. : Did Mr , how come to you this passion for the rachis?

. : It is an interesting history. When I was young medical student, as my parents were not rich, I had to find an odd job. It was that Carl , one of the csotcina.comedic surgeons of the hospital of Stockholm, sought somebody to prepare the rachis on which it made experiments. Carl was a relation of family and he told me that if I could devote a few hours to him, I could work in his laboratory. I thus started to interest me in the rachis at the end of the Fifties by collecting bovine and human columns. It was my first contact with the rachis and I have more left it for more than forty years! You can think that I am , but I must say that it was a very interesting company and that I will keep until the end.

. : Did your first studies relate to the measurement of the pressures intra-of the intervertebral discs?

. : Carl was csotcina.comedist and it did many biomechanical studies. It is what I also did. I thought at that time that it was necessary to know which stresses underwent the vertebral column. Then, I started to think of a method of measurement of the pressures intra-of the intervertebral discs. It was about 1956 and I was ready to begin in the life as doctor. Having to make my thesis, I met people who measured the intracardiac pressures with catheters, then I am known as here “! it is with that I should measure the pressure of the intervertebral discs since the nucleus is absorbent”.

 

. : But why pressure of the intervertebral discs?

. : I thought that it was important compared to the lumbar pains and that I could thus evaluate the stresses which were exerted on the column. For me, biomechanics played a part. This disputed forever since forty years. That took five years to me to develop the good method. At the end of my studies of medicine in Stockholm, in 1956, I left to make my boarding school with . It is there that I showed that it was possible to measure the pressures on cadaveric specimens. It was the subject of my thesis of Then I were invited as researcher in a very important laboratory of biomechanics in San Francisco during one year. This laboratory received much money of the US government. I was still an young man at that time and I had just finished my boarding school. It is where I developed these measurements of pressure intra-of the intervertebral discs in vivo. We had started to make these measurements on patients who were to be operated the following day.

 

. : You found volunteers easily?

. : By chance, there were surgeons in particular Paul , who provided the patients. Paul operated by former channel, removed all the disc, and thought that it could discuss slipped discs by this channel. At all events, it was ideal for my study. Because on one of the subjects at which I made my first experiment, when I my pointer, the small plastic thing wanted to leave which measured pressures disappeared! You should not publish that if not one will make me a lawsuit! It was the day or Kennedy wanted to invade Cuba then I remember some very well! It is this study on the pressures of the intervertebral discs which returned to me celebrates, if as well is as I am famous. This work it was basic physiology, anything else. I doubt that is enough to explain pathology or the basic pain but physiology is a good starting point to understand.

 

. : You were also interested in biochemistry?

. : I thought that biochemistry also was important because there was to be some problems of this type in the degenerated disc. I thus made some biochemical studies in laboratory with Alice and , of London. My first study was randomized and published in 1967. I had measured lactates of the intervertebral discs. I had found that certain patients that I operated for slipped disc had a pH of the intervertebral discs low. We showed that it was dependant on lactates and a bad oxygenation. Certain teams still continue this type of search. In the same way, I had found that certain patients who had adherences and fibrosis around the root had a pH lower than the others. Then I told myself that perhaps we could prevent this formation of fibrosis. At that time, there was a promising anti-inflammatory drug which was called the . I asked manufacturing of me to give some, with also tablets of the same placebo aspect. I gave the processing into pre and postoperative, during a few days. I had included sixty patients, thirty in each group, and they had been re-examined at the end of one year by an independent observer. Obviously, at that time, we did not have a MRI and one could appreciate only clinical elements. In conclusion, there was no difference between the two groups. Obviously, this substance did not have any negotiable instrument. It was the first randomized trial which I made. At the time there was very little of it.

. : But you are before a whole surgeon?

. : It is true. Of return in Sweden, I had started to develop the surgery of the scoliosis. At the beginning, I was even the only surgeon of the country to operate scolioses. I used stems of , which I had brought back from the United States. At the end of the Sixties, I operated a hundred of it each year. Then, when in a congress somebody claims that I am not surgeon, I defend myself by saying that I probably have arthrodesis more discs than whoever in the audience! Approximately 55 706!

 

. : But are you really against the intervertebral arthrodesis?

. : In fact, it is an complex issue. The vertebral deformations as the scoliosis are a real indication. With regard to the low back pains, I became more and more skeptic. It seemed to me that we knew some less and less. Nothing really indicates to us from which the pain comes. And I did not understand why so many people did so many arthrodeses. The arthrodesis was sails very about it in the United States and in Sweden us also did much of it. By re-examining the patients during audit trails, we realized that they were not good whole. It is from there that my mistrust for the arthrodesis came. For a long time, had invented the discography. It used it since the end of the year 40 to know which was to be arthrodesis. It had shown me its figures that besides Carl used before making lumbar arthrodeses: but it was a complete failure. As you know it, I criticized the discography much, especially because of his poor utility. Even if you can say that sometimes the disc is well the source of the pain, it is never certain because other structures can be implied in this pain. There is not only one study of the literature which proves to you that the data drawn from this examination enable you to improve your therapeutic results.

 

. : Speak us about your collaboration with Volvo…

. : In fact it is , the other Swedish automobile company installed not far from at home, which came to see me the first while telling me: we want better seats for our cars. I said agreement, I have proposals to make you but search should be made. I am not interested only in comfort of the conductor, I want to also study the various postures, etc I made them an estimate of 6000 dollars. Not, it is too expensive has one says me, one will not do it. The next month, Volvo came while asking me the same question. I made them the same answer and they accepted my conditions. Thus my collaboration with them started. It lasted thirty years and finished the last year. Volvo also wished to solve the problems, in particular low back pains, related to the work stations in their factories. They had much absenteeism because of the evil of back. We made three or four randomized studies which showed that on the work place, the schools of the back seemed effective, then later, that the behavioral supplementary programmes based on psychology were even more effective. All that was confirmed later on by other researchers. What shows the interest of an multidisciplinary approach in this field, in particular on the work place. There does not need many ergonomic changes. It is enough for example to say to the person “made more this rotation movement”. This simple opinion is often sufficient so that people can turn over to work and take again confidence in their capacity to conclude it. With Volvo, we worked well. I was the chief of their advisory committee and their foundation for search, during fifteen years. They gave much money for search and the prevention and this in manner really not involved.

 

. : Did occupational medicine interest you?

. : I was department head at that time and I developed the first department of csotcina.comedy of work with the world. I worked with which is now instructor in Chicago, very known in the United States for his search, then with . But I am also a biologist and I think that psychology has a biological base. The spirit produces substances such as substance is what I did these last years as instructor of search in Georgetown. To seek substances which increase or which decrease the pain of the evil of back, in particular in the , and whose presence is certainly abnormal. For example much of substance P, nerve growth factors and very few endorphins. They are causes or of consequences of the pain, one does not know. It is the problem of hen and egg. It is necessary to still seek.

 

. : How did you make to carry out this life of surgeon and researcher at that time?

. : I do not need to sleep much. Four to five hours are enough for me. What enables me to work much. I must as say as in years 70-80, the situation of a department head was much better as as it is today, in all the Western countries. There is now a real burden of administrative tasks, in particular for the clinicians. At that time, it held there a meeting from 15 to inutes every month with the administration. And that was enough! My wife is chief of a department of surgery of the hand. Each day, it passes the third party of its time for administrative tasks. And it is the same thing for everyone.

 

. : Worked in the United States?

. : Yes. I already said you to have spent my first year to the United States in 3969 96 Then, when I was instructor in Sweden, it was possible to take nine months a sabbatical leave every five years, while being paid. I passed five of this vacation to the United States. The first was in Seattle in 1980, where I worked under investigation Boeing on what the workmen in the factories did. We had added to the questions of a mechanical nature, lived compared to the work from the psychological point of view. With our great surprise, these psychological questions were better predictors that the mechanical aspects, incapacity to work because of the evil of back. It was the first exploratory study made on the psychological aspects of work. These psychological aspects are, even more important as much than the biomechanical aspects. The results were published seven to eight years later.

I passed my other sabbatical vacation with , then in San Francisco, Boston (in Harvard) and finally in 1990 in Georgetown. I thus could observe what occurred to the United States. It became similar in Sweden and, I suppose it, in France too. More and more of administrative tasks restrict search. And also, the young doctors today do not wish any more to pass their evenings and their weekends for the love of search, as we did. That could cost you a wife or two, as it was case for me… But, at all events, I was very happy to do all that.

 

. : Moreover, one cannot make search any more all alone…

. : You are right. The things are intricate. It is now necessary to be surrounded by a team. And if you move, you lose the contact with your collaborators. This is why, in my opinion, the American system is devastator, because they move all the five or six years. Another thing which I must say, even if that resembles socialism, it is that the medicine of state or insurances or social security gives better possibilities for the clinical research, or at least gave some.

 

. : You obtained recently…

. : The list of the prices of search which I obtained is long. I obtained that there for the last thesis which I directed. With do the fact, you know how much I directed from there? Eighty one! Eighty csotcina.comedists passed their thesis in my service. In short, for the latter it was a question of re-examining the patients whom I had operated of scoliosis between 1970 and 1975,25 years later. It found of them 93% which returned to consult. One day whole of examinations, including questionnaires on quality of life. We could show that practically all had an at the same time physical normal quality of life, psychological and even sexual. Today, it is not sufficient for an csotcina.comedist to be satisfied to measure the angles and the movement. The patient is important. it is him whom one must study with psychosocial questionnaires, the 36 or other questionnaires of evaluation of the wellbeing. It is as that which we gained the price.

Another thing, since one speaks about price, I had told to Volvo: “the best thing than you can make is to give money each year to reward the best scientific study in connection with the evil for back”. One started with 5000 $. There were three prices each year. The next year, it will be the 24th one and last price. Volvo, in this field, was exemplary.

 

. : You were also one of the creators of the review?

. : To did the beginning of the year seventy, the editor come us to see, Henry and me to ask to us whether we were interested by the creation of a review on the rachis? We told yes. Henry dealt with the United States, me of Europe. One started with four annual numbers. One is to 24… I continue to make the number devoted to the Volvo price. About at the same time, there was creation by and some others of International Study off . A stupid name for a very beautiful society…

 

. : Why stupid?

. : Because it is intricate to tell!

. : Did this Society exist before the review?

. : Yes. It was an argument moreover to create the review.

 

. : Speak to us about “Cochrane Collaboration”.

. : Since we do not know what causes the evil of back, we must trust with the good randomized trials to know which processing goes or does not go.

It was that I had been invited to to give a conference, and there, I had heard of of Oxford which had initiated “Cochrane collaboration”. This group had had an enormous impact on the perinatal mortality of premature, by revealing the effectiveness of a simple preventive medication. They scanned the medical literature to tell: this method is much better than that there. This attracted me intellectually and it is as that which I started to work with them. We really started in 1993, in Oslo. I do not think that we still have an enormous impact, but nothing has impact before ten years. In a near future, the politicians and the insurance companies will make sure that a method has a cost-effectiveness positive ratio. If it is not, they will reject it, if it is yes, they will impose it. It is what will arrive, but that will take time, at least until we know the real cause of the evil of back, which will also end up arriving. But it is difficult because the personal relation with the doctor, the placebo effect is very important, more than elsewhere. For example, for the lumbar arthrodesis, you will listen to the Volvo price in Edinburgh. It took ten years to know the test results Swedish. It is on the whole a reduction of 30% on the ladder of the pain and a similar improvement of the function, and it is all, with some complications. Forty operated percent of are turned over to work, not more. You can announce that with the patients. The cost-effectiveness ratio should now be calculated. Such studies will be increasingly frequent. The difficulty with the group Cochrane, it is to note with relevance an item. The group in is very conscious. It developed statistical procedures and epidemiologic to this end.

In short, here what I currently do. I also deal with some studies
randomized on various procedures of conservative treatments, and the fibromyalgia. I stopped operating. I have just been 70 years old last week.

. : You started to work at one time when the disc reigned as a Master on pathology. It is always the case?

. : For an csotcina.comedic surgeon, yes, of course. But I must say that the total responsibility for the disc is not proven, not more than that of the breakages, the muscles or the ligaments. And that the problem is different at each patient. Moreover, all the degenerative hinges are not inevitably painful. There are also the vertebral plates and the adjacent bone whose amendments could be significant. For the sciatica, there is the new one. We learned now that many hernias were asymptomatic. Biochemistry of the disc also will play a part: not only with , but also of other cytokines, immunoglobulins, making the root more sensitive to the pressure. From here four to five years, there will be a pharmacological solution with the severe sciatica.

 

. : And the mechanical problem?
The root is often wedged between the disc and the bone, trapped in the …

. : I think that there is a combination of all that. But if you look at MRI, you will find also this type of problem among asymptomatic people. To have a sciatic nerve a pressure is needed but a also little chemicals! The canal coarctation is also a beautiful subject of search because people live older. I think that the number of compressed levels is important. If compression is done on only one stage, it can not involve any symptom. But if two or three levels are related to, the things become completely different. On the other hand, more you open the channel, more you risk complications… In my service, one showed using randomized studies which the patients with merger were definitely better than those which had not had of it. Other studies show that at the end of 5 to 10 years, the bone pushes back and the symptoms repeat. In any event, there will be an increasingly keen demand to maintain old people in a position to go, and there, the surgery is effective. But, again, this relates to only the pains in the legs. Not the low back pain, which remains a unsolved problem. The surgery is not the solution of the low back pain.

 

. : It should be said that in the United States where many arthrodeses are done, the patients have the choice only between the chiropractor and the csotcina.comedist…

. : It is a question of economic order, I am sorry to say it. Initially, remember that in the United States, much of people do not have an insurance health. Here, in Europe, we are protected in one way or another, even if we cannot work. In the United States, you have protection only if you have incomes of your work. The demand for a “fast repair” is much keener than in Europe. The other economic factor, they is that the more the surgeons operate, the more they are paid… If you live in a society where your statute is judged according to the number of your cars or your houses, it is difficult to resist temptation to do one or two million dollars moreover while operating! I often say it to my American friends. They answer me: yes, you are right, but, for example, I need to pay the studies of my children in the best school, or of going on vacation with my wife. It is a company name or socio-economic. And this is relatively more important for American, their social life, than for us in Europe. They are less good doctors than us. But we prefer to walk in our pretty cities, paid by our taxes. Here is the great difference. There is also a competition, since there are more csotcina.comedic surgeons (and surgeons of the rachis in particular) per capita in the United States that everywhere else.

 

. : And what do you think of the instrumentations of the USA?

. : If I were malicious, I would say that they were well reported that the simple arthrodesis was not a great success. Then, when and others saw and its plates, they were told that could improve the output of the arthrodesis. They are very inventive and the money counts. Some had much success by manufacturing a rachidian instrumentation, which they sold for not some dollars, but for hundreds, thousands of dollars! And these first successes stimulated other csotcina.comedists, other inventors. This is why we now have instrumentations of arthrodesis per hundreds. But it is not all. Others were told that perhaps this instrumentation was vain, that it was necessary to pass by ahead and to put cages. One of my friends developed his own company of cages, a method completely not proven, and sold it for illion dollars. Other types of instrumentation per former channel were developed. Now, we see new things. To put a pointer in the disc and to make an electrocoagulation (method ), by burning the nerves of the . My first operation of csotcina.comedic surgeon for an hip osteoarthritis had been to burn the obturating nerve. Ca went only in one certain number of cases and in general not more than three weeks… A beautiful result! Another innovation, the artificial disc. The prosthesis of the intervertebral discs, you know it, was born in old East Berlin. I made experiments in the Sixties with a prosthesis which I put in the disc, while thinking of restoring a normal physiology. For sure, physiology was restored. But silicone disintegrated after having undergone a few tens of thousands of weight-bearings. With that there, you did not can have gone well far! Then I forgot it. One tested other types of prostheses on monkeys, that did not walk either: the baboons would die! Then another inventive type, of Antonio, posed prostheses on coyotes. It operated a whole heap of them, to put to its prosthesis with by precaution an control group not operated to them. When it was necessary to study the results at the end of one year, all operated and their prosthesis had been devoured! It is not good, that one? The famous experiment of the coyotes!

 

. : Let us return to the prosthesis of the intervertebral discs human…

. : The history of the prosthesis “Charity” started with a surgeon, a woman, who had the aid of the East-German authorities to develop her prosthesis because it had gained #D1FFFF medals with the Olympic Games. She wanted to preserve the movement. It was helped because it was thought that there was a market which would make it possible to garner currencies. The first developed model failed, the second also but the third is disseminated little by little. However there is yet no randomized study to know at which it to put and which is the result. In a study, there was more than 20% of reintervention. For me, all that involves more than 2 to 3% of reintervention is a failure. So for any operation, an csotcina.comedist came in a congress while telling: we owe a fifth of our patients, it would be rotten outside. Look at the surgeons of the hip with their prostheses: they can say that it improve 98% of their patients with 5 or 10 years. And us, csotcina.comedists of the rachis, we are badly placed for the competition.

 

. : But it is necessary well to progress and innovate…

. : Of course, but with method. The weather is necessary to be initially biomechanical experiments or on animals. Then if these studies you receive the authorization to operate ten patients but you prove to be profitable need randomized studies. And it is necessary that it is someone else whom the designer who makes the study, because without that, there would be an enormous internal skew. There are as well examples showing as if the inventor of a method makes part of the team of evaluation, the results are always much better than if she is made elsewhere. Skews, it are what there is of more important to avoid in a study.

Then, nowadays, we speak about economic medicine. If we can show by a randomized study which a method has is higher than a method B to look after people, the problem which installation is that there is much of under patient groups, but you do not know what are these under groups. Even if you prove that a method is better than another, it cured not with all the blows. You did not show yet formally that for such patient, it is necessary to make such method. You simply showed that at a patient, there is a certain percentage of chances that a method goes.

. : But isn't the economic pressure it not carrying other skews?
It could impose a less effective processing to us, if it is less expensive.

. : There is perhaps a risk. This is why is to the doctors to decide what is good or not for the patients and not with the politicians, who them, look at only the economic side of the things and anything else. Made good studies and called to the politicians: here what I find, here what I do. And you will see that it will be the final word.