. : It is what ?

: was founded following an official report made by Charles , and myself. We are saw that in society scientific existing, in particular North-American, it was very difficult to make pass from the communications on the techniques of vertebral not-merger and prosthesis of the intervertebral discs because the academics and academicians of today are probably not very with the current of what is done in this field. Thus rather than to spend 15 years to take a little scientific capacity in these organizations, we decided to create from the start a society dedicated to the techniques of not-merger in the rachis. And joined us , Michael and . It is thus an international scientific society, whose first Meeting took place in Munich in 2001 and the second in 2002 in Montpellier. The next one in 2003 will be held in Phoenix.

. : What do you understand by techniques of not-merger?

: This terminology is criticizable because one is defined compared to what was done before and not compared to what we make. They are in fact all the operative techniques which are practiced on degenerative rachis apart from the arthrodesis, such as for example the techniques of replacement of the intervertebral discs nuclear, the techniques of percutaneous surgery of rebuilding and the techniques of . But the most important technique, in term of indication, is and will be probably in the future the prosthesis of the intervertebral discs.

. : Where is one prosthesis of the intervertebral discs?

: There are two types of prostheses. The mechanical model “total disc ” is that which everyone knows and which, in the case of that I use, has a retreat of a dozen year. The different system is the partial model which aims to the nuclear replacement and which would be indicated before the stage of complete crushing of the disc. In this last indication, there are many technologies which all emergent but are not 10 years old of retreat. It there with the prosthesis known as of of in the form of small cushions, it there with the spiral with the development of which Jean Louis of Rennes took part, it there in which is a nuclear sphere of replacement; but these last are very new techniques which call upon new materials and new concepts and emergent just of the experimental stage.

. : Can one give a progress report on the mechanical model which is now 12 years old of retreat?

: The mechanical prostheses have an impressive durability. Durability in three categories; the first it is the hold of the initial clinical outcome which is not degraded; the second, it is the hold of found mobility and the third it is the hold of prosthetic material set up in space of the intervertebral discs because there is no loss height, not remains and not complication related to the wear of the prosthesis.

. : It is currently true for the two models on the market?

: In any case it is true for , for the other the model SB Charity I do not have of it an personal experience. It would seem that long-term the results published by Thierry David are satisfactory subject to a correct implantation based on a long learning curve.

. : Is this the same model that you have used for 12 years?

: It is a prosthesis which is composed of three parties: two plates and a core of polyethylene. The only changes that there was in 12 years relate to on the one hand the insertion of the polyethylene core which in the new version can be done after the fixing of the plates and on the other hand the suppression of one of the two ailerons of fixing of the plates. These small amendments without mechanical angles of attack have enormous practical consequences because they make it possible to establish this prosthesis by minicomputer-incisions thanks to the techniques of surgical.

. : How did you proceed 12 years ago?

: In the Eighties, each time one had a difficult surgical problem with a lumbar disc, the only solution was to sacrifice the function with all that contains in the field of the balance of the rachis, of loss of intervertebral rotation, loss of the mobility and risk of degradation of adjacent structures. On the basis of there, I thought of a prosthetic replacement by basing me on the experiment which we had acquired on the replacements of hip and knee. It was necessary to find a mechanics which can restore the functional mobile unity, with a primary and secondary stability. One needed a polyethylene dome to be used as shock absorber and to maintain a certain elasticity with the system. But it was necessary that polyethylene is constrained at its basis not to become deformed. All these elements were on the specification of a prosthesis of disc. For that, it was necessary to develop a prosthesis which was compatible with intervertebral mechanics, not only that of the disc but also that of articular posterior. It is a little as that which this prosthesis took shape. It is necessary to abolish any risk of migration because ahead there are the vessels and behind there is the bag . This was obtained by primary anchoring thanks to the keel and by the titanium surface coating. With regard to wear, the tests carried out showed an infinitesimal quantity of remains, without deformation of the polyethylene core. Moreover, it is not a question here of a synovial hinge and thus there is little risk of reactions to foreign body. But it had by the conservation of the quality of surfaces to be shown that mobility is maintained long-term. We ended to the first model of in 1989 and I then began the implantations . At the end of 64 patients, because of the good quality of the series, I stopped by telling me that it was necessary to see what that would give with a sufficient passing. As for any other arthroplasty, a minimum retreat from 5 to 10 years is essential to judge a technique.

. : By which channel initially did establish them you?

: By channel of access either retroperitoneal, or median . I was at the time completely faithful to the techniques taught by Rene Louis.

. : Did you have early troubles?

: Not. I had a complication rate on the accesses which was very weak but I had a large practice of the former accesses because of my formation at Jacques and of Rene Louis. I had migration of prosthesis, neither of paralysis, nor of hematoma. I had some minor complications dependant on the access but absolutely any other complication. In addition none the prostheses of the first generation was withdrawn. Certain patients were arthrodeses by other surgeons for persistence of pains, 5 cases out of 64, therefore less than 10%.

. : For which reasons they were grafted?

: They are patients who continued to suffer. The consulted surgeons decided that it was the prosthesis which hurt and they thus fixed the stages prostheses without complementary browsing. With the result that one passed a little beside the true diagnosis in some case (a patient had a thoracic hernia, the other a compression ). But it is obvious that one can have badly with a prosthesis when the indication is not good, or that the prosthesis itself was not established under good conditions. However, in the event of repetition of pains and in front of a new technique whose surgeon does not have experience, the first diagnostic reflex is to show the technique in question.

. : Then why you stopped?

: For several reasons. Initially when one is all alone to do something of innovating, one puts questions. All those which made raids in the desert know this impression: even if one is certain of his option of navigation, if no other competitor takes the same one as yours, when one is turned over, one realizes that one is all alone on the selected route. One starts to worry especially that at the time the prosthesis of the intervertebral discs sulfur felt. Then, one started to have echoes of problems of settlement. Lastly, when one really innovates out of surgical matter, it is necessary to know to stop to see what that gives. Because so at the end of 5 to 10 years of implantation that does not go, one will not have 64 patients who will not go but 500 and it will be a catastrophe. That was seen with certain knee prostheses and the mobile cups. It was thus necessary to advance with prudence and in any event I could not, to be credible, publish a result of prosthesis before 10 years. I thus stopped the installations during seven years, of 1993 to 2000.

. : During these 7 years which did you note?

: We have now, on a 10 years retreat, a good performance on the lumbar pain. But what is surprising, it is the quality of the development of the radicular pains, since it is still better than that of the lumbar pains. This is due to the of the stage, the reopening of the foramen and the re-callipering of the channel. If one associates with that the of the intervertebral discs complete with all the breakdown products of the intervertebral discs which are not present any more, one understands better why one is also effective at the radicular level. One noted the absence of loss height of all the measured prostheses, therefore there is not premature wear of polyethylene at 10 years. One made scanners with all the patients, he does not have there no bone resorption around the keels of anchoring, not of , any visible reaction and a mobility which is maintained in time. I.e. the prostheses which are mobile at one year will be mobile at 10 years with an excellent hold of the sector of mobility. Lastly, the last point is that one did not see major degradation of the overlying discs, since except a repetition of slipped disc to the top of the level of the prosthesis and a patient who and who has restenosis with the top, there was not of surgical resumption of the adjacent discs.

. : How did the articular breakages evolve/move?

: Our first components were out of titanium and we thus profited from an excellent quality of imagery with scanning it and the MRI. The development of articular is favorable. There is no destruction and on the patients who had already the articular ones used there is a stabilization, even in certain cases an improvement of joint spaces. That is explained by the fact that the drawing of the prosthesis restores the function of the functional unity overall, and thus neutralizes all the forces of horizontal shearing. Thus the of articular and the neutralization of the horizontal forces of shearing relieve the articular posterior ones. This neutralization of the forces of shearing is related to a translation which is done automatically by the drawing of the prosthesis and not by an update in intervertebral space.

. : Which your indications were 10 years ago?

: 10 years ago, one proposed this prosthesis for the worst cases, since one did not know what this technique was going to give. Thus much of on two floors, some on three floors. 50 patients out of 64 had already been operated and for some on several occasions. They were thus the exceeded cases, and always .

.: Were the immediate results better than those of an arthrodesis?

T. Mr.: The results were better because the pain in 60% of the cases disappeared immediately. And in the three months, one went up to 78% of good performances. The patients could take again an occupation what was remarkable because of the fact that they were in sick leave for a long time. 50% were in sick leave long life and most of the time the patient with the alarm clock started by telling “I do not have more badly with the back”. Only 18% of the cases were delayed by a radicular pain related to the handing-over in height of space, primarily at those which were operated several times and where the roots were fixed a little at the level of their posterior canal access.

. : From which did the sulfurous reputation come from the prosthesis of the intervertebral discs 10 years ago?

: I think that there were three reasons. The first, it was the channel initially. There is 10 years the initially former channel was used little in the degenerative lumbar disease even if J. had published the former arthrodeses in the lumbago-sciatica in 1952 and had carried out a conference of teaching with the in 1968. The era of had passed by there and the Eighties had seen flowering of osteosyntheses of quality per posterior channel in the line of certain schools remained attached there were like Marseilles and Montpellier, the Parisian schools were not very partisan of the former channel. The second reason, it was that one projected on the disc the experiment of the other total prostheses and everyone predicted that one would have reactions to foreign body with enormous cysts, rejections of prosthesis, ruptures of hardware and that one was going to find oneself with a bone resorption and catastrophes impossible to begin again.  It was to probably ignore local mechanics, the biomaterials used and the fact that it is not a question of a synovial hinge. The third reason, it is that 10 years ago, the instrumented arthrodesis was in full expansion and that it was the panacea. Then to pass to the prosthesis directly it was something of excessive. It was necessary initially that the majority of the surgeons made their routing with the pedicular fixing which triumphed. One tended to make too long arthrodeses with hooks. One had not arrived yet at the arthrodesis and well far from the cages and thus to put a prosthesis was to want to run before knowing to go. It would have been necessary that each one becomes aware that the result did not depend on the type of arthrodesis but on the principle even of the aforementioned.

 . : What is what decided to you with the restarting?

: When I finished the review of all the patients, and that I noted the quality of the results at the end of an exhaustive study documented perfectly well, statistically valid, I told myself that it was time to take again my implantations. During these 7 years, I had not remained the arms crosseds, I had thought of the problems of access, how to establish in better position, and thus I slightly had amended at the same time the prosthesis and had amended the instrumentation to make it compatible with the video-assisted surgery, minicomputer-invasive. Two elements thus came to be combined at the good moment: firstly the former channel is become again with the last style since we had succeeded in making it minicomputer-invasive and video-assisted; secondly, there was a sufficient retreat with a prosthesis which had evolved/moved in the technological plan and which was plantable in an almost perfect way.

. : Same materials: titanium and polyethylene?

: Not, unfortunately titanium on the international plan is not recognized like couples articular with polyethylene and one was obliged to change for chromium cobalt. It is imperative for certain countries such as for example the United States. It is damage for the quality of controls scanners and MRI. However the interface bone-prosthesis is always out of titanium. But the articular articular couple is out of chromium-cobalt /poly ethylene. I hope for the future that we will be able to take again the Titanium implants for the quality of the follow-up in imagery.

. : For the implantation, do you recommend the aid of a surgeon , or think you that an csotcina.comedist alone can leave himself there?

: Times when the csotcina.comedists had a formation of general surgery and where they passed to the peripherals before joining the are completed. Therefore, they are specialized from the start and one does not become surgeon of the former access without a long formation, a good tradition of the school where one is trained, and a long practice. Initially because it is necessary to learn how to find the good accesses, then because there is gestural to assimilate, and finally because it is necessary to know to manage the complications. It is a formation long and delicate and I think that following the example Anglo-Saxon countries which practice this type of binomial since many years, the French surgeons should approach this surgery with a team spirit. But with all to take it is to be better done to help by a vascular surgeon. But the generalization of the former access for the future will make it possible the new generations to again know the former channel during their formation. That already started with the introduction of the minimally invasive surgery, thoracoscopy and lumbar minicomputer-invasive.

. : What did you have like vascular or nervous troubles?

: In addition to 20 years of surgery per former channel, which represents several thousands of case, there is inevitably a day an per-operational vascular wound or an arterial thrombosis into postoperative, whatever the besides indication. It is clean surgery by former channel: there is a certain number of things to check and that is certainly not improvised day at the following day. I think that it is necessary thus to make exchange rates for the csotcina.comedic surgeons to learn how to them to set up this type of implant, which they must know about the former channel, and probably which it will be necessary to make the same thing for their vascular binomial. It is the best solution and the pledge of an excellent guarantee of the result. I noted it in the United States with a certain number of vascular with which it is a pleasure of working because they are very gifted for the former exhibition of the rachis. And it is nevertheless less stressing for the csotcina.comedist.

. : Since when took again the installations?

: December 16th, 1999, that done three years and more than 100 patients. Broadly everyone is very well.

. : Why continue to make arthrodeses by posterior channels?

: It is the question which it well will be necessary to be posed. When the follow-up of the current series is finished and that many surgeons will have been trained with the joint replacement, the frequency of the arthrodeses considerably will decrease because the result of the prosthesis is better and that the future of the patient is preserved. With a better immediate result, a better functional result and a preserved future, it is difficult not to change for the prosthesis. But it will remain a long time indications of arthrodeses, former, posterior and circumferential because any rachis will not be candidate with the prosthesis; too advanced and unstable coarctation, osteoporosis, dislocations, but one day each surgeon will evaluate if such patient can be a good indication of joint replacement.

. : What enables you to say that the results are so good?

: First of all the immediate result. The patients are relieved immediately with a recovery into postoperative of a few days. They do not need for the majority of them for immobilization, they take again a normal life subject to the cure of their former cicatrice. Only a small number requires a center of rehabilitation. The resumption of work starts to be done as of the first month and the majority of my cases began again in nths. It is completely different from what one notes with the arthrodeses. This is valid some either number of stage and some or surgical antecedents of the patient. Only one flat in this board: those which were operated several times can forward a residual radicular pain for nths and that accounts for 7% of my cases. That ended up passing, I never had with in . These analyzes are very rigorous since all the studies were made under control of the American FDA and by independent observers.

. : Which are the teams which follow you?

: In Europe, the two large initial teams were Michael in Munich and in . Now, there are 60 teams in Europe which pose some. In the United States, the HSS with and and the Gasket with Thomas in New York, Texas Institute with Jack in Dallas, David in San Francisco, and of many other centers in the USA and in the whole world. In France Patrick at Dominique in Marseilles, two teams of the CHU de Bordeaux, Thierry Villa in Paris, and Jacques with the of Dijon. Others currently start like the service of and one hopes for soon a French multicenter study. All, French like foreigners, came to be formed during meetings of teaching on Montpellier. Their experiment agrees with ours.

. : It is not thus any more one experimental technique?

: With 10 years of retreat, it is not any more experimentation. When this technique which was that of only one man, could be transmitted to more than 60 centers in Europe, without major difficulty and in about fifteen center in the United States with the drastic control of the FDA, including for the training of the surgeons, one cannot speak any more about experimental technique.

. : Why did you come to the spine surgery?

: For various reasons. Family initially; I had a father who had a scoliosis which had not been discussed and it was to suffer probably even more psychologically than physically. In any case, very small I had seen the bump in the back. I was 9 years old, I told him: “But hold to you right dad, or you will have a bump in the back”. My mother answered me: that I was not to speak like that with my father, that had done much sorrow to him. That has to mark me some share. Then, later there were my meetings. I was external in Saint-Joseph and I found myself in the service of Jean where there was Michel and a certain Jean came to make former channels there. I was fascinated by this surgery which appeared extraordinary to me. Then I realized that it was a surgery where there was enormously to make and to imagine.

. : And then?

: After some training courses of house surgeon in Parisian periphery, I made a stay in overseas during my military service. Then I made my boarding school in Montpellier with especially 4 six-month periods at , a nths stay of at Rene Louis in inter , and of the “” in Jacques and the Master Raymond .

. : It was how at ?

: It was a large house. I.e. that there was an owner who was present and who taught a catechism. It was a school where you learned how to make your trade and which made you become a man very as much as a surgeon. The owner taught us several things and initially humility. The more one was a good surgeon and the more it obliged us to be humble because it was afraid that our young ego of swelling surgeon, we do not burn ourselves the wings in surgical catastrophes. The more it was due to us, the more it supervised us, so that we do not exceed our personal capacity too quickly. Then he taught us the respect: respect of the trade and the respect of the patient a little as in music, the respect of the work which one plays and at the same time the respect of the public. When there was a failure to begin again, some is the surgeon who had operated in first hand, the irony was banished, and it taught us that the sarcastic remark is always turned over against its author. He adored the quotations in particular those with biblical connotation, “do not judge and you will not be judged” and for the growing surfaces granted to the exponents at the time of the congresses “it is necessary to drive out the merchants of the temple”… vast program!

. : How long did you remain with him?

: I remained 8 years. I was hospital practitioner there.

. : It is in its service that you developed your hardware of rachis?

: Yes, I developed that into 83 at . The initial idea was to have an anchoring in the to be able the . It was necessary to stop making distraction with which was and and thus granting the techniques with my ideas on balance . And of needle and thread I developed a whole rachidian system of implants. I went to see Swiss manufacturers directly and I exposed to them my project of hardware for the rachis. In answer they showed me the publication of the patent of the hardware of CD (which was not yet on the market and which was going to be forwarded to spring 84 with the hotel during the congress of the Group of Study of the Scoliosis in Paris). Then they told me that there was already also , and that there would not need another instrumentation of rachis in the future. I adore this kind of visionary! The system that I proposed was carried out by society four years later. It was which became now Evolution and it was the first titanium hardware for the scoliosis.

. : You had career-advancement opportunities hospital?

: The owner never proposed directly; it was a , and the king of the “unvoiced comment.”  I was pH, he had not aggregated there in the service, the route was open. Once or two it had invited me to prepare my list of the bonds and work with a view an inscription with the short list, and to begin the turn of France but it had asked me at the last time to withdraw me, because it was not politically playable or whereas did not have to be revived the local quarrels. Then, with time, I wearied myself a little. There was also the risk to be found day at the following day in a wall cupboard (hospital ) at the time of the retreat of the owner. I finally went to tell him that I was going to leave because the things did not move. I did not have the impression that the weather was large thing to retain me. He told me “you are like the goat of Mr ; the wolf (the private one) attracts you and it will devour you this night on the hill like ”. Alphonse is a crop of the south.

. : Thus you settle?

: I settled in Nimes in private clinic. But with a very important activity, I was limited a little in my work tools and I did not have all the technical plate necessary to the spine surgery. I thus returned into 94 to Montpellier where I found the essential conditions with this activity.

. : Which memories did you keep your first years of private practice?

: My first impression was that all that I thought of being a good performance in practice hospital was often a poor result into private. Because there are in practice hospital “details” of which one makes fun a little. Into private, these details are very important. The good performance is not only the good procedure carried out on a good indication, it is also the assumption of responsibility of the patient, his family, her continuations and its attending physician. Only the result counts. One makes fun completely of the glory which the surgeon can fire from a complex gesture. At the hospital, one is very sensitive to the impressions which one produces with the staff and the brilliance of the operative procedure. I realized that if I had been appointed departmental manager while having remained at the hospital, I would not have been also good and as powerful as while having been confronted with the surgery of deprived, where it was necessary to leave his tripe 24:00/24 to hold his shop. It is very important to leave the environment of sound the school. I think that any operator who must become departmental manager should undergo what the Athenians called a “initiatory voyage”, to leave the group, to undergo a proof before being reinstated in the group but on a level with the top. A public hospital surgeon could profit from his passage in the private one before being a departmental manager. But I always tried to keep a teaching hospital spirit first of all while remaining attached to the service of Jacques then, with his retreat with that of Philippe , and it to carry out the spinal surgery there. In the same way I continued to publish, write books and to communicate in the congresses. I even organized a half dozen personally of it. Finally I organize many training seminars remaining faithful so that Robert had learned to me on the pressing need for forwarding his Article.