The 12th Annual Meeting of the European Section of the Cervical Spine Research Society (CSRS) was held in Nice, in June 1996. The atmosphere both inside and outside the conference venue was warm and friendly - as warm and friendly as the welcome by the President, Prof. Claude Argenson.

M.O. : You organized this CSRS meeting. What is it all about?

C.A. The European Section of the Cervical Spine Research Society was set up some ten years ago, by Pierre Kehr, Fritz Magerl, Dietrich Hohmann, and René Louis; the driving force was Mario Boni, who became the organisation's first President. The Section is the European daughter of the American Society. It provides a forum for those interested in the surgery of the cervical spine - that is to say, orthopaedic surgeons and neurosurgeons, but also rheumatologists and radiologists. It is interesting to note that one of the most active founder members was none other than A. Wackenheim.

M.O. : How did you come to organize this Congress?

C.A. The Congress is held annually, each time in a different country. As luck would have it, my application to host the next Congress was accepted by the officers of the Society. I have, of course, been interested in the cervical spine for a long time; however, the fact that we were suggesting Nice as a venue must have been very persuasive, especially as I am currently the President of the European Section of CSRS.

M.O. : What is new in cervical spine research?

C.A. The first subject of this Congress was whiplash injuries, which are very common, and about which there is a lot of argument: Some are convinced that whiplash causes anatomical lesions - mainly of the discs - that can be shown by MRI. Others (mainly in Britain) doubt the importance of anatomical lesions, and are even less certain that the injuries cause chronic sequelae. This can, of course, lead to forensic problems. As things stand, MRI can certainly demonstrate lesions. The question is, however, whether these are recent lesions caused by whiplash, or whether these lesions were there prior to the accident. If so, to what extent were they made worse by the accident? The fact that we are asking all these questions means that the whole subject needs to be reviewed every year. This point was very well made by Dieter Grob, in his summing up. This is, in fact, the third year that we have been looking into this matter. The second main subject was bone grafts. Bone grafts are "in." The disadvantages of autografts were underlined by a number of speakers: Pain at the graft harvesting site, and the possibility of wound dehiscence. It is striking how often one sees patients who, after cervical spine surgery, do not mention any C-spine problems, but complain about the graft removal site. On the other hand, allografts and xenografts, which may transmit viral diseases, have had a terribly bad press. This is why, increasingly, the search is on for synthetic graft materials.

M.O. : Whatever the theoretical advantages of bone substitutes - do you really think that they can stand comparison with good old-fashioned autografts?

C.A. No, I don't think they can. In fact, the current trend is towards the use of bone substitutes as spacers only, in conjunction with a larger or smaller cancellous graft. Studies are being performed to see whether bone cells could be inserted into a collagen matrix. All orthopaedic procedures are directed towards promoting bone formation. This osteogenesis is not a pipe dream: From everything that we have heard, it is obvious that there are already some osteoconductive materials available, and I think that we will, eventually, have osteogenic materials as well. The third subject addressed at this year's Congress was the treatment of trauma of the lower C-spine. We have done a lot of work in this field, and have produced a classification of these lesions, which has been accepted by Spine. There is as yet no agreement on how such injuries should be managed. As you will have noticed, there are two diametrically opposed schools of thought - that of Raymond Roy-Camille, represented by Christian Mazel, whose followers are all for a posterior approach and plating; and that of Jacques Sénégas, represented by Jean-Marc Vidal and Vincent Pointillart, whose disciples prefer an anterior approach. I must say that in 15 years' experience with cervical spine surgery, we have found that 80% of these lower C-spine injuries are tackled through an anterior approach, after orthopaedic reduction with traction, or manual reduction; this anterior fixation has always worked very well in our hands. Unfortunately, we had insufficient time at the Congress to discuss the postoperative aspects in depth. I think that the postoperative course is less straightforward in patients who have been treated via a posterior approach, where this enormous muscle bulk on the back of the neck has to be stripped off the spine. This makes for much longer and more difficult rehabilitation, and there is always the risk of residual stiffness. With an anterior approach, one can get directly to the spine, without having to go through muscles; hence, as we see it, a much smoother postoperative course, with most of the patients returning early to their usual activities, with just a cervical collar for protection.

M.O. : Is France still leading in the surgical treatment of spinal injuries?

C.A. Yes - but we should not crow too much, because things are happening elsewhere, especially in Europe. Anterior plating is quite a novelty in the United States, and in the English-speaking countries in general. Since when have we been doing anterior plating in France? The Sénégas plate was first used back in 1971. Do you see the difference? Our anterior fixations with a plate-and-graft technique have produced much better results than the Cloward procedure, which relies exclusively on a bone graft, and has often resulted in mechanical complications. Fixation through a posterior approach was devised by Raymond Roy-Camille more than 25 years ago, at a time when, in the English-speaking countries, the only hardware used for C-spine stabilization was, maybe, a few wires.

M.O. : There are some new aiming devices coming in ...

C.A. Yes, they are quite attractive, but they are very expensive, and they are not really in line with spine surgery as we know it. Also, handling these devices requires a special learning process. The question is whether all this effort will, ultimately, benefit the patient. Will the creation of an additional man-machine interface really reduce the error rate? As things stand, I believe in human know-how, which I think is reliable in the majority of cases; however, that may be an old-fashioned view. Who knows - in a few years' time, today's junior surgeons may well be doing "remote" surgery, pulling handles and looking at what is happening on a screen. That, I think, will be the end of surgery as we know it, and teach it, and practise it, especially if patient selection, too, will be performed by a computer.

M.O. : Do you think that surgeons will be investing in these new devices in the foreseeable future?

C.A. In the present economic climate, I do not think that the majority of practitioners would be able to afford these devices.

M.O. : Tell us about your Department here in Nice.

C.A. Until quite recently, I had a 90-bed unit; recently, however, I decided to split it in two. So now there is a more strictly trauma unit, with 65 beds, that is still at the Saint-Roch hospital, under Prof. Fernand de Peretti; and a more specifically "orthopaedic and spinal" unit of 30 beds in the new Archet II hospital, where I work with Pascal Boileau. We are hoping to extend the orthopaedic sector at the public hospitals even further - before I came to Nice, in 1978, this kind of surgery was offered only by the private sector.

M.O. : Which aspects of spine surgery are you particularly interested in?

C.A. Traumatology is a field of special interest; Jean-Pierre Farcy, Yizhar Floman and myself have written a textbook of thoracolumbar trauma, which is aimed at English-speaking surgeons. With the late Bruno Lassalle, we organized a panel discussion at the 1995 SOFCOT congress, on the management of thoracolumbar spine fractures. Trauma accounts for the bulk of our spine work, since Saint-Roch is the regional centre for spinal injuries. This has given us the opportunity to develop our own fixation technique using screws and hooks. The hooks were modified to our specification by the manufacturer. As regards the C-spine, Fernand de Peretti, Adnan Ghabris, and myself, working with Patrick Eude, a radiologist, reviewed 250 patient records. As a result of this exercise, we drew up a classification which, we think, is simpler than the Allen one, and which, to us, provides direct and logical guidelines for the management of trauma cases. I have also developed spinal surgery for chronic disorders; and supervised several research fellows working on spondylolisthesis or thoracolumbar malunion in my Department.

M.O. : What is your preferred technique for the management of spinal canal stenosis?

C.A. An anterior approach, wide anterior decompression, and sound stabilization with a plate and graft.

M.O. : Do you monitor your patients with somatosensory evoked potentials?

C.A. We got ourselves a device for SEP recording a year ago. We use it widely, not only in scoliosis surgery, but also in the reduction of spondylolisthesis or the insertion of fusion cages, where nerve root damage may occur. SEP recording is also very useful in trauma work. Recently, we had a patient referred to us who was clinically classified as completely paraplegic, with no prospect of recovery. However, his SEPs suggested that the prognosis was, perhaps, less bleak - and at three months, we were surprised and delighted to see that he was beginning to move his lower limbs again.

M.O. : How did you come to do spine surgery?

C.A. To answer this question, I have to go back to my friendship with René Louis and Maurice Bergoin. We were in the same year as junior surgeons, and were all of us taught by Michel Salmon. After that, we all went slightly different ways. René Louis, who was a genius, passed all the exams ahead of us, and was sent to Dakar. Maurice Bergoin got an appointment at the Nord hospital, to do paediatric surgery; and I went into the independent sector when I had finished my specialty training. When René Louis returned to Marseilles, there was a vacancy in Dakar. I was proposed for the job by my former Anatomy teacher, Mr. Grisoli - a larger-than-life character, whom we greatly admired both for his human qualities and his sometimes wild behaviour. It was a personal choice, which caused some amusement and which made people think that I was a bit odd, since I was giving up a comfortable job in Marseilles to go to Africa. However, teaching has always been one of the things that make me tick, and going to Senegal meant that I would be able to teach. In Dakar, I was in charge of the Department of Anatomy, where we were able to work on the spine. Also, René Louis had built up spine surgery, and the surgical treatment of TB of the spine; and I was able to continue his work. This way, I acquired valuable experience in this discipline. After my return to Marseilles, I was fortunate enough to be René Louis' second in command for two years, during which time I went on improving my skills as a spine surgeon. Two years later, I was appointed to the post in Nice. At that time, there was virtually no spine surgery performed in the public hospitals. However, we had lots of trauma cases, and that way I was able to develop this specialty. I have always had excellent surgeons working in the Department; this made our unit widely known, and by and by we started tackling degenerative disorders of the spine, rather than just trauma. Thus, the three of us - René Louis, Maurice Bergouin, and myself - are now working in the same discipline, and we are still the same good friends we were 30 years ago.

M.O. : You were all taught by Mr. Salmon. What was he like as a Chief?

C.A. Mr. Salmon was a very unusual personality, someone from a different age, both in his very strict way of life and in the way he dressed. For example, he used to wear stiff collars and detachable cuffs. Everybody knew the story of the fat fishmonger who came to consult him about some elbow trouble, and whom he asked (probably tongue-in-cheek) whether she played tennis. He was very paternalistic, and the ritual Sunday morning ward round, with him and his registrars bringing their children along, was very much in the old paterfamilias tradition. We loved him dearly. He taught us much, because at that time, few people had any "scientific" background and experience, and nobody had the opportunity to go on postgraduate courses here, there and everywhere. The first time I was "let out" was when I was 33; I owed that visit to Gérard Legré, who had initiated me into orthopaedic surgery. I went to see Maurice Müller, and discovered internal fixation. I found this technique so exciting that I bought the necessary hardware there and then, at the factory in Bettlach. This way - and thanks to the understanding shown by Mr. Grisoli and Mr. Salmon -, I was the first to use an AO/ASIF implant at Marseilles.

M.O. : As a surgeon, would you say that Salmon was progressive, or would you describe him as conservative?

C.A. It's difficult to say, because we knew him during the last ten years of his career, when he was more conservative. However, we ought to remember that earlier in his career he had described the anatomy of the limb arteries, and the blood supply of the skin, in a way that these patterns had never been described before. He also introduced blood transfusion in Marseilles, and completely changed the way shelf procedures were done in hip surgery. So, he was very accessible to new ideas. When I came back from Wrightington, he allowed me to do the first Charnley hip prosthesis in his Department. He also liked Robert Judet's inventiveness; and we would regularly go together to attend Robert's seminars.

M.O. : Do you see him as one of the pioneers of plastic surgery?

C.A. Most certainly. When the plastic surgeons started studying flaps and grafts, they would read Salmon's textbook on the "arteries of the skin," which was a totally innovative treatise. For the arteries of the limbs, the textbook by Salmon and Dor was the authoritative reference, for a great many years.

M.O. : How did it go when you first came to Nice?

C.A. When I first came to Nice, there was only a small unit of traumatology, within a department of general surgery, under a general surgeon. After two years, a separate Department of Orthopaedics and Traumatology was created. For the past few years, the hospital unit has been working together with the independent surgeons, in a most important way: I think that the hospital should look after the sickest patients, the ones with multiple injuries, spinal fractures with neurological complications, or severe soft tissue lesions; while the more run-of-the-mill trauma cases should be treated in the independent sector. Obviously, the hospital and the independent sector will need to work hand in hand, if only to treat the large number of hip fractures that reflect the large number of elderly people in our region.

M.O. : There is only one University hospital in this region. How would you cope with a disaster situation?

C.A. We have already had two disasters to deal with: One was when the grandstand at the Furiani stadium in Bastia (Corsica) collapsed. On that occasion, we had a large number of spinal fracture cases to treat in a short space of time. The other one was when the roof of a supermarket caved in. In both cases, there was the most marvellous team spirit, with everybody involved in the care of the victims working with the utmost dedication, without any clock-watching. In the case of the disaster in Bastia, two of my colleagues immediately went out there, and spent more than 24 hours operating side by side with the local surgeons. At our centre in Nice, we set up a triage system in a short space of time, to decide which of our surgical patients could be sent home, or transferred elsewhere, so as to make room for the victims to be brought in.

M.O. : Since yours is the only University hospital, how is the training of orthopaedic surgeons organized?

C.A. The training of junior surgeons has been one of the great challenges at this Department. It has made us look at things with an open mind. From the word go, I have insisted on my colleagues going to other centres, to train with such surgeons as Gilles Bousquet, Henri Dejour, or Gilles Walch. They came back to our Department full of modern and highly effective ideas of how to treat knee or shoulder injuries. Similarly, surgeons from our Department have been to Montpellier, to learn the treatment of open limb fractures from Jacques Vidal; or to Colmar, to study the management of sports injuries under J.H. Jaeger. Since, at the start, there were none of the preconceived ideas that one finds in some centres, we were able to learn from everyone, and I think that this wide horizon has been beneficial to surgeons and patients alike. It meant that I was able to concentrate on spine surgery, without having to worry that our Department would not be able to cope in the other fields which I had not been able to pursue after I had gone to Africa.

M.O. : Do you not find it awkward that you have so few senior registrar's posts to offer in your Department?

C.A. This is undoubtedly a problem: Some of our registrars have to wait a year before a higher surgical training vacancy occurs. I have only two senior registrars, and four staff consultants, which is inadequate for a department that is on take round the clock, every day of the year. Also, our volume of work is increasing all the time, and our occupancy rate is 92%. The small number of senior registrar's posts is a definite handicap; however, we have undertaken to train only one orthopaedic surgeon a year, under the national plan: Flooding the market with specialists would produce serious problems, before long.

M.O. : Your son Jean-Noël is professor of orthopaedic surgery in Marseilles. Would you subscribe to Lamarck's theory that acquired characteristics may be transmitted?

C.A. As far as my son's professorship is concerned, I have no problem answering your question: He got the Chair even though he had not stayed with me. In fact, when I went to Nice, he stayed in Marseilles; and he was made a professor because of his personal merits, and also because he was supported by his teacher, Jean-Manuel Aubaniac. It so happens that Aubaniac was a student on my firm, and later trained in my Department, so perhaps he learned something there early on in his career. This way, there may have been some indirect transmission from father to son. However, Lamarck's theory is disproved most convincingly by the fact that, unlike me, my son does not do any spine surgery at all.

M.O. : Where do you think spine surgery will go from here?

C.A. Spine surgery is a fascinating and very innovative discipline: Everything and anything that we know today may very well be questioned tomorrow. Two years ago, our Department took the plunge, and went into endoscopic surgery. I think that in a few years' time our successors will be doing more and more of this minimal access surgery. At present, we often spend one or two hours making a huge incision through which we then insert, in a matter of minutes, a tiny graft between two vertebrae. With endoscopic surgery, we could keep the incision very small, and could perform the entire procedure in a much less aggressive manner. This new form of surgery is still being evaluated, and we must not overlook the risk of - mainly vascular - complications, which may force the surgeon to convert to open surgery. When one looks at the difference postoperatively between patients who have been operated on through an anterior and those who have had a posterior approach, one can see that muscles don't like being mauled for however long it takes to perform the procedure. I therefore have great faith in endoscopic surgery, which should enable us to do simpler fracture surgery, and which should also be of value in lumbar fusions, degenerative disease, and in the surgical management of tumours and infections.

M.O. : Could minimal access surgery also be used in trauma cases, which involve much bleeding?

C.A. Trauma patients need to be stabilized as rapidly as possible. Our current fixation techniques are not, therefore, going to disappear in the foreseeable future. However, additional bone grafting through an anterior approach is ideally suitable for endoscopic surgery. In urgent (as opposed to emergency) cases of lumbar fractures, we have been using this technique for the past two years.

M.O. : Surely, this endoscopic surgery requires different surgeons to work together?

C.A. The transperitoneal approach that we practise in order to get to the L5/S1 disc has only been made possible by the skill of one of our abdominal surgeons. The retroperitoneal approach is easier. Right now, we need our abdominal surgeons, and could not make progress without their help. However, I am sure that Fernand de Peretti and Istvan Hovorka's "specialists" will soon be able to go it alone.

M.O. : All in all, you seem to have had a very varied career ...

C.A. This is where I have been so very lucky: Things have never become humdrum for me, because every so often, I have had to take a critical look at what I was doing at that time, and go off and do something new. First, getting started in surgery - that was difficult, as it is for every young surgeon. Then, going to Africa, which upset all the old routines, both at the professional and at the family level. However, it was immensely fruitful in terms of human experience. Then, coming back to France and discovering "modern" surgery, after five years of "making do" in an African hospital. That was not an easy transition to cope with, even though I was warmly welcomed by René Louis. And now, at the end of my career, I am here in Nice, where I was once again challenged into creating something new. However, I have been privileged to work with younger colleagues - and I am certain that one never gets anywhere doing things by oneself: A head of department and his staff work together, and what they can achieve together is greater than the sum of their individual contributions. And as I was saying - throughout my career, I have been lucky enough to have to redirect and restructure what I was doing, on more than one occasion.