The 12th annual convention of the Européenne section of Cervical (CSRS) was held in Nice in June 1996. The and the environment of the congress were cordial with the image of the Chairman, the Instructor Claude .

 

. : You organized this congress of the . About what is it?

SALES: It is about a society which was created some ten years ago by Pierre , , , Rene Louis, under the impulse of Mario Boni, its first Chairman. This society is the European subsidiary of the US company. It thus gathers people interested by the spine surgery cervical, i.e. csotcina.comedists, neurosurgeons, but also of the rheumatologists and radiologists, In addition, one of the most active charter members was not other than Mr .

. : How were you brought to occupy you of this congress?

SALES: The congress is held each year in a different country and it was that my candidature was retained by the “officers” of society. I must say that I am interested for a long time in the cervical rachis, but that the attraction of Nice east certainly for much in this choice, more especially as I am the current Chairman of this society.

. : What is nine on the cervical rachis?

SALES: The first topic of the congress relates to famous “the ”, which one knows the extreme frequency, and who gives place to many controversies. Indeed, for some there exist anatomical lesions primarily of the intervertebral discs revealed with the MRI; other authors, in particular English, are very skeptics on the importance of the anatomical lesions, and even more on the continuation of their chronic after-effects, which is not without posing medico-legal problems. Currently, the MRI shows lesions indisputably, but these lesions which had with the traumatism, or are recent lesions already existing lesions? Which is the worsening share of the traumatism? All this shows, like specified well it in synthesis, the need for making an annual revaluation of this pathology, and in what relates to us, it is already the third year that we deal with this problem. The second subject related to the bone graftings. The bone graftings are with the mode. The disadvantages of the autografts were stressed: pains with the site of taking away, possibilities of cutaneous disunion; one is sometimes struck by the fact that, in the continuations of an operative intervention, the patient does not make case of his cervical rachis any more, but complains only about its capture of Clerc's Office. On the other hand, the possible transmission of certain viral diseases by the , as by the xenografts gave to these grafts a very bad press. This is why search is focused more and more towards synthetic materials.

. : Some of the bone substitutes, do you think are the theoretical advantages that they support the comparison with the good old autograft?

SALES: I do not think it. In fact, one directs oneself rather towards the use of the bone substitutes like “” more or less associated with a Clerc's Office of cancellous bone. Studies are in hand to include osseous airframes within a collagen structure. The acknowledged aim of any csotcina.comedic surgeon remains to support the manufacture of bone. This osteogenesis is not an inaccessible aim, I have the impression, according to what we understood, that there is already products which have a ostéo-conductor negotiable instrument, but that little by little one will lead to products ostéo-trainers. The third topic was that of the lower processing of the cervical spine traumas. We worked much on this subject, and we developed a classification these traumatisms which was retained by . The processing of these lesions is still discussed. You could note the opposition, always so sharp, between the school of Raymond defended by Christian , fervent supporter of the posterior accesses and fixings by plate, and that of Jacques defended by Jean-Marc Vital and Vincent who give the preference to the former access. I must say that, in our experiment for 15 years, 80% of the cervical spine traumas inferior have been operated by former channel after an csotcina.comedic reduction by traction or manual reduction, and that this former fixing gave us great satisfactions. We little spoke fault about time, and I regret it, of the operational continuations. They are, in my opinion, heavier after posterior access where one needs these enormous muscle masses than represent the muscles of the ring with, like consequence a longer and difficult rehabilitation, with risk of stiffness. On the other hand, the direct character of the former channel without any muscular line is for us the reason of the simplicity of the operational continuations, the majority of the patients taking again very quickly their daily life and their activity with a simple collar.

. : Does France preserve its advance on the surgical treatment of the traumatisms of the rachis?

SALES: Yes, but it should be said without too much “cock-a-doodle-doo”, because the ideas evolve/move particularly in Europe. Osteosynthesis by former plate is something of rather recent in the United States and in the Anglo-Saxon countries. Since when do put we former plates? The plate of was used since 1971. You report yourselves difference? Former fixings that we make by Clerc's Office and plate have of the results quite higher than fixings of , which used only bone grafts with frequent mechanical complications. As for osteosynthesis by posterior channel, she was invented by Raymond there is more than 25 years and, at this time, no Anglo-Saxon used true metal hardware of stabilization to the cervical level, except perhaps some wire.

. : One sees coming up at the horizon of new technologies of sighting…

SALES: It is rather tempting, but that requires a very important financial investment, and it is nevertheless a guideline which moves away a little the usual surgery. That will require a specific training. Will that in the long term bring a benefit for the patient? Will the interposition of the machine decrease the percentage of error? For the moment, I remain attached to the “human” knowledge which I think reliable in the majority of the cases, but it is perhaps an exceeded design. Who knows so in a few years, our pupils will not operate “remotely” with levers and screens. I think that then it will be really the end of the surgery such as we learned it, known and taught, especially when the surgical indication is entrusted to the computer.

. : In does term of financial investment, the turn appear to you close?

SALES: In the actual position of the economic indicators, that appears to me out of reach for the large majority of the experts.

. : How is your service in Nice organized?

SALES: Little time ago still, I directed a service of 90 beds, but I have just divided it into two: the properly party remains at the Saint-Roch hospital, with 65 beds under the management of the Instructor Fernand de , and the “csotcina.comedic and vertebral” party more specifically (30 beds) is installed in the new hospital with Bow II, where I exert with Pascal . We still hope to develop the hospital csotcina.comedy, which did not exist when I arrived at Nice in 1978.

. : Which are the fields which particularly interest you in the spine surgery?

SALES: We are particularly interested in traumatology, and I wrote in collaboration with Jean-Pierre and a book on thoracolumbar traumatology, intended for the experts of English language. With my regretted friendly Bruno , we directed a roundtable to the congress of the 1995, on the processing of the fractures of the thoracolumbar rachis. Traumatology is the greatest part of our activity on the rachis, since the Saint-Roch hospital receives all traumatized of the rachis of the area. This enabled us to develop an original technique of fixing per association of screw and hooks, hooks which we made amend by the manufacturer. For the cervical rachis, we began again with Fernand de and 250 files; we have, with the aid of a radiologist Doctor Patrick , re-examined all the radiographs, and we ended to a classification which seems simpler to us than that of and which, especially for us, has completely logical and direct therapeutic implications. In addition, I developed the spinal surgery of the chronic disorders and several theses on the thoracolumbar spondylolisthesis or vicious cal were made in the Service.

. : With regard to the coarctations of the cervical channel which is your preferred processing?

SALES: The former access with a broad former decompression and a solid stabilization by Clerc's Office and plate.

. : Do you have control by referred to potentials ?

SALES: For one year indeed, we have been able to acquire an aircraft for the collection of the referred to potentials (PORTABLES EXECUTABLE). We largely use it, i.e. not only for the scolioses, but also for the reductions of spondylolisthesis, or the installation of inter-somatic cages which can expose to radicular attacks. The collection of the PORTABLES EXECUTABLE is also very interesting in traumatology. Recently, we received a casualty who had been clinically classified like paraplegic complete without any hope of recovery, but where the referred to potentials let hope for a less dark forecast; three months afterwards, we have the happy one surprised to see the patient starting to stir up the lower limbs.

. : How did you come to the spine surgery?

SALES: This question brings back to me to my friendship with Rene Louis, and Maurice . We were in the same year of medicine, and we were all the three pupils of Michel . Then, our paths diverged a little. Rene Louis, from his exceptional qualities, passed all the contests before us, and was sent to Dakar. Maurice was placed at the Northern hospital to make pediatric surgery, and me I had to install me downtown after my . With the return of Rene Louis in Marseilles, the post of Dakar was released creating an opportunity from appointment which I seized, thanks to the share of Mr , my Master in Anatomy, legendary character, who fascinated us as well by his human qualities as by his excesses. These was a personal choice which made smile some, and which made me regard as a “original”, because of the very comfortable situation of my Marseilles installation. But teaching was always one of the engines of my existence, and to take the post in Senegal was a means of reaching that point. To Dakar, I directed the laboratory of Anatomy, where we had the possibility of doing work on the rachis, and I could make vertebral surgery following Rene Louis, who had particularly developed the spine surgery and of the evil of . It was easy for me to proceed in its way and to thus acquire a certain surgical experiment. When I returned to Marseilles, I was likely to be the assistant of Rene during two years, and there still I improved in spine surgery. When I was appointed in Nice two years later, the spine surgery practically did not exist in hospital medium, but we received many traumatisms, and thus I could develop this speciality. Thanks to collaborators of value, of which I was likely to be always surrounded, the service acquired a certain reputation, and gradually, we also took charges the degenerative surgery with it. Thus, with Rene Louis and Maurice we find ourselves in the same speciality and it should be said that our friendship has been always also sharp and deep for more than 30 years!

 

. : Your common Master was Mr ; which kind of owner was this?

SALES: Mr was a character out of the commun run, out of time, as well in his very strict way of life as in his clothing. To give you an idea, it carried hard necks and removable cuffs. Everyone knows the history of the commercial gross of fish which arrives while complaining about the elbow and which Mr asked, probably in a wrongfully ingenuous way “Play you with tennis?”. It was paternalist, and the ritual of the inspection of Sunday morning, accompanied by our respective children, represents one of the examples of them more striking. We had all for him a deep affection. He learned to us much from things, because it was one time when little of anybody had “science” and experience, and there was not the possibility like today, to be formed on the left and on the right; my first “visits” outside, thanks to Gerard who initiated me with csotcina.comedy, was done at the 33 years age. I discovered modern osteosynthesis at Maurice , and my enthusiasm was such as I on the spot bought with the factory of the hardware, and thus could place first implant at Marseilles in 1966 thanks to the comprehension of Sirs and .

. : On was the professional level, it rather innovating or rather conservative?

SALES: It is difficult to tell, because known we it in the 10 last years of its exercise where it was rather in favor of the conservative methods. But it should not be forgotten that it is him which, at the beginning of career, had described the anatomy of the arteries of the members, and the vascularization of the skin in a way completely innovating. It, had in addition introduced the transfusion of blood in Marseilles, and had amended deeply the techniques of osseous stop of hip. It was thus opened with the novel ideas, and it had allowed me, with the return of , to place the first hip prosthese of in its service. In addition, he appreciated the inventive spirit of Robert at the Days of which we went together regularly.

. : It would have been a precursor of the surgery of the scraps?

SALES: Completely. The surgeons plastics technicians who started to study the scraps or the Clerc's Offices, first of all consulted the Treaty of the “arteries of the skin” of ; this kind of anatomy had never been described before. As for the arteries of the members, the Treaty of and made authority for a long time.

. : How was held your implantation with the of Nice?

SALES: When I arrived, there was only one small department of traumatology in a general surgery service directed by a general surgeon. At the end of two years, the service was individualized in service of csotcina.comedy-traumatology. For a few years, there has been in Nice, a rather interesting collaboration between the city and the hospital: the hospital owes, in my opinion, to deal with the heaviest cases, like the multiple traumas, the fractures of the rachis with neurologic complications, the dilapidating lesions of the members, whereas more current traumatology should be directed on the private sector for which it is necessary than we are complementary, would be this only because of the considerable number of femoral neck fractures, witness of the high number of old patients in our area.

. : There is one in the area; how do you make in the event of catastrophe?

SALES: We had to deal with two important catastrophes: that of Furiani, where we had a great number of fractures of the rachis to discuss quickly, and that of the hull slamming of the roof of a supermarket. There was in these dramatic situations an extraordinary solidarity which was created within the hospital. All the speakers in the channel of the care invested themselves completely, without taking account of their “normal” schedules. For the tragedy of Bastia, two of my collaborators immediately left on the spot, where they helped to operate during more than 24 hours our Bastiais colleagues. In Saint-Roch, we had very quickly set up a system of sorting, to return on their premises, or to transfer in other the operated medical structures, patients, in order to make place with the casualties.

. : Being only university service, as did you organize the training of the csotcina.comedists?

SALES: I believe that was one of the great “challenges” of the service and encouraged us to adopt a nonsectarian attitude with respect to the various problems. As of the beginning, I sent my collaborators to be formed at Gilles , then at Henri and Gilles : they brought back in the service of the completely modern and completely powerful designs of the processing of the lesions of the knee or the shoulder. Others went to Montpellier, where they were formed with the surgery of the open fractures of the members with Jacques , or in Colmar at for sporting traumatology. Not having personally at the beginning of intangible dogmas as that exists in certain schools, the service thus largely opened, and I believe that this amalgam was really something of very beneficial for surgeons and patients. Thus I could concentrate me on the spinal surgery without fearing that in the other fields, where my experiment had been stopped by my African stay, the service is not exceeded.

. : You are not obstructed by the little of posts of head of private clinic which you can offer?

SALES: Certainly, and our interns are obliged to sometimes wait a year without post office at the end of their boarding school to have a . Indeed, I have only two senior registrars and four hospital practitioners, but that is insufficient for the activity of a service which, do not forget it, receives 24:00 the /24 every day. Moreover, our activity did not cease growing, and our rate of filling is of 92%. It is certain that, the low number of posts of head of private clinic is for us a handicap, but you know that we committed ourselves training only one csotcina.comedist a year on the national plan, and that the multiplication of the specialists would involve big troubles in the short run.

. : Your Jean-Christmas son is instructor of csotcina.comedy in Marseilles; do you believe, following the example , with a hereditary transmission of the acquired features?

SALES: I am very at ease to answer because the appointment of my son does not lie at all within the scope of an employers' continuity. Indeed, it remained in Marseilles, after my departure in Nice, and if it were appointed instructor, it is certainly thanks to its personal qualities, but also in support of its Master Jean-Manual. The history wants that was my external then my intern, and that it perhaps withdrew from them certain lesson at the beginning of his hospital career. You see that there exists an indirect transmission all the same; but what contradicts the theories of formally, it is that my son does not make absolutely spine surgery.

. : How do you see the development of the spine surgery?

SALES: It is a speciality enthralling and innovating, and all the assets to date risk to be called in question on the following day. The service has taken, for two years, the turn of the endoscopic surgery. I believe that, in a few years, our pupils will grant an increasingly important place to this surgery which is less dilapidating. Indeed, it sometimes happens to us to pass one or two hours to make a broad channel initially to go to place, in ten minutes, a small graft between two vertebrae; whereas with a very tiny incision and the aid of the endoscopy, we can carry out this intervention in a less aggressive way. This surgery is still in the course of evaluation, and one should not under considering the risks of complications, primarily vascular, which require to very quickly transform “closed” surgery into “open” surgery. When one sees with the cervical level, the difference of the operational continuations of the former channels where there is no muscular line and of the posterior channels, one is reported that the muscles do not like at all to be maltreated throughout intervention. I thus believe very sincerely in the future of the endoscopic surgery which will enable us to operate, more simply, the fractures, and which will have also a great interest for the lumbar arthrodeses, in degenerative pathology, and for the surgery of the tumors and the infections.

. : Will traumatology, with its particularly hemorrhagic context, be able to profit from it?

SALES: Traumatology implies the immediate need for stabilization. It is certain that the techniques of osteosynthesis we currently have still have a bright future in front of them but, on the other hand, the complementary bone graftings by former channel are excellent indications with the endoscopic surgery. We have carried them out for two years for the lumbar fractures, in deferred urgency.

. : In practice, is this endoscopic surgery a surgery of team?

SALES: The accesses that we made for disc were possible that thanks to the aid and with the skill of a colleague ; for the retro-peritoneal channels, the methods are simpler: for the moment, we require for the surgeons , and we will be able to progress only thanks to them, but I am certain that more and more the “specialists” in the service Fernand de and will be able to fly their own wings.

. : On the whole, your professional course was rather original…

SALES: That was one of the chances of my life, because, I did not have time to see to settle the routine, being obliged to call me several times in question. First of all, the was, as for everyone, one difficult moment. Then, to leave for Africa abruptly changed all my practices of life, as well on the professional level as on the family level, but allowed me to acquire an incomparable human experiment. Then the return in France, the of the modern surgery after five years of “smartness” in a African hospital, was not done without problem, in spite of the friendly greeting of Rene Louis. Lastly, I finish my career in Nice where I again had to create something. But all this was done with young people, and I am convinced that one never advances all alone; there is a synergy between an owner and his collaborators, and it is this union which makes progress the things. Finally, that was my great chance to be obliged, on several occasions, to restructure my community activity.