The first International R. Roy-Camille Spine Symposium was held in Paris, in January, 1996. Many surgeons from abroad who had known Roy-Camille came to show their appreciation of his teachings. James W. Simmons is one of the many spine specialists who knew Raymond both in a personal and in a professional capacity.

 

Apoil A. Argenson C. Arlet J. Beaufils & Chambat Capana Cartier Cartillier Dambreville A. Doursounian L. Grosse A. Gschwend N. Herbert T. Judet J. Kapandji A. Kelly I. Kerboull M. Laude M. Louis R. Maigne J.-Y. Maigne R. Matta & Mast Müller Nguyen Van Nhan Puget J. Postel M. Pouliquen J.-C. Saleh M. Simmons J.W. Tubiana R. Vidalain Wagner H. Weber B.G. Zweymuller

M.O. : What can you tell us about yourself?

J.W.S. I am James Walter Simmons. I go by my first name, which is Walt. I am an orthopaedic surgeon, at San Antonio, Texas. I am in private practice, and have two partners, and I have a Fellow - I have had a Fellowship programme in my clinic for about ten or so years. I have been in spine, without doing anything else, since about 1978. Before that, I did general orthopaedics. I had quite extensive training in hand surgery; and I find that the hand surgery has helped me tremendously as far as my spine work is concerned. My childhood - as far as my background is concerned - was that of a young boy growing up on a farm. My father was a farmer, and my mother was a nurse. This was in Jackson, Mississippi. I went to undergraduate and medical school in Mississippi. I was then assigned to San Antonio, Texas, to do my internship in an orthopaedic clinic.

M.O. : How did you move from hand surgery to spinal surgery?

J.W.S. That's interesting, because one time, in speaking to Roy-Camille, I think he said it was one of his teachers that told him that one of the ways to be successful was to find something that was very difficult and do it well. He reflected on that theme - his origin in spine. It is interesting that I did hand surgery primarily when I got out of the residency, but I had a strong interest in spine. No one else really wanted to do spine. Spine was one of those problems that was cast off to the younger men. So when I was very young, in the late 60s and early 70s, I would take the work in spine, largely because no one else wanted to do it. There was a keen interest in spine, because I wondered why was it that no one else wanted to do it. And I think the reason is that it is a very difficult area, a very difficult specialty, particularly in the diagnosis. The technical aspect of any surgical endeavour can be learned, a person can be trained; but when it comes to actually making the diagnosis, it takes a sixth sense - you got to have a feel for the patient, and an empathy for the patient, to appreciate that they are really having pain. In the late 60s, early 70s, there was no specialty in spine. Spine was dominated primarily by the neurosurgeons. The neurosurgeons came about spine because of the war. The neurosurgical patients, of course, - if you were shot in the head, you were killed. So, if you were a neurosurgeon, there was not enough work for the neurosurgeons to do. So the neurosurgeons were asked to do the spine work.

M.O. : Who were your teachers in spinal surgery?

J.W.S. When I decided to go into spine, I visited what I considered to be the masters at that time. The masters were actually A.R. Hodgson, in Hong Kong, and Ralph Cloward, in Honolulu. And it is interesting that in 1973, when I had visited Hodgson and Cloward, Raymond took a world tour to visit specifically Hodgson and Cloward. But we visited at different times.

M.O. : Since you were in private practice at the time, was it not difficult to take time out for a few weeks or even a month at a time, to go and visit the masters?

J.W.S. No - perhaps because we were young and foolish. But, on the other hand, I had a basic philosophy: If you were going to do something, and certainly if you knew that there was someone who knew the subject, then it would be worth the time to visit those particular people. One of the goals in everyone's life is not particularly what you do, but to be the best in whatever you do. And Medicine is fantastic; it is a continuous learning process. I have done that throughout my career, I have spent quite a bit of time visiting folks all over the world; and I think that has been a very exciting part of my life.

M.O. : Let us talk about the spinal surgery you were doing before you met Roy-Camille, before the introduction of the pedicle screw. What kind of surgery were you practising?

J.W.S. I was doing mostly degenerative spine - disc prolapse and fusion, most of the time; decompression and fusion. When I visited Hodgson in Hong Kong, Hodgson had developed the anterior approach to the spine. He could approach the spine from C1 to S1. He did that because of the tuberculosis in Hong Kong. But when I was talking to him, he said that if he had my practice, which was mostly degenerative disc disease, then he would go in the back, because going in the back you could decompress as well as fuse. And so that is exactly what I did. After visiting Cloward, I realized in my own mind that the PLIF, the posterior lumbar interbody fusion, was the best biomechanical way to do a fusion. So from the very beginning, I was doing the decompression and the posterior lumbar interbody fusion for stabilization. And I have reported and written quite a few chapters just on the PLIF. That came to be known as my procedure.

M.O. : When did you publish it the first time?

J.W.S. The first time it was actually published was in 1985, I think in Clinical Orthopaedics and Related Research. We called it the chip PLIF, because we did not have allografts as Hodgson had; so to decrease the morbidity, I would take the chips that I would take from the posterior elements, and pack them back. At that time, I did not know that it was not supposed to work. In fact, it worked great, it did. I had an 87% fusion rate for two or more levels, and I had a 91%+ fusion rate for one level. So many people are afraid of the procedure because of possible complications. But there is only one basic secret - if there is a secret - of doing a PLIF, and that is adequate exposure. If you dissect the spinal canal out to the pedicle, that gives you plenty of room.

M.O. : What are your indications? Would you do a PLIF on a simple disc prolapse?

J.W.S. No. If there was an extruded fragment, and you could go in and take the extruded fragment out, there is no question that that is all you need to do. But if there is a lot of damage to the annulus, then this is going to leave the patient with an instability and a painful back, and the patient could not continue to work. I had a large blue-collar work population, manual labour. And so most of my procedures I would do by simple surgical means. I might add that during that time, I was doing chemonucleolysis, and we had very good results. So for the contained herniated disc, I would do the chemonucleolysis.

M.O. : But how would you manage a manual labourer with a large herniated disc?

J.W.S. I would do the PLIF. I usually do both sides. I have done what I call a unilateral PLIF. But most of the time you have to decompress both sides. But if I have a situation where one side is completely clean, I just decompress the one side, and do a PLIF from that side. When we got to having a bone bank, I would use the allograft as a supplement. There is two reasons to operate on a patient if they have incapacitating pain, whether it be from mechanical or neurogenic origin, or if they have progressive neurological deficit. It is our job to determine how bad that disc is. Most of the time, we can put the patient on various programmes of exercise and no more than mild analgesics, and sometimes a belt to enhance the abdominal pressure. But when the patient cannot return to his activities - and I need to define that for you: Because if a patient can return to modified activities, even though they have a surgical lesion, they don't need surgery. There is so many elements that enter into our decision-making as well.

M.O. : Before the advent of fixation, did you do PLIF in cases where both the facets were resected?

J.W.S. One of the great advantages of transpedicular fixation is that you can decompress to whatever extent you think is necessary; whereas at that time, we went to great effort to preserve some of the facet.

M.O. : When did you meet Roy-Camille?

J.W.S. Well, it came about in 1985. I remember it quite well, because it was at that time I had realized that transpedicular fixation was not only becoming popular throughout the world and the United States, but that it could indeed become a very valuable adjunct allowing us to do bigger surgery more safely for the patient. It was Steffee who popularized it in the United States. I was, as you might imagine, a bit sceptical, because at that time I realized that it could be a very dangerous procedure. Well, of course, people say that PLIF is a dangerous procedure. So I did the pedicular screw learning the same way I did the basic spine: I found the masters, and went and worked with Steffee - we have been great friends over the years. When I came to Europe to see what were considered to be the masters at that time, I visited with Zielke, René Louis, and Magerl. Later, I went and worked on one of the courses with the AO organization. But the most exciting part of that adventure was when I came to Paris and worked with Raymond.

M.O. : Why was that?

J.W.S. Well, because he was, of course, known as the first person to do the pedicular fixation. When I visited with Raymond, the very first time, I felt, as now I know everyone feels when they visited Raymond Roy-Camille: When you visit him, you feel like you are the only person in the world, and that his whole world is open up to you. He took time himself, and took me to the Anatomy lab, before we even went to the operating suite. And we put in some screws and talked extensively. And as we were having dinner that first evening, we got to talking about the things we like to do. I like to hunt. The next year he invited me to go hunting with him in Spain, and we were together an entire week. So, every year after that, until he became ill, we would go and hunt together for a week. Of course, from that came one of the most marvellous friendships I have ever experienced. He came to the United States, he visited with me in San Antonio - but not to practise medicine. We went hunting in Mexico; but all the time that we were hunting, we were, of course, discussing spinal problems, and I just learned so much from him.

M.O. : Did you change your indications after you had been initiated to the pedicular screw technique?

J.W.S. Only in the fact that now, instead of just doing PLIF, I would enhance it with transpedicular fixation. Nowadays, a plug and plate is more or less my standard procedure. Raymond has influenced so many people over the world. I realize that I am just one of the many that he has educated and become close friends with. I believe that one of the most important parts of an operative procedure is the preoperative planning - and I teach this to my residents and fellows. You don't "explore" a spinal canal. If you don't know what you are going to do before you go in to the spine, you shouldn't be there. You should have your surgical procedure completely planned before you start the surgery.

M.O. : Have you designed your own plates and screws?

J.W.S. I was using Art Steffee's instruments. I had used Zielke's, I had used Wiltse's, I had used Eduardo Luque's; but I could not get Raymond's in the United States. The manufacturers would not sell them. I was somewhat frustrated, because I felt that particularly his lumbosacral plate was the best, and it probably still will be hard to improved upon it. The Richards reps knew that I was doing quite a bit of transpedicular fixation; and at that time, in 1988, Richards decided that they wanted to go into the spine field. So they allowed me to design the plating system that we have today.

M.O. : Have you had any legal problems with the screws?

J.W.S. We are all having the same problem. Hopefully, if the FDA come about with what we call a down-classing of the pedicle screw, then there won't be as much of a problem as there appears now. The FDA has not declared the pedicle screw to be illegal. There is a very strict rule that essentially says that no one other than licensed physicians can practise medicine. In other words, if we see something that we think is the best thing for our patients, then it is up to us to do. The FDA goes to very great lengths in stating that if we think that this is appropriate for our patients, we can use it. It is just that they have not approved it. They have not gotten the evidence for them - for the FDA - to say that it's safe and efficacious.

M.O. : In the United States, the lawyers seem to have made a lot of money out of this uncertain situation.

J.W.S. The situation applies to us, it applies to everyone else. In other words, we can use the tools that we think are best for our patients. The lawyers, on the other hand, can sue you for everything and anything. It all has to do with the thing that we call Freedom. But it was quite interesting that one of the most famous malpractice lawyers got in on the breast implant. The lawyers in the United States spent so much money on the legal work on the breast implant; and some companies - Dow Corning was one of them - went bankrupt. So, when you declare bankruptcy in the United States, then all your debts are wiped away. So now the law firm had to go bankrupt, because they put so much money into the breast implant, and they can't retrieve it. It's what you might call poetic justice.

M.O. : Let's talk a little about this Symposium. What is your feeling about complications in spinal surgery?

J.W.S. We as surgeons have a tendency to show off our successes. It's not a reflection on anybody; it's just that we are proud at the people that we can help, and we are embarrassed at the people that we can't help. But we need to share that information, so we won't make the same mistake. So, not only is this Symposium timely; in today's world, it is essential.

M.O. : How do you explain the non-mechanical failures of fusion?

J.W.S. First of all, I never tell a patient that I will cure him. There is two problems: One is the patient thinks you can do more than you can actually do. And the other problem is the surgeon thinks he can do more than he can. And somewhere in that myriad of things, the doctor and the patient have to have an understanding of the possibilities. There is nothing cast in stone about treating a patient with a back problem. That's where, as we were discussing, the sixth sense comes in. You can do all the diagnostics, all the workup - but when it comes to the day to make the decision to operate, you still do not have that one tool that's going to say, "Doctor, operate on this patient."

M.O. : Has the use of pedicle screws and plates improved your results?

J.W.S. I was getting very good fusion rates, even with the PLIF. The stabilization has given me a little better - maybe two or three per cent. better - fusion rate. What the instrumentation does is, essentially, it enhances all the attributes of the PLIF. Before, most of the time, we would leave more than we wanted to; whereas now, there is no problem with decompression. And the patients are usually up within a day or two, but with the transpedicular fixation, you can get them out of bed almost immediately, and without any bracing or casting. It was one of my frustrating things that we had not been privileged to these advancements; and I told Raymond that on numerous occasions. It is interesting also that one of Raymond's goals, as he frequently said, was to build a bridge - an educational and an intellectual bridge - from France to the United States. I think the problem was communication, as it is in so much of our daily life.

M.O. : What special memories do you have of Roy-Camille?

J.W.S. I remember one time in particular, we were actually in my home in San Antonio; and this was when I first started designing the plate for Richards. And he and I had a very free dialogue. There was nothing I would not discuss with him. I was asking him what he thought of the concept of using a plate and using washers to stabilize it. He got very excited, and then he took it and started looking at it and started playing with it, and said, "Well, you are bringing the hole to the screw." He was quite excited that the hole could be put in different places - and that's where he coined the phrase that I use sometimes: "We bring the holes to the screws."