideline by a therapeutic test. We make a therapeutic test with antidepressants and neuroleptic drugs with very light amounts, and not with psychiatric amounts, during a few weeks. When the patient returns while telling you that you relieved it you understand that to deal with the pathology of the rachis one should not be only a mechanic but also complete doctor with the psychological faculty of apprehension of pathology.
Here is a little the 30 years of experience philosophy of vertebral surgery.