M.O. :
You are really interested in the spine?
J.Y.M. : Yes, I have dedicated almost my entire career to it. Ever since I have been in medicine, I have done nothing else – except for one paper on sex hormones in paraplegic adolescents. And that did not leave a major mark in the medical literature.
M.O. : Why this interest in the spine?
J.Y.M. : You could say it runs in the family. My father was one of the first to take a serious interest in back problems. He started in the 60s, or even earlier, at a time when all the others thought the spine rather infra dig. In those days, there were only the publications by de Sèze, which were, however, mainly concerned with sciatica. Robert Maigne was the first to analyze the common syndromes of vertebral pain found in clinical practice.
M.O.: He also described painful minor intervertebral dysfunction. What exactly is that?
J.Y.M.: That is a long story. In those days, spinal disorders were disc problems; and low-back pain was considered to be due to disorders of the discs. De Sèze thought that there had to be radiological evidence of disc disease. One could, somewhat crudely perhaps, summarize his views a follows: either there is this sort of evidence, then it's discogenic; or there isn't, then it's psychogenic. My father, on the other hand, had seen that vertebral pain would often subside quickly or immediately once vertebral manipulation had been performed, often in the absence of any radiological abnormality. One therefore had to postulate the existence of a reversible lesion that was different from a – definitive – disc disorder. Since palpation showed the facet joints to be tender, these joints also had to be part of the lesional pattern, which thus became a disorder of the entire motion segment. He therefore went back to the writings of Junghanns, and was the first – way before Mooney and Robertson – to attribute a major role to these joints. This lesion also had to be independent of the radiological condition of the disc, since there were many patients with normal x-rays. So, all told, he saw this MID as a painful “limp” of the motion segment that was perpetuated by the automatic mobility of the spine. And manipulation got rid of the problem.
M.O.: Is your father, Robert Maigne, an osteopath?
J.Y.M.: He is a rheumatologist. In the early 50s, he spent a year in England , at a College of Osteopathy ; this was a very unusual thing to do in those days. When he came back, he first started practising as an osteopath. However, he very quickly came to review what he had been taught, and think beyond it; and he came to the conclusion that someone with a medical mind could not accept the theory of osteopathy as it stood. Many of the claims made by osteopaths had not been confirmed in practice. So he developed a fusion of rheumatology and osteopathy. The rheumatology approach to medical problems is the one we are familiar with: there is pain, so there must be a lesion that accounts for the pain, and the physician must find the site and the nature of the lesion. From osteopathy, he retained the manual treatments; however, he abandoned the reasoning and the diagnostic techniques of the osteopaths. One could say that he brought osteopathy into the medical arena, and made it into a discipline that complements rheumatology.
M.O.: Did you go in for medicine to follow in daddy's footsteps?
J.Y.M.: When I was little, I wanted to be a cabinetmaker. I was very interested in carpentry, and would make small pieces of furniture, bookcases for instance; and I loved working with plates and screws and drills. I loved physiology, too. At high school, we had to prepare a sheep's skull, as part of our biology work. We had to get a head from the butcher's, and boil it for 3 hours in a bicarbonate solution to remove the flesh, and poke the brain out through the foramen magnum with a knitting needle. I got top marks. And because my father was a doctor, Medicine was a very natural choice. However, because of my interest in manual work, I wanted to go into orthopaedics. In my junior years, I was due to go to Roy-Camille's unit in my fourth year. I had already spent six months with him at Poissy, towards the end of my undergraduate training. However, my surgical training did not start very auspiciously. I did a urology placement, with Berge, at the Diaconesses Hospital , where I became a dab hand at putting in catheters ; but then I went to a gastrointestinal unit in the suburbs, which I found really depressing. There wasn't much surgery to do, and the little I saw did not fill me with enthusiasm. I was in my first year of specialty training, and there wasn't a good orthopaedic post to be had before Year 3. So I thought that surgery wasn't my ideal career, and probably wasn't the shortest way to get to do what I really liked. So I decided to go back to what my father had done about the spine, and to take it further. This is how I ended up in physical medicine, which, in those days, was called “rehabilitation”. I did my specialty training concentrating on rehab, neurology, and rheumatology. In the end, I got qualifications in rehabilitation and rheumatology.
M.O.: But what you were heading for was the spine?
J.Y.M.: Yes, I was heading for the spine, because I thought that was the most interesting and the most promising aspect. I wanted to find out about it, to understand it. I did not want to be just a practitioner who applied the recipes thought up by others. The vertebra is a very complex structure; and 25 years ago, very little research had been done into it, except for sciatica. To me, the spine was a wide-open field.
M.O.: What were the highlights of your specialty training?
J.Y.M.: My favourite memory is that of my last year of rheumatology, with Menkès, at the Cochin Hospital . He had a very open mind; there were interesting cases in his Department, both bone and joint disease; and he put a lot of trust in his juniors. There were also quite a lot of hands-on stuff, all those aspirations and infiltrations. But I also found that there was a void as far as the spine was concerned.
M.O.: So what did all these doctors do with their “backache” cases?
J.Y.M.: What one has to remember is that lots of back problem patients weren't hospitalized; so we didn't see them. As a general rule, they got sent to a physio. We were taught to look for a cancer, a secondary – and if there wasn't one, it was: “get them to strengthen their abdominal muscles”. That was, however, a rather simplistic view, especially considering that my father had developed a different approach to vertebral pain, through clinical examination and a description of pain syndromes. I thought that things were more complex than what we were being taught, and that physiotherapy was not by any manner of means the only way of managing these patients. So I too started thinking about these issues. What helped me a lot was anatomy. Towards the end of my specialty training, I got a teaching qualification in general anatomy and neuroanatomy. I was able to teach the subject and to get a better understanding of the whole problem. The spine is hugely complex, anatomically; and doctors know very little about this complexity. My anatomical studies were a very important part of my training.
M.O.: Where did you go for your Senior Registrar's post?
J.Y.M.: To the Raymond Poincaré Hospital in Garches, where I worked for one year in the neurological rehabilitation department, with paraplegics and head injury cases. However, that was very obviously not my vocation. I remember patients who were in the same condition when I left as when I had first arrived in the department. Next, I spent seven years as Senior Registrar/Senior Lecturer at the Paris Hôtel-Dieu Hospital , with patient management and teaching functions. I taught anatomy, and worked in the Rehabilitation Department which my father had established and of which he was head.
M.O.: Is that where you developed your work on the spine?
J.Y.M.: Yes. I started with the anatomy of the spine, because my father had taken a great interest in the posterior branches of the spinal nerves, which supply the entire posterior portion of the trunk; he had thought that they had an important role in back pain at the lumbar, thoracic, and cervical levels. So I published a few papers on the anatomy of these posterior branches, and in the course of my research I discovered some things that had previously gone unnoticed, in particular that there can be entrapment where the nerves cross the iliac crest; and I was able to draw up an anatomical map of the dermatomes that was an improvement on the maps that had been available in the past. I must admit though that there wasn't much competition in this field. Later on, when I had been in this business for some time, I became interested in the clinical syndromes.
M.O.: That was in the 80s, when there was a lot going on in spine surgery. What did you make of these invasive treatments?
J.Y.M.: I think I went through the various stages that are also reflected in the literature: initial enthusiasm, and then sudden disappointment on seeing the first failures; followed by a more balanced view of the problem. It is true that, professionally, I grew up with this craze of the orthopods for the spine. There were the nucleotomies, and operations for more or less rigid stabilization . At the time, it was made out to be the thing to do; eventually, it was realized that patients had to be selected more carefully.
M.O.: So the upshot is that one should not send all back pain patients to a physio?
J.Y.M.: No, I think patients should be assessed by a competent physician, and only those who actually need physiotherapy should be referred. There are horses for courses .
M.O.: But what is there, apart from rehabilitation?
J.Y.M.: Lots of things. Firstly, one needs to know what the case is like. With every new patient, one must try to classify the back pain, so as to know what one is dealing with. The current classification systems are not very good, especially the ones that overemphasize psychosocial factors. It is fashionable nowadays to say that these factors are important in the development of chronic back pain. Unfortunately, they are difficult to control. And, above all, there are other factors involved.
M.O.: Such as?
J.Y.M.: Inflammation, for example, because what is called “mechanical” pain is often associated with inflammation +++. Else, why would one prescribe NSAIDs? There are also neurological phenomena of “pain memory”. I have developed a different back pain classification, which is of greater practical relevance. I distinguish three groups of back pain. The first is made up of pain that really stems from the spine, either from the discs or from the facet joints; this pain has a discernible anatomical origin. What I mean is that there is a pattern that accounts for the site of the pain, what triggers it, what relieves it, and what one sees on images. The anatomical pattern explains the radiation of the pain, and the biomechanical pattern explains the things that can make the condition worse. For instance, the things that hurt the patient are the ones that stress the disc in the experimental set-up. There could also be an inflammatory pattern: pain that is relieved by NSAIDs, and which is more pronounced during the night and early in the morning. Where these patterns are seen, it pays to study the patients more intensively; to do more imaging, if need be; to offer more intensive treatment, maybe even surgery. These patients rarely have psychosocial factors. They are the only group of patients that could be described as having vertebral pain in the strict sense of the term.
M.O.: What about the second group?
J.Y.M.: Those are completely different patients. Their pain has two main features: it is more diffuse, the patients “hurt all over”; the pain is continuous, and nothing affords relief. This pain is most likely “neurological”, due to dysfunctioning of the pain pathways. This is non-vertebral back pain. Patients with fibromyalgia, depression, or long-standing anxiety are in this group. In these cases, it would be useless to do umpteen imaging studies; the usual medications do not work; and one will often have to use something like amitriptyline. And, finally, there is a third, smaller, group, which is made up of patients in whom there really are major psychosocial factors. These patients may have been unemployed for a long time, or be involved in litigation. These patients must on no account be treated with surgery , since the failure risk is high. The only things to be considered are social measures such as early retirement, or physical measures such as restoration of exercise capacity .
Overall, when faced with a back-pain patient, one needs to perform this classification first of all; in the light of the results, one will then have to decide whether further investigations should be requested, and which treatments should be envisaged. I am convinced that one needs a physician with experience of many disciplines, rather than an expert in a single discipline, to do this first classification. After that, in order to find out more, one obviously has to know the disorders of the spine, and to realize how extremely complex this subject is.
M.O.: What do you think of the craze for vertebral manipulation?
J.Y.M.: There definitely was a craze some twenty years ago, when there were more young doctors than now, and they all wanted to carve out their niche in the profession; and Robert Maigne had just introduced these techniques into medicine. Manipulation is still popular, but we now have fewer young colleagues, and the craze has faded somewhat. What we do have nowadays is a great increase in the numbers of what used to be called illegal practitioners, who are not only working legitimately now, but have become an allied health profession. I am talking about the osteopaths, of whom there are some 10,000, and the chiropractors, who number 400. This reflects the interest there obviously is in manipulative treatments. Manipulation has been investigated in many randomized clinical trials and in biomechanical studies. No other back pain treatment has been studied and assessed as exhaustively; it is a treatment which works. No wonder people are interested in it.
M.O.: So you think one should put the vertebrae back in their place?
J.Y.M.: Most definitely.
M.O.: But how do you put something back in place that wasn't displaced in the first instance?
J.Y.M. The cracking noise heard during manipulation “proves” that the vertebra has gone back into place ... I am only kidding. Of course, saying that the vertebra is displaced is a simplified way of looking at the problem. It has been taken over from the bone-setters, who used to say that the vertebrae jumped. Nobody is claiming any longer that manipulation reduces displaced vertebrae. However, it appears to act on contracted paraspinal muscles, which may be painful in themselves or perpetuate impingment or painful conditions at the motion segment. I think that that is its chief mechanism of action. There is probably also a sudden decompression of the disc, and nonspecific inhibition of pain.
M.O.: But how does that happen?
J.Y.M.: Muscle relaxation is linked to the fact that manipulation produces sudden muscle stretching. When a muscle is sharply pulled, over a pretty long distance, it will relax. That has been demonstrated. I do not know what contracted muscles are; I do see, however, that patients with low-back pain or neck pain have painful paraspinal muscles, and that, after manipulation, these muscles are no longer tender. So I think that permanent muscle tension and pain go hand in hand. This is a key aspect of the efficacy of manipulative treatments. If this “painful tension” is kept going by a minor vertebral problem that is healing or clearing up, the tension will not come back after manipulation, and the patient will be cured. On the other hand, if, behind this “painful tension”, there is a major problem, such as a big herniation compressing a nerve, or disc inflammation, or a slipping vertebra, then the “painful tension” will recur very soon. The patient will have had no, or only fleeting, relief. This means that manipulation is great for minor problems, but just because they are minor does not mean that they aren't painful.
M.O.: What else can be done about low-back pain, apart from surgery and manipulation?
J.Y.M.: Anti-inflammatories, either systemic or by infiltration, are excellent in some forms of pain. Since they work, it is clear to me that one cannot say that nonspecific backache is invariably mechanical in origin. Obviously, it frequently will be mechanical, but in many cases the backache will be due to inflammation, either of the disc or of the facet joints. If it is an inflammation, then there are pharmacological treatments available; if it is mechanical, manipulation may be an option. There are other mechanical treatments, such as braces or physiotherapy; and, obviously, surgery, as a last resort. I tend to use braces in conjunction with anti-inflammatories.
M.O.: It looks as if infiltrations are being done a lot more...
J.Y.M.: Yes, they are still used a lot; and why shouldn't they? When I read in the literature that “infiltrations don't work”, I am not convinced. What is wrong, though, is to go on using infiltrations in cases where they have been found not to work.
M.O.: Where exactly are these infiltrations made?
J.Y.M.: Into the epidural space, or the root, or the facet joints.
M.O.: And what about intradural injections?
J.Y.M.: Intradural infiltration, which was described by Luccherini 50 years ago, has been abandoned – at least, I hope it has. The technique had been suggested as a treatment of severe sciatica. What happened was that cortisone was injected into the CSF. This was not only pathophysiologically dodgy, because the problem that gives rise to the pain is epidural; it is also dangerous, since germs may be introduced into the CSF together with the cortisone, which would have promoted the growth of the bug. What is amazing is that there should have been so few cases of septic meningitis; however, there was an unexpected and dire complication: cerebral thrombophlebitis. Another technique, using infiltration through the first sacral foramen, was described by Lièvre, a rheumatologist, in the 50s. This infiltration was supposed to be epidural. We tried to find out the success rate of the technique when the injection was made that way. Fluoroscopic checks afterwards unfortunately show that the injection was epidural in less than one third of the cases. It is simply an intramuscular injection. There is also an interspinous route. The problem is that the material injected tends to go up rather than down. Also, it tends to remain on the posterior surface of the epidural space, behind the sac. Since it is easier to go in at L3-L4 than at L5-S1, one may safely assume that, in seven cases out of ten, the target will be missed: even if the material is deposited epidurally, it will not be against the correct disc. The bottom line is that the only sound technique is to use the sacral hiatus, where one has about 95% anatomical success, with good distribution over L5-S1 and L4-L5. So, if I think that an epidural infiltration is indicated, and the patient tells me that they have already had one by the interspinous route, I redo it via the hiatus. For foraminal problems, an injection at the foramen and the root is the appropriate technique.
M.O.: And what exactly gets injected?
J.Y.M.: Always cortisone. It's the best that has been found so far.
M.O.: Why does cortisone make patients better?
J.Y.M.: Because “mechanical” pain, which is said to account for virtually all cases of nonspecific back pain, is not always mechanical. Many times, there will be inflammation, of a disc, a nerve root, or the facets. And infiltration combats the inflammation. The trouble is that one doesn't know that well beforehand whether there is inflammation or not. The diagnostic work-up is quite complex. I have been interested in all this for quite some time. History-taking is 80% of the diagnosis. Roughly speaking, inflammation may be suspected if the patient wakes up at 4 or 5 in the morning with a stiff back, or when anti-inflammatories provide relief. I also have a standard question: “What is the worst time during the 24-hour period?” The answer has to be, “In the morning.” These are the three conditions in which there is a reasonable prospect that epidural infiltration will work. Chronic pain, lumbar stiffness in flexion, and pain in extension, are also pointers.
M.O.: How can an epidural injection work if the inflammation is in the intervertebral disc?
J.Y.M.: The disc is worst affected in its posterior part. The disc is sickest at the back; very rarely at the front. Just being in contact with the agent appears to be enough for the most superficial part of the inflammation to be controlled. Does the disc gorge itself on cortisone? Perhaps – who knows?
M.O.: Last question on infiltrations: what do you think of intradiscal infiltrations?
J.Y.M.: There was a craze for intradiscal infiltrations some twelve years ago, with Hexatrione. That is a steroid that remains active in situ for quite a long time, associated with a solvent that retracts the tissues. One group had suggested it as an alternative to nucleolysis. They had done a double-blind study, and the effect on HNP was almost as good. Unfortunately, the patients later developed disc calcifications, which could migrate backwards and cause renewed sciatica. Perhaps it was all to do with the dosage, which was sometimes high; or with epidural leaks. Above all, the nucleolysis lobby immediately started hollering: the technique had not been properly assessed, it was too dangerous, etc. They got the treatment banned. One ampoule of Hexatrione cost 20 francs; one of Chimiodactine, 2000 francs. One cannot help feeling that the drug company had a hand in it. I did twenty or so, at the time, and I saw some of the patients again later on, for other problems. The results were good, but the really interesting thing was that Hexatrione produced spontaneous intervertebral fusion. So, a few years later, the disc would have disappeared, the vertebrae would have fused spontaneously, and all the patients I saw were very happy. They no longer had sciatic or low-back pain. I did not use large doses, and I had no calcifications in my patients. This treatment should have been investigated properly.
M.O.: So what about nucleolysis today?
J.Y.M.: It's finished. The drug company stopped making the agent, allegedly because they could not guarantee supplies; I don't know what really was behind their decision. The door remains open to generics.
M.O.: Were there any accidents?
J.Y.M.: No, as a treatment it was not as good as surgery, but it worked reasonably all right, and produced quite good results. I have virtually never sent patients for nucleolysis. If a patient needs something major done, they should be referred to a surgeon. Nucleolysis affects only the soft part of the lesion, and with a herniated disc, there are often problems in the adjacent bony structures that need sorting out. For a herniated disc, surgery is more suitable.
M.O.: Do you believe in surgery for the treatment of HNP?
J.Y.M.: I have a very basic attitude: if something compresses a nerve, then it should be removed. So I am all for of surgery. However, I think the hernia should be given time to follow its natural course. I studied this subject a few years ago: I followed up herniated discs with repeated CT scans. They tended to disappear quite rapidly, within a few months, and the bigger the hernia, the faster it would disappear. So there is a lot to be said for conservative treatment. Nowadays, I feel that letting things go on for a month or six weeks is not on. If a patient is really in a great deal of pain, and if nothing has happened by the end of ten days or a fortnight, surgery should be offered straight away. One should be guided by what the patient feels. And in cases where surgery is properly indicated, the patient will obtain immediate relief. And that is pretty important. There has been a lot of talk about surgery causing fibrosis. I think the fibrosis risk exists only under certain circumstances. The majority of cases of painful fibrosis that I have seen were patients in whom surgery had not been unequivocally indicated. The hernias had been very small; in some cases, there had just been bulging of the disc. In these cases, the pain – and I mean the pain that had led to the operation – could not have been due to compression. I would think that it was caused by inflammation of the disc and the nerve roots, and by curetting out the disc, the surgeon had spread inflammatory debris into the epidural space, which had then produced an adverse chemical reaction in this space. It is possible that many cases of painful fibrosis are due to this mechanism. One has to be very careful with tiny hernias and with bulges: by themselves, these lesions cannot cause compression.
M.O.: Why do you stress nerve root compression so much, if sciatica is mainly an inflammatory condition?
J.Y.M.: In sciatica, there are at least two phenomena: compression and inflammation. Compression is related to the size of the hernia; the diameter of the canal; and a third factor, which cannot be assessed on CT or MR scans – the pressure inside the herniated disc. There can be very large but very soft hernias, and equally small hernias under great pressure from within. The degree of nerve root compression is well reflected in the straight-leg raising test, an antalgic posture, and stiffness of the spine. Inflammation, on the other hand, cannot be “measured” that readily. There is no correlation between the severity of the pain and the classical laboratory parameters used for quantification, such as the lymphocyte count or chemical mediators inside the hernia. The best way to assess inflammation is to do an infiltration and see if this provides relief. At equal pain severity, I think that the response is the better the less nerve root tension there is. Unfortunately, there is no other way of assessing inflammation. Imaging techniques provide only a shadow show, and tell us nothing about the true nature of the hernia. They do not answer the two really crucial questions: “Does this hernia squeeze the nerve root really hard?” and “Is this lesion inflammatory or not?” These are the most important bits of information required by the therapist – and they are not provided.
M.O.: What is the percentage of back-pain patients that should be managed with surgery?
J.Y.M.: Very low – around the 5% mark. In 95% of the cases, the patient will have low-back pain at the weekend, or a bit of neck pain after driving 200 miles ; etc. Obviously, these patients will not be referred for surgery. Fortunately, spinal pain is largely benign and will remit quite quickly; so there is no longer any reason why these patients should be operated on. However, some patients will need HNP surgery, laminectomy for lumbar spinal stenosis, or fusion.
M.O.: What have been your main lines of research?
J.Y.M.: After my anatomical research into the posterior branches of the spinal nerves and the nerve supply to the spine, I started looking into the natural history of lumbar, and then of cervical, herniated discs. And then I did all manner of studies of the sacroiliac joints, manipulation, instability; and, more recently, disorders of the coccyx. There are some 50 papers in the literature of which I am the senior author.
M.O.: What made you choose the coccyx?
J.Y.M.: It came to me in the bath. I was thinking long and hard about the origin of coccydynia, and I came to the conclusion that – just like low-back pain – it might be due to disc problems. So I said to myself, “We'll need discography of the coccyx.” I started injecting anaesthetic into the disc. To my great surprise, the patients experienced relief. I treated ten patients or so with these injections, adding a little cortisone to the anaesthetic. It worked well, and I thought this through a bit more and decided that it would be interesting to take X-rays in the painful position. So I X-rayed one lady standing up, then sitting down; however, these views are difficult to do, and the quality of the films was poor. When I put the X-rays up on the view box, I couldn't see a thing, and I said, “No, that's not a useful technique.” But one member of my staff took a look at the film and said, “It's there! And it looks as if it was out of joint.” He was right: the bottom of the coccyx was in the dark, but when one looked closely at the spot film, one could just about see a true dislocation. This was the first patient in whom I had done dynamic radiography, and she had a dislocation – what a stroke of luck! After that, I started doing dynamic radiography, and was eventually able to establish a system and describe different syndromes involving dislocation, hypermobility, impaction, a spicule, etc. To start with, though, it was just serendipitous.
M.O.: But surely that is a rare condition?
J.Y.M.: Of course, but not at my hospital or in my community practice. There must be something there that produces lots of coccydynia cases. Since I published my first papers, I have been seeing some seven or eight every week. Over the past 12 years, I have clocked up around 1000 cases.
M.O.: But they used to be considered hysterics...
J.Y.M.: Funny you should say that, because that's exactly what I was told by an old fogey of a rheumatologist when I was presenting my first cases at the French Rheumatology Congress. I was showing absolutely obvious instances, where the coccyx dislocated when the patients were sitting down, and with positive anaesthetic tests. The chairman got up and said, “But Dr. Maigne, what's all this in aid of? Everyone knows these patients are hysterics.” I saw this colleague as the archetypal member of our profession who will not accept anything that is new. When I sent the paper to the Revue du Rhumatisme , one of his clones told me that the paper was of no interest, that all this was known already, and that it had no place in “a quality journal like the Revue du Rhumatisme ”. No, these patients are not all hysterics. I think that in 70% of coccydynia cases there is an identifiable organic cause.
M.O.: How do you treat them?
J.Y.M.: The first problem is to establish a correct diagnosis, of the lesion and of the level. Treatment-wise, there are three methods. Infiltrations work best. The success rate is about 70%, regardless of whether the injections are made into the disc or into the tip, in cases of a coccygeal spicule. The problem is recurrence, which frequently happens after a few months. The second method is manipulation. This works in about 25% of the cases, and is a bit better than placebo. The third method, surgery, is excellent in cases where one is sure that there is a lesion, especially where infiltrations have temporarily relieved the pain caused by this lesion – in other words, where there is evidence of an organic cause.
M.O.: Where do you work?
J.Y.M.: I am a part-time Consultant at the hospital. This means that I work mornings at the Hôtel-Dieu, where I head a department of Physical Medicine, which is really an outpatient service, 90% of whose patients have vertebral problems. In the afternoons, I am in my consulting room in Paris .
M.O.: Do you think it is useful to work part-time at a hospital and the rest of the time in independent practice ?
J.Y.M.: I think it is a good way to combine business with pleasure. I have a part-time hospital contract, which means that my hospital salary is not huge. However, having a hospital department at one's disposal is a major asset if one wants to do research, publish, and teach. None of this I could do if I were in non-hospital practice only. It allows me to be productive, at what I consider a reasonable rate as far as the hospital is concerned. The downside is that my 35-hour working week is done in three days, and then there is still half a week left.
M.O.: Do you manage to do some university teaching as well?
J.Y.M.: In principle, the hospital pays me to see patients, not to do research. However, the department runs a University Diploma course, and we all teach. All the Consultants in the department give lectures or conduct practicals. We try to train doctors who will be able to manage vertebral problems and who will be good at manual medicine.
M.O.: You also organize a congress every year?
J.Y.M.: There had been an earlier symposium, the Journées de l'Hôtel-Dieu , which will be held for the 50th time this year. In 1988, I thought that another event should be added, to allow scientific papers to be presented. This forum for papers on topical subjects in spinal disease is called the Actualités Médicales du Rachis – the Spine Update. That is now being held for the 16th time.
M.O.: What's the difference between Robert's and Jean-Yves' ways of treating back pain?
J.Y.M.: My father had put the emphasis on vertebral manipulation. He had introduced the technique, established the indications, and described the syndromes that lend themselves to manipulative treatment. Me, I have been more interested in what causes back pain, and this has led me to envisage a broader range of therapies. Among these, manual treatments are irreplaceable in at least 50% of the cases. Both for my father and for me, they are still the first-line treatment.
M.O.: Do you think that it was a good idea to allow non-medics to administer such treatments?
J.Y.M.: They were doing them before they were allowed to. There was no need for a law, which, by the way, is not being applied yet, because the ministerial paperwork is not yet complete. The gist of the law is that training centres should be approved in some way. Many of these schools are still a bit strange , and I don't think the approval procedure will be in place in the near future. Of course I would prefer to see manual therapies administered by medics, who are better able to diagnose and to treat, since they are qualified to do everything, including the prescription of medicines. The important thing in the proper treatment of patients is to know when to switch treatments, and to switch quickly. So, if manipulation doesn't work, one tells that patient that one is going to prescribe something or to do an infiltration. As a doctor, one can respond so much better. Splitting up the treatment by having practitioners who cannot provide the full range of treatments is not a sound solution. If recognition of their status will allow these non-medically qualified practitioners to raise their standards, that would not be a bad thing. What one has to bear in mind is that there is a difference between chiropractors and osteopaths.
M.O.: Don't you think that the American chiropractors are doing a good job?
J.Y.M.: They are doing an OK job, but all they can do is manipulation; and let me repeat: manipulation is appropriate in only 50 per cent of the cases. What we need above all are medically qualified back pain specialists.
M.O.: Is “back pain” still the Cinderella of the rheumatology units?
J.Y.M.: Firstly, low-back pain patients are not admitted as in-patients; and, secondly, rheumatology is still concerned with inflammatory and immunological conditions. Hospital rheumatologists have not got the mindset to approach low-back pain correctly. If you have a low-back pain patient, you need to palpate, you need to love to use your hands; and rheumatologists are not too fond of that. They are like the neurologists – they never touch a patient.
M.O.: Why is that?
J.Y.M.: I did a year of neurology, and I never saw a neurologist touch a patient. When they work up a patient, they do it with a pin. It's an attitude. When I was doing neurology, they'd call in a rehab physician to do the testing of a motor deficit case. The neurologist will just ask questions. At most, he might use a reflex hammer. Rheumatology derives from neurology, in some respects. De Sèze was originally a neurologist. In both disciplines, there is still this reluctance to palpate; they value the cerebral more highly than the physical.
M.O.: Could “back pain” be seen as a discipline in its own right?
J.Y.M.: Not as things are at present, but in theory – yes. After all, there are hepatologists; so why shouldn't there be vertebrologists, except that it's such a funny word. The spine is quite capable of standing up to the liver. Let's have some vertebrologists!
M.O.: But mightn't that be what the chiropractors are trying to do?
J.Y.M.: They are trying, yes. And the chiropractors more than the osteopaths. They are trying to understand the real problems of the spine. The osteopaths, in France at least, are still fixated on some weird ideas. They see the human body as a collection of bits of bone that float around in relation to each other surrounded by a fluid. This faulty view makes them reposition the various joints. The sacrum is too much to one side, or to the other – that sort of thing. It's the famous “pelvis that is moving”. The cranial bones are thought to move in relation to each other: “The sphenoid has moved, so I'm going to reposition it very gently.” The chiropractors, at least the ones trained in the recent past, have a more medical way of looking at things. Their reasoning goes: there is a pain; so there must be a lesion; and that lesion should, in theory, be able to cause the pain. The source of the pain is sought in the real-life anatomical structures. There is no search for some imaginary cause. Inherently, chiropractors are closer to physicians; and I think it would be easier to get in touch with them than with pure osteopaths. Nowadays, tackling a multi-facetted disorder in purely mechanical terms is insufficient for anyone who wants to be a back specialist. To use a simile: they know the engine, but haven't got all the tools it takes to repair it. While the osteopaths try to fix an engine that is largely imaginary.
M.O.: Is there a specifically French way of treating back pain?
J.Y.M.: Maybe there is. We have gone further in the clinical analysis of the condition. French authors have developed a more clinical approach to back pain. Other countries tend to have a radiological, psychological, or social approach; they have not got the detailed clinical approach that we have here in France . We start with the patient, not with a study of the literature. Among the patient's symptoms, we try to identify the ones that are significant; to group them in syndromes; and to deduce therefrom the most appropriate treatment. In the English-speaking world, it's done the other way round. They don't think in terms of associations of symptoms – like, such and such a symptom often goes with such and such another one, but not with a third – they just look at frequency figures. They reason in terms of frequency of symptoms, and of how often a given treatment is found to work, without any real patient selection: NSAIDs work in 45% of cases, heat in 40%, manipulation in 30%. This is “evidence” that one should start with NSAIDs. This form of reasoning is taken to extremes in some guidelines, where it is often stated that low-back pain becomes a problem for doctor s only when it has been going on for three months, and then only so that the patient gets referred to a psychologist.
The other feature is that we have doctors who can practise manipulation, as one of several treatment modalities. The upshot is that, in France , there may still be room for improvement , but by and large the management of back problems is pretty good.
Maîtrise Orthopédique N°125 - June-July 2003
