Editorial BY JEAN-PAUL STEIB p112 - ArgoSpine

FOCUS ON 

Spine Surgery 

and Advances in 

Medical Imaging 

112 

INTERVIEW WITH 

J. RANDY JINKINS 

By Denis Kaech 

117 

CLINICAL APPLICATIONS 

OF THE EOS SYSTEM 

By Jean-Marc Vital & Jean Dubousset 

129 

EARLY OUTCOMES AFTER ALIF : A 

QUANTITATIVE ANALYSIS 

By Sabina Champain & Vincent Fière 

137 

A LOOK INTO THE WORKINGS OF 

ARGOSPINE 

Interview of Prof. Christian Mazel 

by Armelle Wiart, HealthPointCapital 

NUMBER 20, DECEMBER 2008 

News from the world of spinal surgery and biomechanics 

143 

WHO ARE OUR SPONSORS ? 

FOCUS ON DEPUY SPINE 

By Rob. C. Slootman 

ISSN 1957-7729 The official ArgoSpine publication / www.argospine.org

FOCUS ON 

Spine Surgery 

and Advances in 

Medical Imaging 

111 

112 

117 

116 

122 

124 

126 

129 

137 

139 

143 

ArgoSpine News & Journal summary 

Editorial BY JEAN-PAUL STEIB 

Interview with J. Randy Jinkins BY DENIS KAECH 

Clinical applications of the EOS system in diseases of the locomotor apparatus BY JM. VITAL, J. DUBOUSSET, 

O. GILLE, O. HAUGER, N. AUROUER, 

I. OBEI 

Dynamic foraminal disc herniation revealed by functional MRI (fmri ® ) of the spine BY J. NAXERA, D. KAECH, JP. ELSIG 

Report on the JPSSSTSS and its congress BY K. KUMANO, S. SANO 

Cervical kyphosis after a minor trauma BY ICHIRO KIKKAWA 

Book review BY PIERRE KEHR 

Early outcomes after ALIF with cage and plate in discogenic low back pain BY S. CHAMPAIN, V. FIÈRE 

Interview with Christian Mazel BY ARMELLE WIART 

2008 ArgoSpine membership 

Who are our sponsors ? Focus on DePuy Spine, Inc. BY ROB. C. SLOOTMAN 

ArgoSpine News & Journal N°20 December 2008 

110

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Editorial 

Spine surgery is born, lives and 

dies through medical imaging… 

Effective assessment of our patients’ condition necessarily involves clinical examination. 

However, the image attests to the possible error which will be recorded and transmitted. The 

surgical indication will be based upon this image justifying an invasive surgical procedure. It is 

lasting proof of the clinical reasoning that underlies our decision 

maging techniques still prove useful 

I 

intraoperatively to perform the required 

surgical step at the right level, on the 

appropriate side and to successfully monitor the 

progress of the surgery : release, reduction and fixation. 

Thereafter, it will be one of the criteria in support of the 

follow-up, evidencing once again the validity of the 

surgical treatment. On the other hand, the image could 

be turned against us by revealing an error and may 

serve as proof of the offence. Let us learn how to put 

imaging to good use and to take advantage of this tool 

while avoiding, so far as possible, to succumb to its 

charms without our noticing. 

The 13th International ArgoSpine Symposium which 

will be held on January 29 and 30, 2009, in Paris, will 

focus on medical imaging. We will cover many aspects 

of this issue from the perspective of the radiologist 

with the demonstration of its usefulness for the 

diagnosis but also from the viewpoint of the surgeon 

who will describe his day-to-day practice and the way 

to gather as many imaging data as possible. The 

optimal use of this modern ever-progressing tool 

should allow us to achieve more effective results. 

Appropriate use of imaging for surgical complications 

is in many cases the key to find the beginnings of a 

solution : efficacy can only be achieved through a 

better understanding of the data collected. Besides 

these radiological examinations we are supposed to be 

familiar with and about which this meeting will allow us 

to learn more, nowadays, radiology proves helpful for 

the visualisation of the spine in motion and weightbearing. 

Standard myelography is now complemented 

by dynamic MRI which is showing gradual 

improvement over time. A “gold standard” of the spinal 

balance, teleradiography, will most likely be replaced 

by EOS offering enhanced quality and increased 

possibilities with high-precision automatic calculations. 

Yet, radiology is no longer used for diagnostic and 

informational purposes only. Interventional radiology is 

now a reality and a great help to the surgeon. The 

accuracy achieved by the scanner allows biopsies as 

well as infiltration tests (block tests) and is helpful to 

pinpoint the painful area (diskography with memory 

pain test). Here, the image is replaced by sign of pain 

or its absence which is no longer hypothesized but 

identified or relieved. Vertebroplasty and kyphoplasty 

are salvage procedures for patients with osteoporotic 

collapsed spine unable to undergo surgery. Laser 

treatment reaches tumours otherwise difficult to locate 

and target, for which surgery would be risky and 

resulting in severe injury. The disc can show poor to 

excellent response to a variety of treatments, including 

surgery. We are now able to gain better knowledge of 

the vascular anatomy through a thorough examination 

of the arterial supply of the spinal cord (i.e. the artery 

of Adamkiewicz) which remains controversial; the 

surgical approach is also made easier with the 

embolization of hypervascularized lesions. 

Ongoing progress is being made in mini-invasive 

surgery (MIS) which has become increasingly popular. 

Clear view of the spine, usually obstructed by the 

human body, can be achieved using virtual or real 

image. It is in this field that the greatest advances will 

most probably be made over the next few years 

through navigation which is now gaining ground with 

the preoperative scanner. What makes this technique 

attractive is that it saves time and enables enhanced 

precision, not to mention reduced radiation exposure 

for the surgeon. We will all be able to start using it 

thanks to imaging tools. 

Today, the radiologist should be our companion and 

associate in treating a diseased spine. A surgeon and 

a radiologist working in tandem are a winning team. 

Our field of action is wide and the number of patients 

is ever growing. Jealous competition is to be avoided 

and only team work can enable us to improve our 

practice for the greater benefit of our patients. For all 

these reasons, you are cordially invited to join us in 

January in Paris, where you will gain valuable and 

unexpected insight into these issues. I am confident 

that this meeting will allow us to further improve our 

passionate commitment to spine surgery. 

EDITO BY JEAN-PAUL STEIB, MD

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INTERVIEW WITH J. RANDY JINKINS 

You were the first neuroradiologist to 

routinely perform upright-kinetic open MRI 

examinations of the spine. Could you explain 

why you take a special interest in this 

technique ? 

— If I may, I would like to begin at the 

advent of recumbent MRI in order to put 

upright-kinetic MRI in proper context in 

which it emerged quite a bit later (c. 2001). 

At the time, when the first unit became 

available, which was 1980, CT was scarcely 

10 years in use, and the medical community 

was not certain if this new - and initially very 

poorly understood by radiologists - imaging 

technique would benefit health care. And, 

at the time, there were legitimate concerns 

that this new device would only add to the 

cost of health care without yielding a 

consistent or even greater gain, both 

economically as well as medically. 

A fundamental if complex rule in imaging 

diagnosis is that once an initial diagnostic 

imaging method has been employed, and 

the required or desired information from this 

first imaging examination concerning the 

discovered pathology is deemed insufficient, 

then it is acceptable and even recommended 

to employ a secondary imaging modality. 

This is particularly true if it replaces the 

primary imaging method that has been 

found to be less specific in diagnosis, less 

sensitive in the detection of the disease 

under question, and/or is of lower 

spatial/contrast resolution. It is also 

appropriate to utilize a supplemental imaging 

112 ArgoSpine News & Journal N°20 December 2008 

INTERVIEW WITH J. RANDY JINKINS BY DENIS KAECH 

The present state of medical imaging 

in the diagnosis of spinal disease and its role 

in integrated medical-surgical therapy 

procedure if it significantly augments the first 

imaging technique’s findings. However, it is 

unacceptable to use an imaging method that 

only duplicates the information that is already 

known from the initial imaging methodology. 

The significant point is that we must 

endeavor to contain the cost of health care 

and not abusively escalate these expenses, 

because we find ourselves incompetent in 

our understanding of the concept of ILAC 

(Indications, Limitations, Alternatives and 

Contraindications of medical imaging 

studies). Furthermore we should be selfinterested 

in participating in this process for 

reasons of medical as well as personal 

ethics.* 

In the event, over the past decade, as the 

technology gradually improved, we have 

witnessed many clearly obvious and 

medically important advances in imaging 

with which MRI would enable us to take 

advantage. This has been proven to be 

progressively true over the ensuing years. 

And, the technologic MRI development is 

not at all presently at a standstill. Without 

question, novel focused techniques, are 

now being studied and will subsequently be 

developed and implemented. If proved to 

be of clinical value, we should naturally 

embrace these advancements. 

For example, some of the advancements 

include : greatly improved differential tissue 

resolution, greater spatial resolution, three 

dimensional volume rendering and the 

development of safe low volume contrast 

agents that have a much higher contrast 

resolution as compared with other imaging 

modalities. 

More recently, a newly developed MRI unit 

enables upright weight-bearing and 

dynamic-kinetic imaging (Upright MRI©; 

Fonar Corporation, Melville, New York). This 

has been a major quest of spinal specialists 

and clinicians alike, dating from the early 

*NB : while the medical community must remain solvent for the benefit of our patients, secondary gain must be kept in check. 

decades of medical imaging. I personally 

have been working with this upright MRI 

device since the year 2000. At that time I 

was using a prototype unit in the factory 

where it was being constructed and went 

through rigorous tests regarding efficacy 

and patient safety. This was even before it 

was approved by the FDA (Food and Drug 

Administration : USA) for general release to 

the medical community. I was then 

specifically studying the clinical applications 

of the instrument, and in which clinical 

situations it might most profitably be used, 

in order to reduce the overall failure rate of 

spinal treatment. 

Although the advantages inherent in 

upright-kinetic (upright, weight-bearing 

multipositional imaging) MRI are applicable 

to all parts of the body, it quickly became 

apparent that the most practical and 

valuable application is without doubt the 

spine. We, and our patients, all spend much 

of our lives in a weight-bearing position, 

performing self-directed kinetic maneuvers 

almost continuously. Myself being a spine 

imaging specialist, I was naturally eagerly 

interested early on in determining the 

indications, limitations, alternatives, and 

contraindications of open-uprightmultipositional 

MRI as it applies to clinical 

spinal diagnosis. Ultimately, this led to 

publications in scientific journals and 

textbooks which outlined the full range of 

possibilities that might be realized with this 

new and important imaging instrument. 

You have authored several textbooks, one of 

them about “Post-therapeutic 

Neurodiagnostic Imaging”. We would very 

much like to have an overview of your main 

comments on this topic. 

— One of the most challenging areas of 

imaging diagnosis is to be found in 

acquiring and interpreting medical images

in the patient who has undergone one or 

more forms of therapy. This may have 

involved conservative management, 

surgery, radiation therapy, chemotherapy 

or other forms of medical/surgical 

treatment. The imaging findings may be 

either of an expected or unexpected 

nature. In some instances, the treated 

tissues may be left with benign 

alterations; in other post-therapeutic 

cases, there may be a recurrence of 

disease or spread of the disease beyond 

the original site. In still other situations, 

the observations may represent a true 

acute/subacute complication of the 

treatment, including postsurgical 

hemorrhage or infection, for example. 

All of these possibilities complicate the 

medical imaging analysis. Long-term 

alterations similarly may contribute to the 

failed back surgery syndrome (e.g., 

arachnoiditis, adjacent level disease…). 

In order to critically evaluate the posttherapeutic 

patient, it is imperative to 

understand several factors in reasonably 

specific detail. These include the primary 

pretherapeutic clinical diagnosis, the 

posttherapeutic provisional diagnosis, the 

treatment or treatments previously 

undergone by the patient, the elapsed 

time since the various therapies that have 

been completed and finally, the current 

clinical spinal syndrome. The answers to 

these questions will determine in large 

part which imaging modality or modalities 

are chosen for the imaging evaluation, 

how the images are specifically acquired 

and whether or not a contrast enhancing 

agent is used. 

In summary, it is mandatory to integrate the 

complex clinical information with the image 

interpretation in order to enable the 

surgeon to take this data into consideration 

when determining the optimal surgical 

algorithm. However, it is equally important 

to integrate the clinical data with 

pretreatment diagnostic imaging planning, 

thus empowering the radiologist to utilize 

this information in determining the selection 

and flow pattern of imaging examinations to 

be performed in an attempt to ensure the 

most efficient, efficacious and cost-effective 

image package. 

Could you give us an overview of the latest 

developments in spinal imaging ? 

— The latest developments in spinal 

imaging have largely been purely technical. 

These include the ability of obtaining faster, 

higher spatial, temporal, tissue contrast 

resolution images. The goal of this endeavor 

in part is the eventual capability of 

visualization of spinal cord substructure 

reliably in a similar manner in which we are 

able to investigate brain substructure 

presently. This will without doubt be 

accomplished with future amplified MRI 

units. 

Significantly, faster scanning is also 

becoming a reality. Scans can now be 

completed with reasonable resolution in 

less than 30 seconds. This can be an 

important factor in the evaluation of 

incoherent or fearful patients (i.e., 

claustrophobic), allowing successful 

imaging that is now not possible because of 

the long scanning times obtaining during 

MRI as compared to CT acquisition time. In 

addition, faster scanning techniques may 

also mean the ability to obtain higher 

contrast and spatial resolution images, 

because in reality the majority of modern 

MRI constitutes a type of averaging of 

multiple repetitive short scan time echo 

trains. 

Recently, on a separate subject, intrathecal 

gadolinium contrast agents have gone 

through clinical trials for the evaluation of 

spinal and cranial pathology. These include 

cranial and spinal CSF leaks, central spinal 

canal CSF functional obstruction analysis, 

the determination of the presence or lack of 

communication of cranial arachnoid cysts 

under consideration for surgical treatment 

and the evaluation of chronic 

communicating hydrocephalus. This is an 

exciting area of diagnosis to which we have 

previously been “blind” with MRI. 

Nevertheless, the use of intrathecal 

gadolinium is not universally approved, and 

each hospital or institution must gain 

approval for its use from their respective 

ethics committees. 

Finally, as referred to earlier, upright-kinetic, 

or functional MRI of the spine is a 

technique that holds great promise with 


regard to making the most sensitive and 

specific diagnosis of degenerative spinal 

disease, before treatment options are being 

considered. It is clear that some potentially 

clinically important degree of degenerative 

disease of the spine is being missed on 

recumbent MRI of the spine. Personal 

investigations and international research by 

others on this subject has shown that over 

15-18% of degenerative disease is 

completely overlooked, and over 65% of 

potentially clinically significant degenerative 

disease is underestimated. So, not only was 

potentially clinically significant spinal 

degenerative disease missed, but the 

degree of this disease was also being 

miscalculated. Specifically, degenerative 

disease was found to be represented by 

dynamic emerging/enlarging disc 

herniations, hypermobile dynamic 

degenerative spinal instability and dynamic 

central spinal canal and spinal neural 

foramen stenosis. As you are aware, these 

are some of the principal conditions for 

which physicians request MRI 

examinations of the spine in order to 

include or exclude neural compromise. 

There are of course many other disease 

categories that affect the spine, but MRI 

also characteristically better differentiates 

degenerative disease from these other 

pathologies. In principle, surgeons and their 

patients demand and deserve to obtain a 

critical understanding of the entire 

clinicopathologic picture before 

constructing a therapeutic regimen. 

Positional-kinetic MRI of the spine is 

currently the superior method for this 

analysis in terms of imaging. 

Where available, what type of imaging 

procedure would you recommend in the 

detection of spine tumors ? 

— In my opinion, and given no patient 

specific contraindications such as steel 

cerebral aneurysm clips or electronic 

pacemakers of any type that cannot be 

switched off temporarily during the imaging 

procedure, contrast enhanced MRI should 

be the first choice. It is the most sensitive 

imaging technique and has the highest 

spatial and contrast resolution of any 

imaging method that is accessible to us at 

present. 


113


For primary intraaxial and extraaxialintraspinal 

neoplasia, there is no question 

that contrast enhanced MRI is the superior 

method of medical imaging. 

The one relative exception is in cases of 

calcified neoplasia, relative because MRI 

will miss or not characterize correctly 

calcifications if present within tumors. 

However, in the spine this is not very 

common except in the case of spinal 

meningiomas. If it is not considered 

important by the surgeon to know before 

surgery if a tumor mass is calcified, the CT 

examination may not be a valuable 

supplemental imaging technique. 

Ultimately, the surgeon must make this 

decision. 

However, another more complex 

consideration is in the case of metastatic 

neoplastic disease involving the bony spinal 

column. Although CT certainly 

demonstrates the bony detail in radiolyticsclerotic 

disease of the bony spine more 

accurately and specifically than MRI (e.g., 

prostate carcinoma metastatic disease), in 

fact MRI does give the surgeon an 

excellent graphic representation of the 

disease process while at the same time 

revealing the enhancing-necrotic tumor or 

tumors, the degree of spinal column 

collapse if present, the severity of related 

spinal cord or cauda equina compression 

and the presence of direct 

extraosseous/epidural perispinal spread. In 

such cases, if the spinal cord compression 

is sufficiently severe, MRI will also 

demonstrate underlying spinal cord edema. 

It should also be noted that MRI is 100% 

more sensitive that CT for bony metastatic 

neoplastic disease of the spine in cases of 

infiltrative bone marrow neoplasia that has 

not yet caused radiolytic bony destruction; 

the latter will be regularly missed with CT 

examinations of the spine. 

In summary, as a general rule I believe that 

MRI should be the first imaging tool of 

choice in this clinical situation, 

supplemented by CT with reconstructions 

and perhaps conventional radiographs 

when deemed necessary, the latter two 

imaging methods employed principally to 

enable the surgeon to effectively plan a 


surgical bone grafting and/or surgically 

instrumented spinal reconstructionstabilization. 

What type of imaging procedure would you 

recommend in the evaluation of degenerative 

disease of the spine ? 

— With progressive improvements in the 

various technologies utilized today in 

medical imaging of the spine, I can 

confidently say that personally I feel that 

MRI best delineates all forms of 

degenerative disease of the spine. 

However, there are two deficiencies with 

MRI diagnosis in this area of evaluation. 

The first shortcoming is in the imaging of 

spondylosis involving calcified or ossified 

degenerative pathology (e.g., calcified 

intervertebral disc disease, ossification of 

the posterior longitudinal ligament). In such 

cases, MRI either poorly characterizes the 

calcium/gas containing tissue or misses it 

altogether. The second failing is in the 

specific diagnosis of benign-degenerative 

intraspinal gas containing pathology (e.g., 

nitrogen gas degeneration either within a 

degenerated intervertebral disc, or 

escaping from the disc and leaking into the 

epidural space). This arises from the simple 

fact that the gas associated with benigndegenerative 

spondylosis contains no 

protons; since MRI is principally a proton 

imaging technique, imaging of gas shows 

nothing but a subtle void. This can be easily 

confused with other processes that contain 

few or no protons (e.g., foreign bodies), 

that have few or no mobile protons which 

are susceptible to magnetic resonance 

(e.g., dense bone or calcifications) or that 

cause magnetic susceptibility (e.g., 

hemosiderin-chronic hemorrhage). 

Generally speaking then, I think that MRI is 

the imaging tool of choice in cases of 

intervertebral disc herniations, central 

spinal canal stenosis, spinal neural foramen 

stenosis and chronic spondylolisthesis 

(e.g., anterolisthesis, retrolisthesis or 

laterolisthesis). 

Besides the absence of axial loading, the 

other major problem that has faced 

recumbent MRI is the obvious fact that it is 

a nondynamic imaging technique : it fails to 

reveal translational hypermobile 

intersegmental spinal instability. However, 

today, where it is available, upright-kinetic 

MRI solves this quite competently. And, it 

does so accurately in the absence of 

magnification and rotation errors that are a 

common failing of conventional flexionextension 

radiography. 

The textbook "Spinal Restabilization 

Procedures" that you co-edited with Dr. D.L. 

Kaech was a collaboration between 

neurosurgeons, orthopedic spine surgeons, 

biomechanics researchers and radiologists. 

How important is a close interdisciplinary 

approach to spinal pathology, especially 

when attempting to avoid failures of surgical 

treatments ? 

— Without doubt, the failed back surgery 

syndrome is heavily impacted by sometimes 

situationally inexperienced and ill equipped 

individuals attempting to treat a very 

complicated clinical problem with a 

combination of inadequate personal 

knowledge and experience, deficient 

diagnostic information and a poor 

understanding of the indications, 

limitations, alternatives and all important 

possible complications inherent in the 

consideration of any form of therapy. It is an 

empirically accepted rule that the better 

informed one is of a clinical condition and 

its various possible therapeutic approaches, 

the better are the probabilities of a longterm 

successful outcome of a selected 

therapeutic regimen. This success is partly 

determined by an interdisciplinary 

approach to planning the treatment of any 

and all spinal pathology. I certainly know 

that I have personally benefited enormously 

from my interdisciplinary interaction with 

clinicians. There is no question that I am 

more effective in assisting in the diagnosistreatment 

pathway now that I was before I 

realized the importance of such interaction. 

A physician that tries to function in a void 

(e.g., alone in a dark reading room) is not 

properly following the Hippocratic Oath. 

One other point that I would like to address 

is the medical imaging department as the 

source of error in the patient diagnosistreatment 

algorithm. If the radiologist is not 

properly trained, if the radiologic

technologist or radiographer does not have 

the knowledge to enable the acquisition of 

proper images for the disease under 

question, if the imaging equipment is not up 

to date or is deficient in some significant 

manner, then both the surgeon and the 

patient are not being properly served. 

Insufficient information will almost inevitably 

be transmitted to the surgeon who may 

then construct a management regimen that 

could ultimately fail through no fault of his 

or her own. It is undeniable that this is one 

uncalculated but possibly significant factor 

in the incidence of the fail back surgery 

syndrome. 

As founding member and past-president of 

the American Society of Spine Radiology, 

would you recommend that spinal surgeons 

and medical imaging specialists would meet 

and exchange their experience more often ? 

And, would this be also important for 

teaching the future generations and 

promoting clinical research ? 

— In fact, at present this interspeciality 

exchange is being carried out worldwide at 

surgical and radiologic spine imaging 

conferences. However, it strikes me that in 

the larger, general interest medical 

meetings that are not focused on the spine, 

there is poor interest and attentiveness as 

well as sparse attendance and inadequate 

audience participation in the discussions, 

the latter being an essential part of any 

symposium experience. I feel strongly that 

one who goes to a congress but does not 

participate actively might as well not attend 

at all. It is a detriment to his/her own fund of 

knowledge, the audience’s and even the 

speaker’s experience. I feel that any 

conference that I attend and deliver a 

lecture that is not followed by a spirited and 

thoughtful discussion, is one that has not 

been successful. 

Therefore, I believe that such discussions 

are best suited to small focus group 

organizations, such as ArgoSpine, to give a 

relevant example. This is the most effective 

venue : individuals from related disciplines 

meeting periodically, and gathering 

together out of a sincere interest in the 

subject under discussion, and in hearing 

and understanding the supplementary and 

contrasting views of colleagues. This 

concept is what really forwards optimal 

patient care with reference to a full 

understanding of the multidisciplinary 

approach to an array of very complex 

clinical problems that have a virtually infinite 

number of possible solutions, not all of 

which will be ultimately successful. 

With reference to the teaching of future 

generations, it is clear that the best 

informed are the best individuals to educate 

students. 

Toward the direction of promoting clinical 

research, as an academic professor myself, 

I cannot recall a symposium that I have 

attended where I did not come away with 

ABOUT 

J. Randy Jinkins 

3096 INDIANA ST., COCONUT GROVE 

FL33133, FLORIDA USA 

Professor Jinkins 

completed his Medical 

Degree at the University of 

Texas Medical Branch, 

Galveston, Texas, and his 

Radiology Residency at Emory University, 

Atlanta, Georgia. He subsequently 

attended his Neuroradiology Fellowship 

at Massachusetts General Hospital, 

Harvard University, Boston, 

Massachusetts. His most recent research 

has encompassed the clinical 

development and initial clinical research 

on positional/kinetic imaging of the spine 

using the first dedicated upright, weightbearing, 

dynamic-kinetic MRI unit 

(Upright MRI). Other current research 

includes the study of the practical 

applications of intrathecal gadolinium 

enhanced MR 

myelography/cisternography, the 

radioanatomic analysis of degenerative 

changes of the discal and nondiscal 

structures of the spine, and the 

anatomic-physiologic delineation of 

spinal syndromes. He has published or 


new ideas that might be applied profitably 

to my own areas of investigation. As 

another practical suggestion, meeting 

organizers should endeavor to invite 

members of related specialties to deliver a 

pertinent paper and join in the discussions 

carried out during the clinical sessions of 

the symposium. This can be a most valuable 

stimulant to the progress of research, and 

indeed, the body of knowledge in this field 

of study. 

I applaud the many 

successes of ArgoSpine. 

Bravo ! Encore ! 

INTERVIEW BY DENIS KAECH 

has in press as author, co-author, or 

editor a combined total of over 275 

textbooks, textbook chapters, scientific 

articles, abstracts, editorials, and digital 

teaching matter. His most recent 

textbooks are entitled: “Atlas of 

Neuroradiologic Embryology, Anatomy 

and Variants” (Lippincott, Williams and 

Williams, Philadelphia, 2000), “Spinal 

Restabilization Procedures: Diagnostic 

and Therapeutic Aspects of Intervertebral 

Fusion Cages, Artificial Discs and Mobile 

Implants” (Elsevier, Amsterdam, The 

Netherlands, 2002), and “Emergency 

Neuroradiology” (Berlin-Heidelberg, 

2006). Worldwide, he has presented a 

total of over 400 scientific papers and 

invited lectures, and has contributed 

more than 75 scientific posters and 

exhibits. He is a Fellow of the American 

College of Radiology (F.A.C.R.: Reston, 

VA), founder and past President of the 

American Society of Spine Radiology 

(ASSR: Oak Brook, IL), past Chairman of 

the Texas Chapter of the Explorers Club 

and present Fellow of the Explorers Club 

(F.E.C.: New York City, NY). He has 

traveled to over 120 different countries, 

both teaching as well as learning, in an 

effort to promote education, 

understanding and Peace. 


115

DYNAMIC FORAMINAL DISC HERNIATION 

REVEALED BY FUNCTIONAL MRI 

Dynamic foraminal disc 

herniation revealed by functional MRI 

(fmri ® ) of the spine 

BY JAROSLAV NAXERA, DENIS KAECH, JEAN-PIERRE ELSIG 

This case study demonstrates the possibilities offered by upright, weightbearing, 

multi-position, i.e. functional MRI of the spine (fmri ® ). This 

particular top-front open MRI (0.6 Tesla) system allows imaging in various, 

especially symptomatic, positions. 

40 years old patient has been 

This complaining of position and 

motion-dependent pain along the 

left L4 dermatoma for several weeks, 

associated with a moderate quadriceps 

weakness. A first recumbent MRI (figure 1- 

2) showed only a slight disc degeneration 

with a minimal left lateral to foraminal 

bulging. These pictures could not explain 

the patient’s signs and symptoms. After 

further worsening under conservative 

treatment, he was sent to the fmri Center 

for further investigations in symptomatic 

positions : sitting in extension and upright 

standing with lateral bending to the left. 

Both examinations showed a left annular 

tear with an intraforaminal L4/5 disc 

herniation extending cranially compressing 

the L4 nerve root (figure 3-4). This evident 

fmri finding was correlating with the 

patients’ complaints and clinical signs. 

Most of the patients with comparable 

symptoms are traditionally investigated in 

recumbent MRI. The high field technology 

is presently considered as gold standard. 

In a consecutive cohort of 25 patients 

investigated for low back pain, 13 surgically 

relevant pathologies were revealed by 


positional MRI under loading conditions, as 

reported by Smith et al [6] in 2005. In a 

second study [7] including 58 patients with 

signs and symptoms of spinal stenosis, disc 

protrusions were more prominent in 65% of 

these patients when investigated in the 

upright sitting position, allowing a better 

understanding of the condition of the spine 

which resulted in an improved management. 

Another study from Aberdeen in 2007 by 

Alexander et al [1] analyzed the response of 

the nucleus pulposus to functionally loaded 

positions : the physiological biomechanical 

behavior of the disc could be visualized and 

verifyed by dynamic MRI. 

The most recent paper from 2008 by Zou et 

al [8] points at “missed lumbar disc herniation” 

and confirms the additive value of functional 

“positional” MRI studies in patients with 

symptomatic radiculopathy and no obvious 

anomaly on conventional MRI. 

These statements about the higher 

sensitivity and specificity of upright, 

weight-bearing, dynamic-kinetic or multiposition, 

i.e. functional MRI (fmri), 

confirm the statements made by Jinkins et 

al [3, 4] in various papers and book chapters 

written since 2002, and our own 

experience in Zurich since 2005 [2, 5] . 

References 

1. ALEXANDER, L., HANCOCK E., AGOURIS I., 

SMITH F. AND MACSWEEN A. (2007) : THE 

RESPONSE OF THE NUCLEUS PULPOSUS OF THE 

LUMBAR INTERVERTEBRAL DISCS TO FUNCTIONALLY 

LOADED POSITIONS. SPINE, 32(14) : 1508-1512 

2. ELSIG, JP. AND KAECH D. (2007) : DYNAMIC 

IMAGING OF THE SPINE WITH AN OPEN UPRIGHT MRI 

UNIT : PRESENT RESULTS AND FUTURE PERSPECTIVES OF 

FMRI. EUR J ORTHOP SURG TRAUMATOL, 17(2) : 119-124 

3. ELSIG, JP. AND KAECH D. (2006) : 

FUNCTIONAL MRI : WHAT ARE THE POSSIBILITIES ? 

WILL FUNCTIONAL MRI REPLACE MYELOGRAPHY ? 

ARGOS SPINE NEWS, 14 : 26-27 

4. ELSIG, JP., NAXERA J. AND KAECH, D. 

(2007) : FUNCTIONAL MRI CASES MARCH2007. EUR J 

ORTHOP SURG TRAUMATOL, 17 : 511-512 

5. ELSIG JP. AND KAECH D. (2006) : 

IMAGING BASED PLANNING FOR SPINE SURGERY. 

MINIMALLY INVASIVE THERAPY AND ALLIED 

TECHNOLOGIES, 15-5 : 260-266 

6. JINKINS JR. AND DWORKIN JS. (2002) : 

UPRIGHT, WEIGHT BEARING, DYNAMIC-KINETIC MRI 

OF THE SPINE : P/K MRI. IN SPINAL RESTABILIZATION 

PROCEDURES, PP. 73-82. EDITED BY KAECH, D. L., AND 

JINKINS, J. R., 73-82, AMSTERDAM, ELSEVIER 

7. JINKINS JR., DWORKIN JS. AND 

DAMADIAN RV. (2005) : UPRIGHT, WEIGHT- 

BEARING, DYNAMIC-KINETIC MRI OF THE SPINE : 

INITIAL RESULTS. EUR RADIOL, 15 : 1815-1825 

8. JINKINS JR., DWORKIN JS., GREEN CA., 

GREENHALGH JF., GIANNI M., GELBIEN M., WOLF 

RB., DAMADIAN J. AND DAMADIAN RV. 2002) : 

UPRIGHT, WEIGHT-BEARING, DYNAMIC-KINETIC MRI 

OF THE SPINE : PMRI/KMRI. RIV DI NEURORADIOL, 

15 : 333-357 

9. KAECH D. AND ELSIG JP. (2006) : 

FUNCTIONAL MAGNETIC RESONANCE IMAGING OF 

THE SPINE. RIVISTA MEDICA, 12(3-4) : 69-73 

10. SMITH FW. ET AL. (2005) : POSITIONAL 

UPRIGHT IMAGING OF THE LUMBAR SPINE MODIFIES 

THE MANAGEMENT OF LOW BACK PAIN AND 

SCIATICA. IN EUROPEAN SOCIETY OF SKELETAL 

RADIOLOGY. EDITED, OXFORD, ENGLAND 

11. SMITH FW., POPE M. AND WARDLAW D. 

(2005) : DYNAMIC MRI USING THE UPRIGHT OR 

POSITIONAL MRI SCANNER. IN SPONDYLOLYSIS, 

SPONDYLOLISTHESIS AND DEGENERATIVE 

SPONDYLOLISTHESIS, PP. 67-78. EDITED BY GUNZBURG, 

R., AND SZPALSKI, M., 67-78, WOLTERS KLUWER 

12. ZOU J., YAN H., MIYASAKI M., WEI F., 

HONG, SW., YOON SH., MORISHITA Y. AND 

WANG, JC. (2008) : MISSED LUMBAR DISC 

HERNIATIONS DIAGNOSED WITH KINETIC MAGNETIC 

RESONANCE IMAGING. SPINE, 33(5) : E140-E144 

Our case shows again that position and 

loading-dependent complaints of the 

patients should be investigated further by 

functional MRI. In many cases however, 

such patients are suspected of aggravating 

their symptoms or having a pain syndrome 

of psychosomatic origin.

The comparison of figure 1 and 2 (1.5 Tesla 

MR) versus 3 and 4 (fmri) demonstrates 

that this 0.6 Tesla open MR can provide 

ABOUT 

Denis Kaech 

NEUROSURGERY, KANTONSSPITAL 

CHUR, CH 7000 SWITZERLAND 

PH + 41 812 566 230 

Doctor Kaech graduated 

from the medical School in 

Basel in 1977. From 1978- 

1985 he worked as a 

resident in Germany 

(General Surgery), Switzerland (Neurology 

and Neurosurgery), then as an Attaché in 

Neurosurgery at the Salpêtrière in Paris 

and as a Neurosurgical Registrar at the 

Wessex Neurological Centre in 

Southampton. 

Clinical 

applications of 

the EOS system 

in diseases of the 

locomotor apparatus 

JM VITAL, J DUBOUSSET, O GILLE, O HAUGER, N AUROUER, I 

OBEID. DEPARTMENT OF SPINAL DISEASES, TRIPODE 

HOSPITAL, PLACE AMÉLIE RABA LÉON BORDEAUX FRANCE 

valuable images of the spinal anatomy 

under weight-bearing conditions, and in 

different positions. 

After 4 years spent as a senior resident in 

Lausanne, he was appointed as Chief 

Neurosurgeon in Chur, Switzerland, in 

1989. He then developed special interests 

in Spine Surgery and Neurodiagnostic 

Imaging. As a Co-Editor and translator of a 

book about CT and MRI in the clinical 

practice (French to German), he co-edited 

a first monograph about interbody fusion 

cages and artificial discs in 1999, and a 

book “Spinal Restabilization Procedures” 

in 2002, together with Prof. J. Randy 

Jinkins, a well-known American 

Neuroradiologist. 

A brief glance at the history of EOS 

Georges Charpak was awarded the Nobel 

Prize in 1992 for his work on gaseous X-ray 

detectors. The advantage offered by this 

technique is its high sensitivity to X-ray 

which would allow to reduce dramatically 

radiation exposure while delivering 

remarkably detailed imaging. This device 

dedicated to the diseases of the locomotor 

apparatus was developed through the 

collaboration of multidisciplinary specialists: 

Profs. Dubousset (orthopaedist) and Kalifa 

(radiologist) at the St Vincent de Paul 

Hospital in Paris, with Profs. Skalli and 

Lavaste at the ENSAM (Ecole Nationale 

des Arts et Métiers de Paris), but also with 

Prof. de Guise at the LIO (Laboratoire 

d’Imagerie Orthopédique in Montreal). 

This article has been previously published in 

Eur J Orthop Surg Traumatol (2008) 18 (7) : 549–550 

Dr Kaech was teacher at the European 

Courses in Neuroradiology dedicated to 

Spine in Prague in 1995 and in Bologna in 

1998, at the Eastern European Courses for 

Young Neurologists held in Czech Republic 

in 2000 and 2002, and at the EANS Course 

for Young Neurosurgeons in Luxembourg 

in February 2006. His special interest is 

now the open, upright, weight-bearing, 

kinetic MRI, or functional MRI (fMRI) 

mainly dedicated to spine, establishing a 

close collaboration with Dr Jean Pierre 

Elsig, Orthopaedic Surgeon, the owner of 

this new centre in Zürich. 

The EOS system allows to view the skeletal structure and soft-tissues of a patient in the 

standing position, from head to feet, with 2D and 3D images capturing both the entire spine 

and the lower limbs. Its main features are a great imaging accuracy using a low dose of 

radiation. Combined with 3D technology, it enables thorough examination fully comparable to 

the one achieved with CT scan except for the dramatically reduced radiation dosage (figure 1). 

The system was initially used in clinical 

practice (at the St Vincent de Paul Hospital 

in Paris) then in Brussels and Montreal. As 

from June 2006, we have adopted this 

system at the University Hospital in 

Bordeaux. It is worth mentioning that the 

EOS device is currently used at the 

University Hospital in Marseilles, at the 

Robert Debré Hospital in Paris, in Budapest 

and that many hospitals in France are 

planning to be equipped with this system. 

[1, 2] 

Operating principles 

The gaseous X-ray detectors enable to 

convert pressurized gas, such as xenon, 

X photons into electrons. These electrons 

are amplified with the avalanche effect, 


117

CLINICAL APPLICATIONS OF THE EOS SYSTEM 

1 2 

that is an increase in the number of 

electrons in the electric field detected by a 

suitable electronic chain. 

The patient who may be examined standing 

or sitting, is placed in the field with a total 

coverage of 1m70 high and 45cm wide. 

Images may be obtained using 2D 

anteroposterior and lateral orthogonal views. 

A 3D modelling software was developed 

using semi-automatic reconstruction of T1 to 

L5 vertebrae and at the level of lower limbs 

through calibration on saw bone models and 

CT scans (figure 2) ; accuracy ranges from 

0.9 to 1.4 mm [3] . 2D images can be acquired 

within 20 seconds on average ; whereas 3D 

images are taken by a radiologic 

technologist or a clinician and are completed 

in 15 to 30 minutes on average. 

The assets of the EOS system 

It allows images to be obtained with a very 

low dose of radiation (8 to 10 times less than 

with 2D imaging routinely used in the 

surveillance of orthopaedic treatment of 

scoliosis associated with serious medical 

consequences [4] , 100 to 1000 times less 

radiation than with 3D imaging compared 

with 3D CT scan system). The level of imaging 

accuracy achieved is much higher than with 

traditional images allowing satisfactory 

osseous and above all soft-tissue assessment. 

Simultaneous AP and lateral views are 

taken and 3D images are obtained in an 

unconventional manner, since contrary to 

Semi-automatic 3D reconstruction 


CT scan, it allows imaging of patients in 

weight-bearing position. The EOS system 

can capture whole body images, with the 

exception of very tall patients; in the section 

dedicated to disorders affecting sagittal 

balance, we will see that the accuracy of 

knee positioning is sufficient as well as an 

image of the mid tibia. The patient is 

examined in the standing or seated position 

(figure 3). The flexion/extension dynamic 

views that can be obtained with EOS are 

very useful in the cervical region allowing to 

visualise the cervicothoracic junction. 

Clinical indications and results 

The spinal column 

Whatever the disease explored, it must be 

repeated that high-accuracy can be 

achieved in regions usually non-visualised, 

such as the cervicothoracic junction. 

Analysis of the sagittal balance 

It must be performed under reproducible 

circumstances and if possible from head-totoe, 

i.e. from the external auditory meati — 

located near the middle cranial fossa — to 

the ankles. Patient positioning should be 

carefully assessed ; in order to avoid 

changes in the position of the cervical spine, 

it is recommended to the patient to keep 

his/her pupils fixed and stare at a mirror. The 

optimal position may be with hands resting 

on clavicles or on malar bones, thus offering 

improved visualisation of the cervical spine ; 

patients suffering from balance disorders 

can use the anterior surface of the imager for 

3 

Standing Sitting 

3D images of pelvis ans spine in different positions, standing and sitting 

support (figure 4). It is also of paramount 

importance to verify and adjust knee 

positioning: as far as possible, knee flexion 

must be adjusted, since it is a frequent 

automatic gesture to retain one’s anterior 

balance (figure 5). The patient should be 

examined with the knees in extension. A 

force platform may be used to determine the 

gravity line position [5] . In severe anterior 

imbalance, the system’s limitations and its 

small field-width in lateral view may lead to 

non-visualisation of the skull ; we emphasize 

that in very tall patients, simply checking that 

knees are not flexed is made possible with 

images at the level of the middle of the tibias. 

Scoliosis 

The EOS system is also well adapted to this 

pathological pattern, notably for orthopaedic 

treatments during growth since the radiation 

dose has been kept at a minimum. An 

improved visualisation of the anatomy of the 

deformity can be achieved with 3D images 

(figures 6 and 7), especially, dislocations of 

the lumbosacral spine in adult scoliosis, for 

which 3D reconstructions obtained with EOS 

are much sharper with patients in a weightbearing 

standing position than CT scan 

images taken in a lying position (figure 8). 

The top view of the whole spine and chest 

provides valuable and unobserved data on 

the natural development of scoliosis. The 

efficacy of the orthopaedic treatment may 

therefore be assessed as suggested by 

Labelle [6] . Several studies (Dumas [7] , Steib [8] ) 

have indeed attested to the efficacy of

4 

12 year-old child with cerebral palsy, keeping knees flexed for balance 

and using the surface of the EOS imager for support 

8 9 10 

Dislocation of L3L4 is more clearly seen with 

3D EOS than on a 3D image obtained with 

CT (shown in red) 

surgical treatments using 3D images in terms 

of angle and rotation correction. A detailed 

comparison of the various methods of 

osteosynthesis with regard to angle as well as 

rotation correction is shown on figures 9, 10 

and 11. Preoperative measurements prior to 

transpedicular subtraction osteotomy can be 

readily obtained with 3D images, especially in 

congenital kyphoscoliosis (figure 12). 

Osteoporotic kyphoses 

They are another central field of study 

notably with new treatments such as 

vertebroplasties or balloon kyphoplasty as 

well as intracorporeal instrumentation for 

the treatment of vertebral compression 

fractures. Recently, a bone density 

measurement feature has been added, 

which is an important tool for this indication. 

Spondylolisthesis 

EOS imaging is best performed in severe 

cases associated with lumbosacral kyphosis. 

Dysplastic spondylolisthesis affecting 

5a 5b 

5a : Natural position, knees 

flexed. 5b : accurate positioning, 

knees stretched 

2D images at pre and postoperative follow-up of surgically treated scoliosis 

adolescents and resulting in high-grade slips 

progressing to spondyloptosis is being 

investigated. 3D analysis enables an accurate 

assessment of the shape of the severely 

dysplastic L5 vertebra but mostly the sacrum 

which is also dysplastic at the level of the 

superior endplate of S1 with a dome-shaped 

contour, and also at the level of its body often 

showing a slight forward curve. 

Evaluation of the intervertebral 

foramina and disk height 

It may be performed in patients who can be 

advantageously examined in the standing 

position. An ongoing study compares EOS 

and MRI carried out only with the subjects 

lying in the supine position, which is 

correlated to the work conducted by 

Rillardon on anatomical specimens [9] . 

Analysis of the sagittal balance in specific 

populations of patients. 

The EOS system also enables assessment 

of general balance in specific populations, 


6 7 

2D & 3D images of a 

left lumbar scoliosis 

2D & 3D images of a left 

thoracolumbar scoliosis 

Pre Post Pre 

Post 

Pre and postoperative follow-up 3D imaging of the same scoliosis 

particularly the spine of rugby players, in 

collaboration with the team of Dr Roussouly 

and Ms Dujat, as well as achondroplastics 

typically presenting with thoracolumbar 

kyphosis very often associated with wedgeshaped 

upper lumbar vertebrae (figure 13). 

Dynamic imaging 

EOS images, notably in the cervical spine 

region, offer the advantage of high-accuracy 

and allow for the detection of instability due 

to associated osteoarthritis or to trauma [10] . 

Thoracic cavity 

Through a simplified modelling using 

landmarks, the result of the correction of the 

kyphotic deformity is evaluated, notably with 

the view from above (figures 14 and 15). 

According to Jean Dubousset, this same 

view enables to determine the spinal 

penetration index in cases with severe 

lordosis (figure 16). 3D reconstruction of the 

external envelope of the trunk and lower 

limbs is currently being studied (figure 17). 


119

11a 

11c 

14 

16 


2D images at pre and postop. follow-up of a surgically 

treated adult lumbar scoliosis 

3D images at pre and postop. follow-up (lateral view 

and view from above) ; note the position of the pelvis 

(increased anteversion and reduced rotation 

postoperatively) 

3D reconstruction of the thoracic cavity 

Normal spine 

Measurement of the spinal penetration index (Dubousset) 


12 

11b 

3D images at pre and postop. Follow-up of the same surgically treated 

adult lumbar scoliosis (posterior and anterior views) 

3D preoperative measurements prior to subtraction 

osteotomy in congenital kyphoscoliosis (preop. shown 

in red, postop. in green) 

15 

Before treatment After treatment 

Effects of the orthopaedic treatment on spine and thoracic cavity 

13 

Moderate scoliosis 

Typical presentation of 

achondroplasia with thoracolumbar 

kyphosis, wedge-shaped upper 

lumbar vertebrae and natural knee 

flexion deformity

17 

Determination of 3D shape of the thoracic cavity and 

the buttock region 

Lower limbs 

Pelvic and acetabular tilt (or slope) 

EOS allows simultaneous examination of 

the spine, the orientation of the femoral 

neck and of the acetabulum in correlation 

with a similar assessment of the pelvis. The 

pelvic retroversion observed in 

osteoarthritis disorders of the spine has a 

significant impact on the acetabular slope 

and may possibly affect the outcome of hip 

prosthesis surgery. 

References 

1. DUBOUSSET J, CHARPAK G, DORION J, SKALLI 

W, LAVASTE F, DEGUISE J, KALIFA F, FEREY S : EOS 

SYSTEM : A NEW 2D AND 3D IMAGING APPROACH FOR 

MUSCULOSKELETAL PHYSIOLOGY AND PATHOLOGY WITH 

LOW-DOSE RADIATION AND THE STANDING POSITION. 

BULL ACAD NATL MED 2005; 189 (2) : 287-97 

2. DUBOUSSET J, CHARPAK G, SKALLI W, KALIFA 

G, LAZENNEC JY. : EOS STEREO-RADIOGRAPHY SYSTEM : 

WHOLE-BODY SIMULTANEOUS ANTEROPOSTERIOR AND 

LATERAL RADIOGRAPHS WITH VERY LOW RADIATION 

DOSE. REV CHIR ORTHO 2007, 93 (SUP 6) : 141-3 

3. MITULESCU A, SKALLI W, MITTON D, DEGUISE 

J : THREE- DIMENSIONAL SURFACE RENDERING 

RECONSTRUCTION OF SCOLIOTIC VERTEBRAE USING A 

NON STEREO-CORRESPONDING POINTS TECHNIQUE. 

EURO SPINE JOURN 2002; 39(2) : 152- 8 

4. DOODY MM, LONSTEIN JE, STOVALL M, HACKER 

DG, LUCKANOV M, LAND CE : BREAST CANCER 

MORTALITY AFTER DIAGNOSTIC RADIOGRAPHY; FINDING 

FROM THE US SCOLIOSIS COHORT STUDY. SPINE 2000; 25 : 

2052-63 

5. GANGNET N, POMERO V, DUMAS R, SKALLI W, 

VITAL JM : VARIABILITY OF THE SPINE AND PELVIS 

LOCATION WITH RESPECT TO GRAVITY LINE : A 3 D 

Hip and knee joints in a 

weight-bearing position 

Both AP and lateral views of these joints 

can of course be produced. A comparison 

of hip joints in standing or sitting position is 

possible. 

Assessment of lower limb rotation 

It is conveniently performed in a weightbearing 

position using considerably less 

radiation than CT. 

STEREORADIOGRAPHIC STUDY USING A FORCE PLATFORM. 

SURG RADIOL ANAT 2003, 25 : 424-33 

6. LABELLE H, DANSEREAU J, BELLEFLEUR C, 

POITRAS B : THREE-DIMENSIONAL EFFECT OF THE 

BOSTON BRACE ON THE THORACIC SPINE AND RIB CAGE. 

SPINE 1996; 21 : 59-64 

7. DUMAS R, STEIB JP, MITTON D, LAVASTE F, 

SKALLI W : THREE-DIMENSIONAL QUANTITATIVE 

SEGMENTAL ANALYSIS OF SCOLIOSIS CORRECTED BY THE 

IN-SITU CONTOURING TECHNIQUE. SPINE 2003; 28 : 1158-62 

8. STEIB JP, DUMAS R, MITTON D, SKALLI W : 

SURGICAL CORRECTION OF SCOLIOSIS BY THE IN SITU 

CONTOURING : A DETORSION ANALYSIS. SPINE 2004; 29 : 

193-8 

9. RILLARDON L, CAMPANA S, MITTON D, SKALLI 

W, FEYDY A : EVALUATION OF THE INTERVERTEBRAL DISC 

SPACES WITH A LOW DOSE RADIOGRAPHIC SYSTEM. J 

RADIOL 2005; 86 (3) : 311-9 

10. ROUSSEAU MA, LAPORTE S, CHAVARY-BERNIER E, 

LAZENNEC JY, SKALLI W : REPRODUCIBILITY OF 

MEASURING THE SHAPE AND THREE-DIMENSIONAL 

POSITION OF CERVICAL VERTEBRAE IN UPRIGHT POSITION 

USING THE EOS STEREORADIOGRAPHY SYSTEM. SPINE 

2007 32 (23) : 2569-72 


ABOUT 

Jean-Marc Vital 

UNITE DE PATHOLOGIE RACHIDIENNE 

HOPITAL TRIPODE, PLACE AMELIE RABA-LEON 

BORDEAUX FRANCE 

PH +33 (0)556 795 679 

Upon completing his 

residency with first class 

honours in 1980 in Bordeaux, 

where he spent his whole 

career, Jean-Marc Vital was 

the recipient of the Gold 

Medal Award of Surgery. 

Moreover, he earned a MD in human 

biology in the field of anatomy. In 1981 

he was appointed Instructor of anatomy 

and organogenesis as well as intern in 

orthopaedic surgery and traumatology. In 

the same year, he became Senior 

Registrar of the Department run by Prof. 

Jacques Sénégas. He also earned the 

National specialised Diploma in Sports 

Medicine (CES). 

Since 1989, he has been an Intern and 

University Professor in orthopaedic and 

traumatology surgery at the University of 

Medicine of Bordeaux as well as Head of 

the department of spinal diseases and 

anatomy laboratory Director at the Paul 

Broca faculty. His areas of research 

encompass spinal growth (neurocentral 

cartilage) and intervertebral foramen. 

As a spine surgeon, Dr Vital has a special 

interest in spinal deformities (with 

particular emphasis on sagittal balance), 

and in cervical spine surgery (cervical 

prostheses and myelopathy). 

He has been an active member of several 

outstanding societies such as the French 

Medical College of Anatomy since 1989, 

the European Cervical Spine Research 

Society since 2003, and he is currently 

President of the French Spinal Surgery 

Society (SOFCOT). 

Furthermore, he serves in the editorial 

board of the European Spine Journal, The 

Spine and The French Journal of 

Orthopaedic and Traumatology Surgery. 


121

REPORT ON THE JPSSSTSS & ITS CONGRESS 

ABOUT 

Kiyoshi Kumano 

SHIN YOKOHAMA SPINE CLINIC 

KITA-SHINYOKOHAMA 1-5-5 

YOKOHAMA, KANAGAWA JAPAN 

PH +81 455 335 401 

Kiyoshi Kumano graduated 

from the University of Tokyo 

Medical School in 1963. He 

did his surgical internship at 

Tachikawa Air-Force Base 

Hospital, located near Tokyo. 

Afterwards, he spent seven years at the 

Albany Medical Centre, USA, where he 

completed his surgical internship and 

residency, specialising in orthopaedics, 

and in 1971 he was certified by the 

American Board of Orthopaedic Surgery. 

In 1980 he earned his PhD from the 

University of Tokyo, and in 1989 he 

received the Japanese qualification in 

Orthopaedics. From 1982 to 2001 he was 

Chief Surgeon at Kantoh Rosai Hospital, 

Japan, where later he served as Head of 

the Nursing School. His past 

appointments also included Director of 

Fuji Toranomon Orthopaedic Hospital. 

He is currently appointed as Spine 

Consultant of Shin Yokahama Spine 

Clinic and Orthopaedic Consultant at 

Tokyo Medical and Surgical Clinic. 

Kiyoshi Kumano chaired several national 

meetings including the 13th symposium 

of the Japanese Scoliosis Society and the 

1st, 2nd and 7th annual meetings of the 

Society for the Study of Surgical 

Technique for Spine and Spinal Nerves, 

for which he is also a board member. 

He is very much involved in spinal 

surgery : scoliosis and degenerative 

spinal disorders are his main areas of 

interest. He has also delivered numerous 

presentations at major scientific 

congresses. 

He is a member of several national and 

international societies such as the Japan 

Orthopaedic Association, Diplomate of 

the American Board of Orthopaedic 

Surgery and International fellow of the 

American Scoliosis Research Society. 


About JPSSSTSS 

an its congress 

BY KIYOSHI KUMANO, SHIEGO SANO 

JAPAN SOCIETY FOR THE STUDY OF SURGICAL TECHNIQUE 

FOR SPINE AND SPINAL NERVES WWW.JPSTSS.JP 

This society is aimed at orthopedic 

surgeons, neurosurgeons and nonphysicians 

who are deeply 

interested in surgery of the spine 

and spinal nerves. 

It 

was founded on 6 Dec. 1993 to 

study these surgical techniques. 

The founders were orthopedic 

surgeons specialized in spinal surgery but 

the society members quickly expanded to 

include neurosurgeons. The first 

neurosurgeon to become president was at 

the 6th annual meeting in 1999, when the 

society started to publish the annual journal 

of JPSSSTSS. 

In Japan, spinal disorders have traditionally 

been treated by orthopedic surgeons since 

orthopedics was introduced into the 

Japanese medical field about one hundred 

years ago. Modern neurosurgery was 

introduced into Japan about 60 years ago 

primarily as brain surgery. However, 

recently neurosurgeons have become 

increasingly involved in the care of patients 

with spinal disorders. 

The spine and spinal nerves have an 

anatomically close relationship. The medical 

field concerning the spine and spinal nerves 

is wide and full of variety, covered by both 

orthopedic and neurosurgical fields. 

Therefore both academic and practical 

Located at the heart of the Japanese archipelago, Lake 

Biwa is the largest lake in Japan and is the symbol of 

Otsu where will be held the 15th annual meeting of the 

JPSSSTSS. See next page for details. 

interactions are mandatory between both 

fields in order to improve patient care. This 

society was founded to offer a place for 

interactions between orthopedic and 

neurosurgeons by exchanging ideas, 

knowledge and surgical techniques about 

the spine and spinal nerves. Both the 

academic and practical modalities of the 

society should be up to date and at an 

international level. The members should act 

on their own initiative, should not belong to 

specialized groups and should not adhere 

to the old tradition. 

We are particularly interested in all surgical 

techniques of spinal surgery covering fully 

spinal instrumentation, microscopic 

surgery, endoscopic surgery, interventional 

radiology technique and other emerging 

new techniques. Our society emphasizes 

that surgical technique should be taught in 

a hands-on fashion. The JPSSSTSS pedicle 

screwing seminar first started in 1995 and 

is held annually ; during the seminar, 

participants are able to observe the surgical 

technique of pedicle screwing in the 

operative field. On the occasion of our 

annual meeting, hands-on sessions of 

surgical technique are regularly held. 

Globalization, barrier free and 

uniqueness are mottos of our 

JPSSSTSS to establish the 

identity of spinal surgery.

The 15th annual meeting of 

JPSSSTSS was held at the Otsu 

Prince Hotel (Otsu, Japan) on 

September 19 and 20, 2008. Four 

main themes were discussed : 

My own invention for 

low-invasive spinal surgery 

My own invention for 

avoidance of complications 

My own invention for instrumentation 

Perspectives for spinal surgery 

We have succeeded in creating a meeting 

place for discussing one’s own surgical 

invention, which has been hopefully very 

On its shores is the 38-story Otsu Prince Hotel, where all 540 guest rooms offer a 

spectacular view of the Biwa lake, the largest lake in japan 

Report on the 15th annual meeting 

of JPSSSTSS 

useful for the clinical practice of all spinal 

surgeons. In addition, there has been a 

discussion about the future of spinal surgery, 

which will become increasingly important in 

the aging society. Papers unrelated to the 

main themes were also presented. Otsu 

played an important role in the Japanese 

history. It takes only half an hour from Kyoto 

station to the Otsu Prince Hotel by electric 

train and shuttle bus. The hotel has a 

beautiful location in front of Lake Biwa. We 

hope many spinal surgeons will participate 

in the 16th annual meeting of JPSTSS in 

2009. 

BY KIYOSHI KUMANO 

REPORT ON THE JPSSSTSS & ITS CONGRESS 

ABOUT 

Shiego Sano 

SANRAKU HOSPITAL 

2-5 SURUGADAI, KANDA, CHIYODA, 101 TOKYO JAPAN 

PH +81 3 3292 3981 

shigeosanohosp@sanraku.or.jp 

Shigeo Sano has been Chief of 

the Orthopaedic Department 

at Sanraku Hospital, Japan, 

since 1986. He graduated in 

1973 from the Medical Faculty 

of Tokyo University, where he 

completed his residency in orthopaedics. In 

1978 he did his fellowship in the 

orthopaedic department at Tokyo University 

Branch Hospital. 

He obtained the board certification in 

orthopaedics in 1983 and two years later, 

he earned his PhD. In 1984 he was a 

research fellow at Toronto General 

Hospital, Canada, under Prof. Kostuik. 

The following year he was a visiting 

fellow in the USA, in Minneapolis 

(Minnesota), Louisville (Kentucky) and 

Akron (Ohio). 

Upon returning to Japan, he joined the 

Orthopaedic Department of Tokyo 

University, where he became a lecturer 

and served as Chief of Low Back Clinic. 

He holds several certificates including 

Sports Medicine and Spinal Surgery. 

His main specialties are spinal 

instrumentation – he performed 2200 

cases as first operator - degenerative 

diseases and deformity, lumbar spinal 

canal stenosis and spinal trauma. He has 

also devised original techniques such as 

the corrective PLIF technique for 

deformity correction, as well as authoring 

several remarkable studies such as a 

new classification of spinal instability. 

Dr Sano is one of the founders of the 

Japan Society for the Study of Surgical 

Technique for Spine and Spinal Nerves 

(JPSSSTSS) for which he is presently 

Chief Director. 

He is also involved in several national 

societies, such as the Japanese 

Orthopaedic Association and the Japan 

Spine Research Society. 


123

14th International ArgoSpine Symposium 

NEW TECHNOLOGIES 

GADGETS or FUTURE 

GOLD STANDARDS?

www.argospine.org

CLINICAL CASE 

A case of cervical 

kyphosis after a 

minor trauma 

ICHIRO KIKKAWA, SATOSHI FUJITA, SUEO NAKAMA, 

HITOSHI OKAMI AND YUICHI HOSHINO DEPT. OF 

ORTHOPEDICS, SCHOOL OF MEDICINE, JICHI MEDICAL 

UNIVERSITY, TOCHIGI-KEN JAPAN 

A case report 

The case was a normally developed and healthy 

ten-year-old boy. On Apr. 4th 2004, he felt a 

cervical tilt when leaning on the sofa at home 

with his neck over-flexed to watch TV. Just after 

that episode, he had had a sudden onset of 

neck pain. He was admitted to our hospital for 

fixed flexed neck position and severe neck pain 

on Apr. 8th. His neck was fixed in a remarkably 

flexed position without being able to rotate his 

neck. Examination revealed tenderness on the 

cervical paravertebral muscle, but no 

neurological deficit. 

There was some spondylolisthesis from C2 to 

C5 respectively in plain cervical X-ray 

photograph. The C2-C7 kyphotic angle was 

44 degree and the interval between cervical 

spinous processes from C2 to C6 showed 

increased widening of the intervertebral 

C3/C4 disc space (figure 1). The atlanto-axial 

rotatory fixation (AARF) could not be 

observed on cervical CT ; however, there was 

a slight asymmetry of atlanto-dental intervals 

in open-mouth odontoid view (figure 2). 

Although he received cervical fixation by 

cervical collar orthosis, neck pain worsened 

gradually. Finally, he could not go to school 

nor eat anything due to severe neck pain ; 

he was admitted to our hospital on Apr. 

23rd. The degree of cervical kyphosis was 

almost the same as before and maximum 

cervical extension did not allow correction 

of the kyphotic deformity (figure 3). 

The results of serological and urination tests 

were all normal (data not available) 

showing that he had no acute inflammation. 

He lay in bed all day and received Glisson’s 

traction of 2 kg for 4 days since admission. 

After 3 days from admission, his neck pain 

disappeared and cervical posture became 

normal. We performed MRI of his cervical 


spine after two days from admission, which 

showed no abnormal findings about spinal 

cord and spinal canal although signal 

intensity of disc from C2 to C6 was low in 

T2WI (figure 4). The range of motion of the 

cervical spine got normal in appearance. He 

was discharged from our hospital on Apr. 

27th. He had no neck pain and the plain 

X-ray of his cervical spine showed normal 

alignment upon discharge (figure 5). We 

received a phone call from his mother 

informing us that he had fully recovered, 

played soccer every day and no longer 

suffered from neck pain. 

Discussion 

Winter and Hall have classified kyphosis into 

15 major groups [8] . Kyphosis may develop 

secondary to trauma, inflammatory or 

infectious diseases, laminectomy, irradiation, 

tumors, metabolic diseases, collagen 

diseases, skeletal dysplasia, 

neurofibromatosis, neuropathy and Klippel- 

Feil syndrome [3] . As a rule, cervical kyphosis 

is often caused by strong force applied to 

the cervical spine, which is called 

“hyperflexion sprain”. Hyperflexion sprain is 

characterized as a ligamentous disruption of 

the cervical spine, caused by a distractive 

force [1] . Our case is not a true “hyperflexion 

sprain” because the patient’s kyphosis was 

caused by a mild force created by leaning 

his head on the sofa. There has been one 

case in the literature of a mild force causing 

cervical kyphosis in a subject who had no 

specific disease (e.g., ankylosing spondylitis 

and skeletal dysplasia), such as our case [4] . 

This case was a 1-year-old girl. Her cervical 

spine became kyphotic after she had fallen 

ABOUT 

Kiyoshi Kikkawa 

DEPT. OF ORTHOPEDICS, SCHOOL OF MEDICINE 

JICHI MEDICAL UNIVERSITY. 3311-1, YAKUSHIJI 

SHIMOTSUKE-SHI, TOCHIGI-KEN JAPAN 

PH +81 285 587 374 

kikkawa@jichi.ac.jp 

Currently Professor of Paediatric 

Orthopaedics at the Jichi Children’s 

Medical Center Tochigi, Japan, Ichiro 

Kikkawa earned his MD from Jichi 

Medical School. He later defended a PhD 

Thesis on: Lipopolysaccharide (LPS) 

stimulating the production of tumour 

necrosis factor (TNF) and expression of 

inducible nitric oxide synthase (iNOS) by 

Osteoclasts (OCL) in murine bone 

marrow cell culture. After becoming 

board certified, Prof. Kikkawa completed 

his residency at Yokohama Municipal 

Hospital and was first appointed at the 

department of Orthopaedics, Prefectural 

Atsugi Hospital, Kanagawa Children 

Medical Center. His areas of interest 

encompass spine surgery including 

scoliosis surgery, paediatric orthopaedic 

surgery with a special emphasis on foot 

deformity. He co-authored over 20 peerreviewed 

papers and reports published in 

national scientific journals. Prof. Kikkawa 

is also an active member of the Japanese 

Orthopaedic Association, the Japanese 

Society for Spine Surgery and Related 

Research, the Japanese Pediatric 

Orthopaedic Association and SICOT. 

off one step of stairs. At first, her kyphosis 

was 38 degree from C2 to C6 on plain lateral 

X-ray view, then progressed to 73 degree 

without neurological deficit after four 

months. Her kyphosis disappeared after 

conservative treatments for 12 weeks after 

admission and there was no 

recurrence [4] . There has been another case 

which had no specific cause to the onset of 

cervical kyphosis in the literature [6] . This was 

a cervical kyphosis of 96 degree from C2 to 

C7. The patient needed an operation via the 

posterior approach to correct deformity and 

stabilize the cervical spine. No specific 

diseases had been identified, no trauma 

observed not even a mild one. Cervical 

kyphosis of this type belongs to “Idiopathic 

Cervical Kyphosis” [5] and is different from 

cervical kyphosis due to a mild force. AARF 

is known as a cervical deformity which is

due to a trivial force ; the usual picture is that 

of a persistent torticollis which begins 

spontaneously after trivial trauma or after an 

upper respiratory infection [2] . The etiology of 

this deformity remains unclear. It occurs 

infrequently and always in children ; the lack 

of pathologic specimens leaves AARF a 

poorly understood condition [7] . Our case of 

cervical kyphosis is much similar to AARF in 

the clinical pictures. Cervical spine MRI 

showed that the signal intensity of the disc 

from C2 to C6 was low in T2WI. The same 

MRI findings were obtained in the case of a 

posttraumatic cervical dystonia following a 

minor trauma [9] . We have called on the 

patient’s family several times to make him 

come to our hospital in order to undergo 

MRI of his present cervical spine as we 

would like to know how the signal intensity 

of the disc from C2 to C6 had changed after 

the treatment. However, they have not 

1a 

3 

4 

1b 2 

complied with our request yet. Every time 

we phoned his family they told us he did not 

need to go to hospital because he was 

healthy and did not have neck pain at all. 

Thus, the meaning of the signal changes in 

his MRI after his discharge from our hospital 

remains unknown. 

References 

1) BRAAKMAN M, BRAAKMAN R (1987) : 

HYPERFLEXION SPRAIN OF THE CERVICAL SPINE. ACTA 

ORTHOP SCAND 58 : 388-393 

2) FIELDING J W, HAWKINS RJ (1977) : ATLANTO- 

AXIAL ROTATORY FIXATION. J BONE JOINT SURG[AM] 59 : 

37-44 

3) HOWARD SA, RICHARD AB (1992) : THE CHILD’S 

SPINE : JUVENILE KYPHOSIS. THE SPINE. THIRD EDITION. 

PHILADELPHIA. W.B.SAUNDERS CO. : 487 

4) HYODO H, SATO T (1990) : A CHILD CASE OF 

TRAUMATIC CERVICAL KYPHOSIS. TOHOKUSEISAI- 

KIYO(JAPANESE) 34 : 459 

a b 

5 

c 

a b 

CLINICAL CASE 

Conclusion 

We have experienced a rare case of cervical 

kyphosis due to a minor trauma. The clinical 

picture of this case was very similar to AARF. 


Eur J Orthop Surg Traumatol (2008) 18 (1): 9–13 

5) IWASAKI M, AMANO K, YONENOBU K (2001) : 

IDIOPATHIC CERVICAL KYPHOSIS. SEKITSUI- 

SEKIZUI(JAPANESE) 14 : 29-34 

6) KATAYAMA Y, KAWAKAMI N, MATSUBARA Y, ET 

AL (2003) : A CASE OF CERVICAL KYPHOSIS. 

CHUBUNIHON-SEISAISHI (IN JAPANESE) 46 : 552 

7) KAWABE N, HIROTANI H, TANAKA O (1989) : 

PATHOMECHANISM OF ATLANTOAXIAL ROTATORY FIXATION 

IN CHILDREN. J PEDIATRIC ORTHOP 9 : 569-574 

8)WINTER RB, HALL JE (1978) : KYPHOSIS IN 

CHILDHOOD AND ADOLESCENCE. SPINE 3 : 285-308 

9)YAMADA R, ASAZUMA T, TOYAMA Y, ET AL 

(1998) : SEVERE CERVICAL KYPHOSIS CAUSED BY 

POSTTRAUMATIC DYSTONIA FOLLOWING A MINOR 

TRAUMA : A CASE REPORT. KANTO-SEISAISHI (IN 

JAPANESE) 29 : 204-209 

d 

1a. Lateral view of cervical X-ray photograph. There 

was some spondylolisthesis from C2 to C5, respectively. 

The C2–C7 kyphotic angle was 44° and the interval 

between cervical spinous processes from C2 and C6 

showed widening, respectively, with the widest C3/C4. 

1b. AP view of cervical X-ray photograph. There was not 

any scoliosis and other lesions. 

2a. Open-mouth odontoid view showed slight 

asymmetry of atlanto-dental intervals. 

2b-d ; CT of C1-C2 showed no atlantoaxial rotatory 

fixation although there was a slight asymmetry of 

atlanto-dental intervals. 

3a. Lateral X-ray at maximal flexion showed 

remarkable kyphosis (C2-7 angle : 46 degree). 

3b. Neutral position X-ray view (C2-C7 : 34 degree). 

3c. At maximum extension we did not observe correction 

of posterior curvature (C2-C7 :15 degree). 

3d. There was no scoliotic deformity in AP view. 

4. Sagittal MRI of the cervical spine. These showed no 

abnormal findings about the spinal cord and the spinal 

canal, although signal intensity of disc from C2 to C6 was 

low in T2WI. a). T1W ; b). T2W. 

5a. Lateral view of the cervical spine showed normal 

alignment at one month after discharge. 

5b. Normal AP view at one month after discharge. 


125

BOOK REVIEW BY PIERRE KEHR 

DOUGLAS L. BROCKMEYER 

Advanced pediatric craniocervical surgery 

2005, 150 PAGES, 110 FIGURES, HARDCOVER EURO (D) 109,95 CHF 174,00 

THIEME VERLAG - NEW YORK, STUTTGART ISBN : 3-13-132081-8 (GTV) ISBN : 1-58890-396-6 (TNY) 

dvanced Pediatric Craniocervical 

A 

Surgery offers the state-of-the-art 

concerning the pathology and 

surgical techniques of the craniovertebral 

junction and cervical spine in children. It is 

a welcomed book, as it covers a highly 

deficient, still not well standardized area of 

the medical literature. In a simple but wellstructured 

form, this work presents the 

pathogenetic basis, clinical and radiological 

presentations (including over 100 

descriptive images) of various medical 

abnormalities of the craniocervical region, 

potential indications for surgical treatment. 

For each of these conditions, the author, 

How about 

less radiation 

exposure? 

Placing Navigation Back in Your Hands 


leading authority in the field, has selected 

and presented, according to his experience, 

principles and techniques of treatment from 

the literature, also including embryological 

and biomechanical characteristics of the 

craniocervical region. The book provides 

short and concise descriptions as well as 

clear and straightforward references. 

Various aspects (clinical, pathogenetic and 

radiological), operative indications and 

surgical techniques, are presented 

separately and logically connected, step by 

step, so that the information is easy to find 

and follow. Therefore, it is easily readable 

and can be readily assimilated by clinicians 

 

 

 

 

 

of different specialties, interested in the 

pediatric pathology of the craniocervical 

region. The book features an accessible, 

well-documented reference of a complex, 

highly specialized medical field, thus less 

standardized. Its synthetic approach and 

precise quotation of references from the 

literature invite to reflection and therefore 

the book has considerable pedagogic 

potential. 

In summary, Advanced Pediatric 

Craniocervical Surgery, even if it presents a 

rather rare pathology, is of big interest to 

specialists encountering these specific 

medical conditions. As to the surgical 

aspect, this work can be useful to both the 

vastly experienced clinician and the 

learning apprentice. 

BOOK REVIEW BY P. KEHRLI 

 

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ArgoSpine News & Journal call for papers 

Editors-in-Chief : 

Pierre Kehr, MD & Christian Mazel, MD 

Associate Editors : 

Denis Kaech, MD 


Editorial Board : 

Laurent Balabaud, MD 

Alain Graftiaux, MD 

Stefano Boriani, MD 

Jean-Pierre Elsig, MD 

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Tamas Illes, MD 

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Panagiotis Korovessis, MD 

Charles-Marc Laager, MD 

Robert Melcher, MD 

Anca Mitulescu, PhD 

Karim Boukarabila 

Pierre Pries, MD 

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Wafa Skalli, PhD 

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Christopher Ullrich, MD 

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Early outcomes after ALIF with cage 

and plate in discogenic low back pain — 

a quantitative analysis 

S. CHAMPAIN, W. SKALLI LABORATORY OF BIOMECHANICS, ENSAM 151 BD DE L’HÔPITAL 75013 PARIS FRANCE 

V. FIÈRE SANTY ORTHOPAEDIC CENTER, 24 AV PAUL SANTY 69008 LYON FRANCE 

A. MITULESCU, P. SCHMITT SCIENT’X CLINICAL RESEARCH DEPARTMENT, GUYANCOURT FRANCE 

Acknowledgements : 

The authors wish to thank Maindron V., Mulsant P. and Plantier S. for their precious help in 

data collection and SpineNetwork for their support (grant for a PhD project ruled by the 

National Agency for Technological Research (ANRT in French) : CIFRE n° 677/2002). 

Anterior Lumbar Interbody Fusion 

(ALIF) is widely used to treat 

degenerative disc diseases, as it 

seems to offer the same advantages as a 

posterior approach [23, 24] and perhaps less 

invasiveness [6, 35] when performed through 

mini-open [7, 45] or laparoscopic [31, 37] The 

surgical 

techniques. Moreover, it preserves 

posterior paraspinal muscles, enhancing 

spine stability [6, 11, 35] . Interbody fusion cages 

were introduced in ALIF procedures to 

prevent graft collapse, compression and 

instability, leading to pseudarthrosis [1, 24, 28] , 

as they provided a biomechanically rigid 

environment that seems to improve the 

initial stability and the fusion rates [3, 20, 31, 35] . 

However, new complications (cagerelated) 

occurred, such as subsidence, 


decision is that the manuscript should be 

revised, it will be returned to the Editor-in- 

Chief within 10 days from notification. 

Ultimately, page proofs are sent to the authors 

for a final review before publication. 

Please use the following 

checklist before submission of 

your manuscript : 

• Double spacing 

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numbers in the text 

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in the text 

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identified by numbers in square 

brackets 

• Full reference list at the end of the 

work with entries numbered 

consecutively in order of appearance 

in the text 

• The reference list should adhere to 

the formatting guidelines 

migration or collapse [5, 19, 31] , in spite of the 

diversity of materials [16] and construct 

designs [35] that were evaluated, leading to a 

decrease in the use of stand-alone ALIF 

during the past few years [16] . 

In this context, some authors evaluated a 

“360°” approach for ALIF in the clinically 

unstable spine [16, 21, 29, 33] , while other studies 

showed that stand-alone threaded ALIF 

cages seem to be efficient in the treatment 

of degenerative disc disease [2, 32] . Also, 

recent investigations showed that both 

ALIF and PLIF alone may produce 

inconsistent stability [39] and comparable 

outcomes were found between ALIF with 

Hartshill horseshoe cage and 

circumferential fusion using instrumented 

PLIF [1] . 

Therefore, an alternative option was 

proposed, consisting in ALIF with cage and 

anterior instrumentation (rod/screw or 

plate/screw) [41] , which seems to increase 

stiffness [16] within the fused segment ; 


129

EARLY OUTCOME AFTER ALIF WITH CAGE : 

A QUANTITATIVE ANALYSIS 

ABOUT 

Sabina Champain 

LABORATORY OF BIOMECHANICS 

ENSAM 151 BD. DE L’HOPITAL, 75013 PARIS FRANCE 

PH +33 (0)6 651 387 65 

FX +33 (0)1 442 463 66 

champainsabina@hotmail.com 

Sabina Marcovschi Champain 

graduated in 2000 from the 

Medical Bioengineering 

Department of the “Gr T Popa” 

Medicine University, Romania, 

which includes general medicine and 

clinical engineering (under the MIT model). 

Afterwards she acquired a master degree 

in patient monitoring (Medicine, Romania) 

and another one in biomechanics (LBM 

ENSAM, Paris), the last one concerning the 

validation of a software allowing fast 

accurate analysis of spine X-ray films. 

They were followed by a PhD project 

focused on multiparameter quantitative 

evaluation of long term outcomes after 

spine surgery. The research program, 

involving several outstanding French spine 

surgeons: i. e. Prof. C. Mazel, Prof. JM. Vital, 

Prof. V. Pointillart, Prof. JP. Steib, Prof. O. 

Gille, Dr T. David and Prof. J. Dubousset, 

consisted in a clinical, biomechanical and 

quality of life analysis of degenerative 

lumbar spine, before and after surgical 

treatment, outlining the relationships 

between radiologically measurable 

biomechanical parameters and patient’s 

outcomes and satisfaction. The results, also 

showing the impact of psychosocial factors 

on patient’s perception of outcome, were 

published (6 original articles and 3 others 

in preparation) and communicated in 

international meetings. 

She is currently Clinical Studies 

Coordinator and also actively engaged in 

an independent research activity 

(academic) on the global spine posture, 

balance and mobility and their changes 

depending upon different types of 

treatment. 

however, a quantified clinical and 

radiographic analysis of outcomes for this type 

of ALIF has not yet been conducted. 

The aim of the present study was to evaluate, 

by means of a quantitative clinical and 


radiographic analysis, the early patient 

outcomes in a population treated by ALIF using 

a plate and cage construct and to highlight the 

key biomechanical parameters involved. 

Methods 

Population sample : 

From January 2003 to June 2005, 51 

consecutive patients were enrolled in a 

prospective study, which was reviewed, and 

consent forms approved, by an institutional 

review board. After failure of the 

conservative treatment (analgesics and 

brace), all patients underwent single level 

anterior lumbar interbody fusion (ALIF), 

performed at the Sainte Anne-Lumière 

Clinic, Lyon, France, by the same 

orthopaedic spine surgeon (Vincent Fière). 

Inclusion criteria were : invalidating back 

and leg pain, failure of conservative 

treatment for at least 6 months and 

disabling lifestyle alteration. Exclusion 

criteria were : prior anterior or posterior 

spinal fusion, presence of high grade 

spondylolisthesis, active infection, 

significant cardiac or vascular disease, 

osteoporosis, malignancy and major 

psychological dysfunction. Patients’ files 

with at least one year of follow-up at study 

time, i.e. 41 cases, were analysed by an 

independent observer (SC), from a clinical, 

radiological and quality of life point of view, 

in order to evaluate early outcomes. 

The group consisted of 16 men and 25 

women, aged from 19 to 65 years (average 

42 years), suffering from back and leg pain, 

not responding to conservative care 

(average pain duration of 2.5 years, 

minimum 1 year). Of these patients, 39 

were employed (46% carrying out heavy 

labour, 5% were sedentary while the other 

subjects performed work of average 

difficulty) and in sick/disability leave at the 

preoperative consultation time ; the other 

two were invalid. Diagnosis by plain 

radiographs and magnetic resonance 

imaging outlined (qualitatively) 34 cases of 

degenerative disc disease (out of whom 12 

cases related to a prior lumbar discectomy) 

and 7 cases of low-grade spondylolisthesis. 

All patients underwent one-level ALIF with 

an anterior impacted cage system 

(ANTELYS ® , Scient’x, Guyancourt, France), 

incorporating a stabilizing anterior plate 

rigidly linked to a PEEK cage (figure 1). 

Surgical technique was classical ALIF, as 

described in the literature [25] , and has been 

already presented in another study [12] . The 

approach was transperitoneal for L5S1 

cage insertion and retroperitoneal 

combined with lumbotomy for the L4L5 

cages. Autologous iliac graft was used in all 

patients. Levels involved were : L4L5 in 7 

(17%) cases, L3L4 in 1 (2%) case and 

L5S1 in the other 33 (81%) cases. Low 

grade (0-9°) lordotic cages were used in 20 

patients and medium grade (9-17°) lordotic 

cages in the other 21 cases. Mean followup 

was 1.8 ± 0.4 years and 34 patients 

(83%) reached the 2 years follow-up at 

study time. 

Analysis methods : 

Clinical, socio-professional, quality of life 

and radiological data were collected during 

the preoperative and postoperative (3, 6, 12 

and 24 months) exams. 

1 Clinical, socio-professional and quality of 

life data : Clinical exams findings were 

supplemented with the results of several 

outcome assessment tools (scores and 

self-questionnaires) for an objective and 

accurate outcome evaluation. They 

investigated patients’ health-related quality 

of life (SF-12), perception of pain (VAS), 

condition specific evolution (function-JOA 

score) and patient’s satisfaction (PSI). 

a. Medical Outcomes Study Short Form 

(SF-12) [40] summary measures physical 

(SF12-PCS) and mental functioning 

(SF12-MCS), in order to analyze the 

effect of the intervention on the quality of 

life, which is an important secondary 

outcome. Reference values [15, 40] are 54 ± 

12 points for PCS and 52 ± 15 for MCS ; 

the limit of significance was calculated at 

7.5 points, for the studied sample. 

b. The visual analogic scale (VAS) [44] is a 

subjective, self-reported (patient) 

method that quantifies lumbar and 

radicular pain on a scale from 0 (no pain 

at all) to 100 (maximum, intolerable pain). 

c. The Japanese Orthopaedic Association 

(JOA) score [43] is a physician-reported 

15-points system (appendix 1), 

examining some aspects of the patient’s

physical status : subjective symptoms (9 

points), clinical signs (6 points) and 

urinary bladder function (-6 points), 

before and after spine surgery. The score 

can range from 15 points (no disability) 

to -6 points (maximum disability) and 

improvement/recovery rates were 

calculated with Hirabayashi method [42, 43] : 

JOA final - JOA initial 

Recovery rate (%) = x 100 

15 - JOA initial 

this calculation allows for an estimation 

of outcome as : excellent if the result was 

greater than 75% ; good, with results 

ranging from 50% to 74% ; fair, if the 

results were between 49% and 25%, and 

poor, if less than 24% [42] . 

d. Patient Satisfaction Index (PSI) [8] 

(appendix 2) assesses the patient 

satisfaction after the surgery, relying on 

the subjective self-appreciation of 

symptoms relief pondered by surgery 

pain and discomfort. 

In addition to these questionnaires and 

scores, complications and data concerning 

patients’ work status after surgery were 

recorded. 

2 Radiological data : Sagittal standing fullspine 

X-ray films were available for all patients 

in preoperative and 3-6 months postoperative 

exams, for 38 cases (93%) at 1 year and for 

34 cases (83%) at 2 years. All radiographs 

have been scanned in order to be analyzed 

with a specific software (SpineView ® , 

Surgiview, Paris, France) ; measurements 

Cage and plate system Antelys® (PEEK) : lateral and frontal view of the treated segment C. 

Appendix 1 

Appendix 2 

accuracy and reproducibility have been 

already investigated and documented [4] . 

Fusion grading was performed by the 

orthopaedic surgeon and an experimented 

radiologist on sagittal plain X-ray films (at 1- 

2 years after surgery) for all patients. The 

analysis was based on criteria from the 

literature : evidence of bridging trabecular 

bone and of absence of radiolucent lines 

around more than 50% of the implant for 

the treated spinal level [24, 32] . 

1 2 

EARLY OUTCOME AFTER ALIF : 


Category Items Definition Score 

No low back pain 3 

Low back pain 

Occasional mild low back pain 

Low back pain always present or severe (occurs occasionally) 

2 

1 

Severe low back pain always present 0 

No lower extremity pain or numbness 3 

Subjective 

symptoms 

Leg pain and/or tingling 

Occasional lower extremity pain or numbness 

Lower extremity pain or numbness always present or severe (occurs occasionally) 

2 

1 

Severe lower extremity pain or numbness always present 0 

Ability to walk 3 

Walking at least 500m is possible, but pain, 

numbness and weakness are felt 

2 

Ability to walk In walking 500 m or less, pain, numbness and weakness 

occur and walking becomes impossible 

1 

In walking at most 100 m, pain, numbness and weakness 

occur and walking becomes impossible 

0 

SLR (including 

hamstring tightness) 

Normal 

30-70° 

< 30° 

2 

1 

0 

Normal 2 

Objective Sensory abnormality Mild sensory disturbance 1 

findings Distinct sensory symptoms 0 

Normal 2 

Manual muscle testing Slightly decreased muscular strength 1 

Markedly decreased muscular strength 0 

Total score 15 

Scoring System of the Japanese Orthopaedic Association for Low Back Pain (JOA Score) : 15 point system includes only subjective 

symptoms (9 pts), objective findings (6 pts) and urinary bladder function (-6 pts) [42,43]. 

Grade Definition 

1 Surgery met my expectations 

2 I did not improve as much as I had hoped but I would undergo the same operation for the same results 

3 Surgery helped but I would not undergo the same operation for the same outcome 

4 I am the same or worse as compared to before surgery 

Patient satisfaction index (PSI) [8], as used in the study. 

Biomechanical parameters were calculated 

from sagittal radiographs at all exams, from 

preoperative until the latest observation, in 

order to evaluate spine geometry and 

balance and to investigate their relationship 

with the global outcome. These parameters 

are presented in the following, covering two 

main topics. 

a. Geometry of the treated segment : In 

order to accurately evaluate changes in 

intervertebral segment’s geometry, 

Disc height = P1 + P2 

(here measured for anterior) 

Disc height as defined by 

Frobin et al.[14] is measured 

both in anterior and 

posterior, as the sum of 

distances between the 

adjacent corners of 2 

vertebras and the bisectrix 

of their midplanes. 


131

3 



Global inclination[4] and Total Lumbo-Pelvic Lordosis 

PR-T12 (TLPL)[18]. The line “D” is interpolating the 

centres of all vertebral bodies. 

evolution of several parameters was 

analyzed : i.e. intervertebral angles, disc 

height, disc/vertebra height ratio, sagittal 

listhesis (slip of a vertebra reported to 

the overlying one) and lordosis of the 

fused segment (angle between cranial 

upper and caudal lower vertebral 

endplates of the fused segment). 

Definition of disc height is variable in the 

literature : this study used the one 

proposed by Frobin et al, as they seem to 

obtain better measurement accuracy by 

minimizing distortion [14] . For two adjacent 

vertebrae, given the bisectrix of their 

respective midplanes, disc height is 

calculated (both anterior and posterior) 

as the sum of distances between the 

adjacent vertebral corners and this 

bisectrix (figure 2). A mean disc height 

value was calculated from anterior and 

posterior disc heights, in order to detect 

subsidence (decrease in the vertical 

height of the disc space prior to 

complete incorporation of the fusion 

mass [6] ) as described in the literature. 

b. Global spine geometry and balance : 

Global spine geometry was described by 

the following spinal and pelvic 

parameters [4] : T4T12 kyphosis (angle 

between the superior endplate of T4 and 

the inferior endplate of T12), L1S1 


lordosis, sagittal tilt of T9 (angle made by 

the vertical line with the segment defined 

by the centres of T9 and of the 

bicoxofemoral axis), sacral slope 

(sacrum inclination to the horizontal 

line), pelvic incidence [22] , and total 

lumbo-pelvic lordosis PR-T12 [18] 

(figure 3). Balance was evaluated by 

calculating the global inclination of the 

spine, defined as the angle between the 

straight line D interpolating the centres 

of all vertebral bodies and the vertical 

line (figure 3) [4] . 

Though the radiological analysis may seem 

complicated, anatomic landmarks 

identification (femoral heads, vertebral 

endplates and external auditory meati) for 

each film is sufficient for the automatic 

calculation of all above-mentioned 

parameters. 

3 Reference values : In order to evaluate the 

influence of the instrumentation on the 

fused segment, parameter values 

calculated from sagittal radiographs were 

compared to those corresponding to a 

group of 63 asymptomatic subjects (42% 

men, 58% women, mean age 43 ± 12 

years), available from previous studies [4] . 

4 Statistics : All clinical data, scores and 

biomechanical parameters were analyzed 

by an independent observer (SC), not 

related to the surgical team. The following 

tests were performed : descriptive statistics, 

Student’s unpaired t-test for comparison of 

independent groups and paired t-test for 

comparison of pre and post operative 

measurements (same group), Pearson 

correlation test, Mann-Whitney nonparametric 

test and ANOVA. Statistical 

significance was set at the P

Table 1 

Table 2 

Table 3 

% of patients 

Score Criterion Interpretation 1 year (n=41) 2 years 

b. Perception of pain - VAS : A statistically 

significant difference was found for VAS 

values recorded pre and post-operatively, 

corresponding to an evolution of average 

back pain from 70 to 33 mm and of 

average leg pain from 44 to 26 mm. 

Further postoperative changes in back or 

leg pain were not significant. 

c. Condition specific evolution - JOA score : 

There was a statistically significant 

difference (increase) between JOA score 

values corresponding to preoperative 

> 75% Excellent 80 83 

50-75% Good 12 10 

JOA recovery rate 25-49% Fair 5 2 

< 25% Poor 3 5 

1 Fully satisfied 73 68 

2 Would undergo same surgery for same result 22 27 

Satisfaction index 3 Would not undergo same surgery for same result 5 5 

4 Same or worse compared to before surgery 0 0 

JOA recovery rate[42, 43] and satisfaction index[8] results, expressed as % of patients at main follow-up exams. 

Parameter Measurement Level Reference Before 3-6 1-2 

error* value surgery months years 

L5S1 11,6 ± 4 10,9 ± 4 11,7 ± 6 10,7 ± 5 

Intervertebral ± 3° L4L5 11,1 ± 4 8,2 ± 3 8,4 ± 4 8,8 ± 5 

angle L3L4 8,2 ± 3 5,8 ± 2 7,8 ± 3 9 ± 4 

% of normal values 93 85 90 

L5S1 11,2 ± 2 7,9 ± 3 10,9 ± 3 10 ± 3 

Mean disc height ± 3mm L4L5 10,7 ± 3 10,7 ± 3 11,1 ± 3 10,7 ± 3 

L3L4 10 ± 1 10,8 ± 2 11,4 ± 3 11,2 ± 3 

% of normal values 46 76 78 

L5S1 40 ± 12 32 ± 13 40 ± 14 40 ± 12 

Anterior disc/ ± 10% L4L5 43 ± 8 43 ± 11 40 ± 12 40 ± 12 

vertebrae height ratio L3L4 39 ± 7 39 ± 7 39 ± 7 41 ± 10 

% of normal values 90 

L5S1 22 ± 7 17 ± 8 24 ± 9 22 ± 7 

Posterior disc/ ± 10% L4L5 23 ± 6 23 ± 6 25 ± 8 23 ± 6 

vertebrae height ratio L3L4 24 ± 5 24 ± 4 25 ± 6 23 ± 4 

% of normal values 90 

*For a 95% confidence interval. Main disc-related parameters for instrumented levels : measurement errors[4], reference ranges and 

calculated values from before surgery to 2 years follow-up, presented as mean ± standard deviation for each level. The discontinued red line 

indicates statistically significant changes for a given parameter (paired t-test), which are not always reflected by changes in the averages. 

Parameter (°) Measurement Reference Before 0-1 2 

error* values surgery year years 

T4T12 kyphosis ± 5,2° 39 ± 8 37 ± 10 37 ± 9 33 ± 8 

L1S1 lordosis ± 4,4° 57 ± 11 55 ± 12 53 ± 12 54 ± 14 

Sagittal tilt of T9 ± 0,2° 11 ± 3 9,7 ± 4 10,6 ± 4 10,2 ± 4 

Global inclination ± 0,1° 0 ± 3 0,5 ± 3 0,1 ± 5 2,4 ± 4 

Sacral slope ± 4° 39 ± 8 39 ± 10 37 ± 9 38 10 

Pelvic incidence ± 3,4° 51 ± 11 55 ± 13 53 ± 12 53 ± 14 

Total lumbo-pelvic lordosis ± 2,4° 92 ± 9 89 ± 11 87 ± 9 88 ± 9 

Spinal and pelvic parameters : measurement errors (for a 95% confidence interval), reference[4] and follow-up values, 

expressed as mean ± standard deviation. 

exam and postoperative ones and none 

during the postoperative follow-up. 

Indeed, average values evolved from 9 ± 

1 (range 3 ÷ 11) before surgery to 14 ± 

1 (range 9 ÷ 15) in all postoperative 

exams. Recovery rates highlighted good 

and excellent outcomes in 92% of cases 

at 1 year and in 93% of patients at 2 

years, as presented in table 1. 

d. Patient satisfaction index - PSI (table 1) : 

Satisfaction levels calculated 

postoperatively at 1 year and 2 years 



exams were close : 73% and respectively 

68% of patients were fully satisfied with 

their treatment and 95% of cases would 

undergo the same surgery for the same 

result (in both exams). 

Radiological analysis 

Fusion grading. Qualitative analysis of Xrays 

allowed to evaluate fusion as solid in 

95% of patients at last follow-up ; fusion 

was doubtful in one case and 

pseudarthrosis was identified in one of the 

patients reoperated for parietal splitting. 

The two patients presenting screw 

breakage had a solid fusion at 1 year followup, 

result that was confirmed by the followup 

at 2 years. 

Biomechanical analysis : 

a. Geometry of the treated segment : A 

synthesis of disc-related parameters 

values (calculated in asymptomatic 

subjects and in patients) is presented in 

table 2 and main aspects of their 

evolution follow. Between the 

preoperative and the first postoperative 

exams, a statistically significant increase 

was observed in all disc-related 

parameters at the instrumented levels 

L5S1 and L4L5 (increase corresponding 

to the initial distraction). At this lapse of 

time, mean disc heights values remained 

constant for patients instrumented with 

low degree (0-9°) lordotic cages and 

increased when using medium degree 

(9-17°) lordotic cages ; however, there 

was no statistically significant relation 

between the type of cage and disc 

height evolution or outcome. 

Postoperatively, changes were significant 

only in mean disc height (same levels as 

above) and L5S1 anterior disc/vertebra 

height ratio, illustrating a decrease of 

values less important than the initial 

increase. In detail : postoperative 

significant variations of disc-related 

parameters were observed at the 

adjacent level in 2 cases (5%) and at the 

instrumented one in 13 patients (32%). 

Disc narrowing occurred in 6 cases 

(15%), mainly between 6 months and 1 

year after surgery and without apparent 

influence on the clinical outcome. Mean 

disc height decrease was significant only 

in 2 of these 6 cases, the others showing 

mostly a synergistic variation of 


133



intervertebral angle and posterior 

disc/vertebra height ratio. A minor 

decrease in mean disc height (not 

related to disc narrowing) was observed 

in 5 other patients, associated with 

limited variation of the other disc-related 

parameters and synergistic with a 

variation of fused segment lordosis, L1S1 

lordosis, global inclination and/or 

listhesis. 

Sagittal listhesis : Listhesis values were 

abnormal before surgery in 15 cases and at 

the last follow-up exam in 11 cases ; they 

remained constant postoperatively in 73% 

of cases. L5S1 listhesis was correlated with 

sacral slope and incidence in all exams (r = 

0.5-0.7, p< 0.0001). 

Fused segment lordosis : The evolution of 

this parameter between preoperative and 

immediate postoperative exams was related 

to the use of lordotic cages. Postoperatively, 

this local lordosis decreased significantly 

(difference ranged 9-15°) in three cases : 

between the 1st and the 2nd year in 2 

patients, and progressively during follow-up 

in a third case. Outcomes were satisfactory 

in the first two patients and slightly poorer 

in the third. 

b. Global spine geometry and balance :No 

statistically significant difference was 

observed between pre and 

postoperative values for spinal and pelvic 

parameters, presented in table 3. 

Furthermore, these parameters were 

within normal ranges during the entire 

follow-up for 71% of patients ; the 

specific condition of the other 29% being 

described in the following section. 

Lordosis and pelvic parameters values 

were higher than normal ranges and 

constant from before surgery until last 

follow-up in 5 (12%) patients, presenting 

a spondylolisthesis. Furthermore, low 

values of lordosis and kyphosis indicated 

a flat back syndrome in 7 (17%) patients, 

observed before surgery in five cases 

(out of whom one improved at 2 years) 

and only postoperatively (acquired) in 

two other cases (constant during the 

follow-up). Flat back syndrome was 

associated with disc narrowing, 

decreased fused segment lordosis 

and/or imbalance in four patients, with 


no influence on the clinical outcome 

(good JOA recovery rate and patient 

satisfaction index). The evolution of 

global spine inclination was statistically 

significant between the first and the last 

postoperative exams and highlighted an 

acquired imbalance in 5 patients (12%), 

associated with good clinical outcomes 

in all these cases but also with a lower 

degree of satisfaction. 

Cross-analysis 

The analysis by means of Pearson’s test 

found a good correlation between JOA 

score values on one hand and SF-12 PCS 

and PSI on the other hand, at all follow-up 

exams (r = 0.7). Patient’s satisfaction was 

correlated with the short term (0-1 year) 

values of disc/vertebra height ratios, T4T12 

kyphosis and sagittal tilt of T9 (all r = 0.5, 

p

and plate construct. Moreover, these 

measurements allowed highlighting the few 

biomechanical parameters which were 

related to outcome assessment. 

1 The clinical analysis aimed to assess 

changes in the patient’s general condition 

following surgery, in terms of both 

functional and socio-economic aspects, 

taking into account their impact on patient’s 

quality of life. 

Surgery duration and hospital stay were 

comparable to those described in the 

literature for laparoscopic and mini-ALIF 

procedures [7, 36, 45] . Return to work was 

delayed (40% at 1 year and 74% at 2 years) 

in this population, particularly for the heavy 

labourers, and were often transferred to 

lighter work ; conversely, one of the two 

patients that were invalid at the 

preoperative exam resumed a professional 

activity two years after surgery. 

The analysis of scores generally outlined a 

positive postoperative evolution, most 

changes occurring immediately after 

surgery and being maintained afterwards. 

Globally, satisfactory outcomes were 

observed at 1 year in : 83% of patients 

based on quality of life criteria (issued from 

MOS SF-12), in 92% of cases based on 

functional criteria (JOA recovery rates) and 

in 73% upon patient’s satisfaction, with the 

mention that 95% of cases would undergo 

the same surgery for the same result. The 

results at two years were comparable and 

clinical outcome assessment was 

completed by fusion evaluation, 

highlighting a fusion rate of 95%. 

For comparison, in a general meta-analysis 

of the literature, Turner et al. [36] announced 

that 68% of patients had achieved a 

satisfactory outcome after lumbar fusion 

surgery (range 16–95%) and the average 

fusion rate was of 85.6 (range 56-100%). 

Inoue et al. [17] reported on a large series 

(350 patients), who underwent anterior 

discectomy and interbody fusion, a 94.3% 

fusion rate and good clinical results in 73% 

of patients. Penta and Fraser [30] reported a 

68% patient satisfaction rate and 72.4% 

overall fusion rate at 10 years after ALIF. 

74% of patients improved very much 

clinically after ALIF with posterior external 

fixators in a study of Tiusanen et al. [34] , who 

reported also 71% of solid fusion rate. In a 

more recent study, Madan and Boeree [23] 

announced a satisfactory quality of life for 

71.8% of patients and satisfactory 

outcomes issued from Oswestry score in 

79.5% of cases after ALIF with Hartshill 

horseshoe cages. Though outcome 

assessment is different between studies, 

our results seem to be globally in 

agreement with the literature. 

2 The current radiological biomechanical 

analysis focused on vertebral and global 

spine geometry, balance and their possible 

relationship with the clinical outcome, in the 

purpose to describe the early outcomes 

and possible complications after ALIF with 

cage and plate (such as subsidence). 

Therefore, all parameters describing 

intervertebral segment’s geometry were 

explored in order to give an accurate 

description of its evolution over time. As 

many authors, like Dunlop et al. [10] , showed 

that disc narrowing was associated with 

pain and increased pressure in facet joints, 

the calculation of disc height was of 

paramount importance. However, reference 

values are very heterogeneous when 

presented in the literature, because of 

different calculation methods, providing 

normalized values : Frobin et al. [14] used the 

mean vertebral depth as a norm, Yorimitsu et 

al. [43] presented disc height as a ratio 

between pre and postoperative values 

normalized with the upper vertebral body’s 

height and Choi et al. [6] calculated a mean 

disc height from anterior and posterior 

measures, normalized by the anteroposterior 

width of the upper vertebral body. 

Mean lumbar disc heights obtained as 

reference in this study seem to be in 

agreement with the value of 10.5 mm 

considered by Natarajann et al. [27] and 

allowed to detect 54% of low values for the 

treated population in the preoperative exam. 

Furthermore, changes in vertebral segment 

geometry between preoperative and early 

postoperative exams were related to the 

type of cages used, in agreement with a 

study of Tsantrizos et al. [35] , who showed 

that cage height and wedge seem to have 

an effect on the initial stability of the treated 

segment and need to be further studied. 



Postoperatively, disc-related parameters 

values were constant for the treated 

segment in 68% of patients ; the evolution 

of the other cases seems to be related 

either to minor intervertebral rearrangements 

either to disc narrowing. 

Among the cases of intervertebral rearrangements 

(17%), an interesting 

situation occurred in four patients (10%) 

presenting a minor but continuous variation 

of mean disc height, intervertebral angles 

and both disc/vertebra height ratios until 

1.5 years or last follow-up. This variation 

was in relation with an evolution of fused 

segment lordosis, L1S1 lordosis, global 

inclination and/or listhesis and might be 

due to mechanisms that regulate balance 

and local segmental stability. 

As for disc narrowing, it is often associated 

with subsidence for the interbody fusion 

[1, 6, 9, 13, 19] 

with cages and many authors 

observed a reduction of disc height, after 

initial distraction, but subsidence rates and 

location were different between studies. 

Thus, Beutler et al. [1] announced that 

subsidence after ALIF with BAK cages 

occurred in 15% of cases, mainly at L4L5 

level, in the postero-superior disc area and 

seemed to be associated only to large sizes 

of cages and increased reaming depth. 

They also stated that subsidence was not 

associated with patient’s age, sex and 

weight and did not influence the outcome, 

in agreement with a study of Kumar et al. [19] , 

who also announced 85% of subsidence 

when using femoral strut allograft, 

occurring on the posterior area of the 

vertebral endplate. In a recent study, Choi et 

al. [6] showed that cage subsidence is an 

expected phenomenon after ALIF using 

stand-alone rectangular cages, occurring at 

about 3 and 4 month postoperatively and 

without correlation with the recurrence of 

symptoms or the radiographic fusion. They 

found a subsidence rate of 76.7% in 90 

patients, with a mean follow-up of 27 

months, occurring at the superior endplate 

in 39% of cases, at the inferior one in 17.3% 

of cases and at both for 43.6% of patients. 

Our series outlined 6 cases (15%) where 

disc space narrowing occurred at the 

instrumented level, mainly between 6 

months and 1 year after surgery 


135



and without apparent influence on the 

clinical outcome. However, only two cases 

were detected by a significant mean disc 

height decrease (superior to 3 mm) 

showing an anterior disc narrowing ; in the 

other four cases, disc narrowing was 

associated to minor disc height decrease 

and significant variation of intervertebral 

angles and disc/vertebra height ratios, 

which is a bit different comparing to the 

classically defined subsidence. 

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22. LEGAYE J, DUVAL-BEAUPERE G, HECQUET J, 

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24. MADAN SS, HARLEY JM, BOEREE NR. (2003) : 

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25. MAYER HM. (1997) : A NEW MICROSURGICAL 

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27. NATARAJAN RN, ANDERSSON GB. (1999) : THE 

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28. NEWMAN MH, GRINSTEAD GL. (1992) : 

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intervertebral angles may highlight some 

important details for an accurate analysis. 

A detailed prospective study on a larger 

scale and comparing several implant 

designs for ALIF would be needed to 

validate these findings and to refine 

subsidence definition ; however, this 

perspective is not yet considered, as 

subsidence does not seem to be related 

to clinical outcome, hypothesis supported 

also by Beutler [1] and Kumar [19] . 

31. RAO RD, DAVID KS, WANG M. (2005) : 

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32. REGAN JJ, ARONOFF RJ, OHNMEISS DD, 

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35. TSANTRIZOS A, ANDREOU A, AEBI M, STEFFEN 

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37. VAZQUEZ RM, GIREESAN GT. (2003) : BALLOON- 

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(BERG) : TECHNIQUE FOR ANTERIOR LUMBAR INTERBODY 

FUSION (ALIF). SURG ENDOSC 17 : 268-272 

38. VIALLE R, LEVASSOR N, RILLARDON L, 

TEMPLIER A, SKALLI W, GUIGUI P. (2005) : 

RADIOGRAPHIC ANALYSIS OF THE SAGITTAL ALIGNMENT 

AND BALANCE OF THE SPINE IN ASYMPTOMATIC SUBJECTS. 

J BONE JOINT SURG AM 87 : 260-267 

39. VISHTEH AG, CRAWFORD NR, CHAMBERLAIN 

RH, THRAMANN JJ, PARK SC, CRAIGO JB, SONNTAG 

VK, DICKMAN CA. (2005) : BIOMECHANICAL 

COMPARISON OF ANTERIOR VERSUS POSTERIOR LUMBAR 

THREADED INTERBODY FUSION CAGES. SPINE 30 : 302-310 

40. WARE J, KOSINSKI M, TURNER-BOWKER D. ET 

AL. (2002) : HOW TO SCORE VERSION 2 OF THE SF-12® 

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891810-10-3. 

41. WEBER J, VIEWEG U. (2006)[ANTERIOR LUMBAR 

INTERBODY FUSION (ALIF) : USING A CAGE WITH 

STABILIZATION.]. Z ORTHOP IHRE GRENZGEB 144 : 40-45 

42. YONE K, SAKOU T, KAWAUCHI Y, YAMAGUCHI 

M, YANASE M. (1996) : INDICATION OF FUSION FOR 

LUMBAR SPINAL STENOSIS IN ELDERLY PATIENTS AND ITS 

SIGNIFICANCE. SPINE 21 : 242-248 

43. YORIMITSU E, CHIBA K, TOYAMA Y, 

HIRABAYASHI K. (2001) : LONG-TERM OUTCOMES OF 

STANDARD DISCECTOMY FOR LUMBAR DISC HERNIATION : A 

FOLLOW-UP STUDY OF MORE THAN 10 YEARS. SPINE 26 : 

652-657 

44. ZANOLI G, STROMQVIST B, JONSSON B. (2001) : 

VISUAL ANALOG SCALES FOR INTERPRETATION OF BACK 

AND LEG PAIN INTENSITY IN PATIENTS OPERATED FOR 

DEGENERATIVE LUMBAR SPINE DISORDERS. SPINE 26 : 2375- 

2380 

45. ZDEBLICK TA, DAVID SM. (2000) : A PROSPECTIVE 

COMPARISON OF SURGICAL APPROACH FOR ANTERIOR L4- 

L5 FUSION : LAPAROSCOPIC VERSUS MINI ANTERIOR 

LUMBAR INTERBODY FUSION. SPINE 25 : 2682-2687

Concerning the global spine geometry, 

there was no significant evolution of spinal 

and pelvic parameters. The biomechanical 

analysis globally outlined a high proportion 

of patients having postoperatively constant 

values of mean disc heights (80%), sagittal 

listhesis (73%), fused segment lordosis 

(73%) and also of L1S1 lordosis (95%), 

suggesting an economical construct-related 

balance that preserved the restored values 

(after initial distraction). Though spine 

For the readers who are not familiar with 

the ArgoSpine association, could you tell us a 

little about its history and founding 

concepts ? 

balance was not significantly associated to 

outcome in studied patients, the correlation 

between balance-related parameters 

(sagittal tilt of T9) and patient satisfaction 

suggests its influence on the subjective 

appreciation of the outcome. However, 

these hypotheses need to be validated by a 

long term and larger scale study. 

In conclusion, the early outcomes after 

ALIF with cage and plate seem comparable 

HEALTHPOINTCAPITAL INTERVIEWS PROFESSOR CHRISTIAN MAZEL 

A look into the workings of ArgoSpine, 

a leading spine-research organization 

BY ARMELLE WIART, JUNE 3, 2008 THIS PAPER IS REPRODUCED BY KIND PERMISSION OF THE AUTHOR AND OF OUR PARTNER, 

HEALTHPOINTCAPITAL. IT WAS PREVIOUSLY PUBLISHED ON WWW.HEALTHPOINTCAPITAL.COM 

— The association started off as a business 

collaboration between Prof. Pierre Kehr, 

Prof. Jean-Paul Steib, Guy Viart and myself 

on the creation of two new spinal implants 

called Twinflex and SCS. We all got along 

well and discussed the need for an 

academic meeting that would include both 

the public and private healthcare providers 

and provide them with an arena where 

anyone would be allowed to give a 

presentation and where ideas could be 

exchanged freely. In 1996, Argos was 

created. The name stands for the 

“Association of European Research Groups 

for Spinal Osteosynthesis”. Twelve years 

later, our name has changed to ArgoSpine 

but our original mission has not. 

A LOOK INTO THE WORKINGS OF ARGOSPINE 

to those of ALIF and general lumbar fusion 

from a clinical and functional point of view, 

completed by good levels of quality of life 

and patient satisfaction. Biomechanical 

analysis outlined subsidence in 15% of 

cases and offered a detailed insight into 

the evolution of the treated segment and 

on its impact on spine’s stability and 

balance. 


Eur J Orthop Surg Traumatol (2008) 18 (3) : 177–188 

How is it organized, what does it do, and 

what are its goals ? 

— ArgoSpine is composed of three 

committees: the Sponsorship, Scientific, 

and Managing Committees, who meet 

throughout the year to discuss the topic for 

the upcoming Symposium, current interests 

in the spine market, and the direction taken 

by the Association. We also have a full time 

secretary — Ms Nathalie Richard, 


137

A LOOK INTO THE WORKINGS OF ARGOSPINE 

a treasurer - Dr. Alain Graftiaux, a general 

secretary - Prof. Pierre Kehr and myself as 

president. 

Our main activity revolves around the 

organization of an Annual Symposium at the 

end of January which strives to foster 

greater knowledge in the diagnosis and 

treatment of spinal disorders through open 

discussions and the presentation of clinical 

cases. We also publish a quarterly “News & 

Journal” which was originally called “The 

Connector” - in reference to the element in 

the scoliosis instrumentation of the same 

name. Two of the editions are dedicated to 

the symposium while the other two feature 

interviews with leading physicians and 

accessible and interesting news on the 

spine academia and market. Our goal is that 

it will one day be recognized as a scientific 

journal in its own right, while still keeping its 

informational aspect. 

What are your goals for ArgoSpine during 

your presidency ? 

— My main goal is to transition the 

association so that it becomes an entity 

viable on its own, rather than contingent on 

an individual. Once ArgoSpine continues to 

grow and flourish on its own, I know I will 

have succeeded and will step down as 

President. The transition in that direction is 

already taking place as we have brought in 

Colloquium to organize our symposiums, 

and Springer was selected as our Journal 

publisher. 

The symposium on Spine Surgery History 

and Complications took place in January 

2008. What are your thoughts on what was 

discussed and achieved during the two days 

of presentations ? 

— When it comes to the Symposium, I try to 

stay as far away from the spotlight as 

possible. This holds true for the content of 

the ArgoSpine News and Journal as well. 

Just as I do not want the Journal to simply 

be a medium of what Christian Mazel 

believes, likes, and does, I do not want the 

symposium to be a one-man show about 

my experiences as a spine surgeon. My role 

during the symposium is to encourage 

discussion and guide the exchanges, not to 


express my opinions which would be seen 

as putting an end to the debate. 

How did the idea for next year’s 

Symposium, Spine Surgery and Advances in 

Imaging, come about ? 

— The topics of each Symposium are the 

product of hours of brainstorming by our 

Scientific Committee. During our 

discussions, we came to the conclusion 

that the two major changes that have 

affected the treatment of spine disorders in 

the past years are the materials used in 

surgery and our diagnostic capacity, 

resulting mainly from the advances in 

imaging technology. The symposium, which 

will be chaired by one of the founders of 

ArgoSpine, Prof. Jean-Paul Steib, will focus 

on these new technologies and their use by 

surgeons, by discussing when they should 

be prescribed, how they should be done, 

and their correct analysis. We will also 

explore the relationship between spine 

surgeons and radiologists by seeking to 

understand how each views the 

procedures, their necessity, and what they 

are hoping to derive from them. 

Topics we are planning on exploring include 

the assessment of vertebral artery injury in 

trauma, MRI gadolinium enhancement and 

traditional angiography versus angio-MRI 

in tumour assessment, decision making in 

tumour resection, and pitting the surgeon 

against the radiologist when assessing 

vascular anatomy and bone density in the 

pre-operative planning of a TDR or anterior 

procedure, or in case of a revision. 

You are not only the President of ArgoSpine 

but also the Director of the Department of 

Orthopedic Surgery at L’institut Mutualiste 

Montsouris in Paris, France. Can you tell us a 

little about this hospital and your work 

there ? 

— I have been head of the Orthopedic 

Department at IMM (Institut Mutualiste 

Montsouris) since 1994. In building my 

team of surgeons, I was very much inspired 

by the Hospital for Special Surgery model 

where each surgeon has his own specialty, 

be it spine, large-joint, foot, hand, etc. This 

is what I sought to recreate here. 

The IMM is a private, non-profit hospital. 

Anyone is admitted provided they are 

enrolled in the French Sécurité Sociale (the 

French public health coverage). The IMM is 

housed in what used to be the building of 

the Paris University International Hospital 

which was completely gutted and 

remodeled in 1999. The architect in charge 

of the project, Adrien Fainsilber, also 

designed the Strasbourg Museum of 

Modern Art. The result is a modern and airy 

building of 440 beds where the floor-toceiling 

windows overlook manicured 

gardens. We’ve had patients walk past the 

hospital and call saying they couldn’t find it, 

thinking that the building housed a bank ! 

It’s really a pleasure working in this type of 

environment. 

Thank you for your time, Professor Mazel, 

we look forward to seeing you at the next 

ArgoSpine Congress and other industry 

events ! 

HealthpointCapital is a proud sponsor 

of ArgoSpine since June 2007 and 

we’re excited to support their 

innovative mission and their 

commitment to an international 

exchange of research, technology and 

ideas.

ARGOSPINE MEMBERS 

2008 Argospine members 

Dr ANDREAKOS Anastasios 

G. LIRA 119 - KIFISIA 

14564 ATHENS — GREECE 

a-andreakos@hotmail.com 

Dr ANTONIETTI Pierre 

27, BVD VICTOR HUGO 

92200 NEUILLY — FRANCE 

pierre.antonietti@wanadoo.fr 

+33 148250019 

Dr ARTIERES Xavier 

CLINIQUE JEANNE D’ARC 

9 RUE DU VIEUX SÉMINAIRE 

22000 ST BRIEUC — FRANCE 

artieres.xavier@cja-armor.com 

+33 296 01 66 31 

Dr BALABAUD Laurent 

INSTITUT MUTUALISTE 

MONTSOURIS 

SERVICE CHIRURGIE 

ORTHOPÉDIQUE 

42 BOULEVARD JOURDAN 

4E ÉTAGE 

75014 PARIS — FRANCE 

lbalabaud@wanadoo.fr 

+33 156 61 64 01 

Dr BAREK Mondher 

CENTRE DE TRAUMATOLOGIE 

BEN AROUS 

2013 BEN AROUS — TUNISIA 

mondher.mbarem@rns.tn 

+216 20 306 306 

Dr BASSANI Roberto 

POLICLINICO UNIVERSITARIO SAN 

MATTEO, PLE GOLGI 5 

27100 PAVIA — ITALY 

robertobassani@hotmail.com 

pamelatelesca@mbalomb.191.it 

+39 0331777312 

Dr BEDAT Philippe 

2, RUE DU BEAU SOLEIL 

1206 GENEVA — SWITZERLAND 

pbedat@bluewin.ch 

+41 22 347 52 87 

Dr BENAZZO Francesco 

POLICLINICO SAN MATTEO IRCCS 

PZZA GOLGI N°1 


f.benazzo@smatteo.pv.it 

+39 038 2502 851 

Dr BITAN Fabien 

130 EAST 77TH ST, 7TH FLOOR 

NY 10021 NEW YORK — USA 

bitanf@manhattanorthopaedics.com 

+1 212 717 7463 

Dr BONFIGLIO Giuseppe 

STUDIO MEDICO-ORTOPEDICO 

VIA CONTE SECCO SUARDO, 21 

20040 BELLUSCO (MI) — ITALY 

giuseppebonfi@tiscalinet.it 

+39 602 2753 

Pr BORIANI Stefano 

OSPEDALE MAGGIORE, LARGO B 

NIGRISOLI, 2 

40133 BOLOGNA — ITALY 

+39 051 64 78 28 


Dr BRAUN Emmanuel 

6BIS, AVENUE DE LA LIBÉRATION 

54520 LAXOU — FRANCE 

dr.emmanuel.braun@wanadoo.fr 

Dr CASAMITJANA FERRANDIZ 

José Manuel 

DIAGONAL AVENUE 491 

6TH FLOOR, 1A 

8029 BARCELONA — SPAIN 

9239jcf@comb.es 

+34 93 410 6810 

Dr CAUX Isabelle 


MONTSOURIS 

42, BOULEVARD JOURDAN 

75674 PARIS CEDEX 14 — FRANCE 

+33 01 56 61 64 01 

Dr CHOI David 

58 LLANVANOR ROAD 

NW2 2AP LONDON — UK 

david.choi@uclh.nhs.uk 

Dr CHOPIN Daniel 

INSTITUT CALOT, SERVICE 

ORTHOPÉDIE 

47, DU DOCTEUR CALOT 

62608 BERCK SUR MER — FRANCE 

dchopin@hopale.com 

+33 321 89 20 30 

Dr CORDONNIER Denis 

HOPITAL SAINT PHILIBERT 

115 RUE DU GRAND BUT 

59160 LOMME — FRANCE 

cordonnier.denis@ghicl.net 

+33 320 22 50 60 

Dr COSTA Henri 

SCSPRL COSORTHO 

ORTHOPÉDIE TRAUMATOLOGIE 

RUE DE LA SOLITUDE 2 

7540 RUMILLIES — BELGIUM 

cosortho@skynet.be 

+32 69 84 12 02 

Pr COSTANZO Giuseppe 

ISTITUTO I.C.O.T. 

VIA FAGGIANA, 34 

4100 LATINA — ITALY 

m.sottovia@scientx.com 

+39 07736511 

Dr CUZZOCREA Fabrizio 

POLICLINICO SAN MATTEO IRCCS 

PZZA GOLGI N°1 

V.SAN MARTINO 12 


cuzzofabri@tiscali.it 

+39 0382 502 851 

Dr DE GUISE Jacques 

ECOLE DE TECHNOLOGIE 

SUPERIEURE 

1100, RUE NOTRE DAME OUEST 

H3C 1K3 MONTREAL — CANADA 

jacques.deguise@etsmtl.ca 

+1 514 396 8922 

Dr DEBURGE Alain 

HÔPITAL BEAUJON 

100 BLD DU GÉNÉRAL LECLERCQ 

92110 CLICHY — FRANCE 

Dr DEHOUX Emile 

CHU REIMS, HOPITAL MAISON 

BLANCHE 


ORTHOPEDIQUE 

46 RUE COGNACQ JAY 

51092 REIMS — FRANCE 

edehoux@chu-reims.fr 

+33 326 78 77 52 

Pr DEPRETEIRE Bart 

UNIVERSITY HOSPITALS - DEPT OF 

NEUROSURGERY 

HERESTRAAT 49 

3000 LEUVEN — BELGIUM 

bart.depreitere@uzleuven.be 

+32 16 34 42 90 

Dr DESMETTE Damien 

CHR MONS WARQUIGNIES 

AV. B.DE CONSTANTINOPLE 

7000 MONS — BELGIUM 

ddesmette@skynet.be 

+32 69 77 60 02 

Dr DESROUSSEAUX Jean- 

FranÇois 

HOPITAL SAINT PHILIBERT 

115 RUE DU GRAND BUT 

59160 LOMME — FRANCE 

Desrousseaux_JF@ghicl.net 

+33 320 22 50 60 

Dr DORIA Carlo 

AZIENDA OSPEDALIERO 

UNIVERSITARIA DI SASSARI 

VIA TEMPIO, 9 

7100 SASSARI — ITALY 

m.sottovia@scientx.com 

Dr DOSCH Jean-Claude 

CHU DE STRASBOURG 

CCOM 

10, AVENUE A. BAUMANN 

67400 ILLKIRCH — FRANCE 

jean-claude.dosch@chrustrasbourg.fr 

+33 388116768 

Dr DU TOIT François 

83 MOUNTAIN ROAD 

3201 ROTORUA — NEW ZEALAND 

devon15a@xtra.co.nz 

+64 734 74428

Dr DUBOUSSET Jean 

26 RUE DES CORDELIERS 


j.dubousset@svp.ap-hop-paris.fr 

Dr DUMAS Raphaël 

LBMH 

B‚TIMENT OMEGA, 43 BOULEVARD 

DU 11 NOV 1918 

69622 VILLEURBANNE CEDEX — 

FRANCE 

raphael.dumas@univ-lyon1.fr 

+33 472 448 575 

Dr DUTOIT Michel 

HOPITAL ORTHOPEDIQUE 

AVENUE PIERRE DECKER 4 

1005 LAUSANNE — SWITZERLAND 

Michel.Dutoit@Hospvd.ch 

+41 21 31 03 603 

Dr ECHEVERRY-BARREIROS 

Angel Jorge 

C/ANGEL LIMESES 

30 MONDES-MOURENTE 

36001 PONTEVEDRA — SPAIN 

Dr EFSTATHOPOULOS Nicolaos 

KONSTANTOPOULION HOSPITAL 

A. OLGAS 3-5 - N. IONIA 


b-orthop@otenet.gr 

+302102719863 

Dr EL BANNA Sabri 

DEPUY SPINE 

EIKELENBERGSTRAAT 20 

1700 DILBEEK — BELGIUM 

egesquie@medbe.jnj.com 

selbanna@skynet.be 

+32 2 481 74 47 

Pr ELSIG Jean-Pierre 

SEESTRASSE 122 

8700 KÜSNACHT — SWITZERLAND 

jeanpierre.elsig@fmri.ch 

+41 191 422 00 

Dr EMERY Evelyne 

CHU DE CAEN 

SCE NEUROCHIRURGIE, NIV 12 

AVENUE CÔTE DE NACRE 

14033 CAEN CEDEX — FRANCE 

emery-e@chu-caen.fr 

Dr EMERY Richard Alain 

4 MOUNT ELLIOTT DRIVE 

4816 QLD ALLIGATOR CREEK — 

AUSTRALIA 

rickyspine@yahoo.fr 

Dr EZZAHOUI Abdelilah 

HÔPITAL DES CHANAUX 

350, BOULEVARD LOUIS ESCANDE 

71000 MACON — FRANCE 

Dr FARCY Jean-Pierre 

BROOKLYN SPINE CENTER 

927 49TH STREET BROOKLYN 

NY 11219 NEW YORK — USA 

spinecenter@orthospine.com 

718 283 65 20 

Dr FAVREUL Emmanuel 

CLINIQUE SAINT-CHARLES 

25, RUE DE FLESSELLES 

69001 LYON FRANCE 

emmanuel.favreul@wanadoo.fr 

Dr FERNANDEZ GONZALEZ 

Manuel 

HOSPITAL DE LEON 

SERVICIO DE TRAUMATOLOGIA Y 

CIRUGIA ORTOPEDICA 

ALTOS DE NAVA S/N 

24080 LEON — SPAIN 

mfdezg@telefonica.net 

+34 987 23 74 00 

Dr FINIELS Pierre-Jacques 

CLINIQUE KENNEDY 

AVENUE KENNEDY 

30900 NÓMES — FRANCE 

dr.pjfiniels@club-internet.fr 

+33 466 635 555 

Dr FOKTER Samo Karl 

CELJE GENERAL HOSPITAL 

DEPT FOR ORTHOPAEDIC SURGERY 

OBLAKOVA 5 

3000 CELJE — SLOVENIA 

samo.fokter@guest.arnes.si 

+386 3 49 15 620 

Dr FORTHOMME Jean-Paul 

CHR ST JOSEPH 

AV B. DE CONSTANTINOPLE, 5 

7000 MONS — BELGIUM 

forthomme.jp@tiscali.be 

+32 65 38 58 75 

Dr GAILLARD Stephan 

HÔPITAL FOCH - SERVICE DE 

NEUROCHIRURGIE 

40 RUE WORTH, BP 36 

92151 SURESNES CEDEX — 

FRANCE 

s.gaillard@hopital-foch.org 

Dr GANEM Franck 

CLINIQUE SAINT MARTIN 

18, RUE DES ROCQUEMONTS 

14050 CAEN CEDEX — FRANCE 

franckganem@aol.com 

+33 231 433 232 

Dr GHYAMPHY Karim 

CH LE MANS SERVICE 

D’ORTHOPÉDIE 

194 AVENUE RUBILLARD 

72037 LE MANS — FRANCE 

kghyamphy@ch-lemans.fr 

PR GODINHO Francisco 

RUE FONTE DA SAUDADE, 87 

LOGOA 

22471 RIO DE JANEIRO — BRAZIL 

godinhofrancisco@terra.com.br 

Dr GOGOS Christos 

KONSTANTILIERI 48 

16231 VIRONAS — GREECE 

gogos@neurocare.gr 

+30 210 7600 224 

Dr GRAFTIAUX Alain 

CLINIQUE ST FRANÇOIS 

1 RUE COLOMÉ 

67500 HAGUENAU — FRANCE 

alain.graftiaux@wanadoo.fr 

+33 388 907 021 

Dr GUILLAUMAT Michel 

99, RUE BRIANCION 


Mguillaumat@aol.com 

+33 144 123 432 

Dr Guingand Olivier 


MONTSOURIS 

42 BD JOURDAN 


+33 1 56 61 64 02 

Pr HARMS Jürgen 

SRH KLINIKUM KARLSBAD- 

LANGENSTEINBACH 

GUTTMANNSTR. 1 

D-76307 KARLSBAD — GERMANY 

juergen.harms@kkl.srh.de 

+49 7202613892 

Dr HEISSLER Pierre 

CENTRE HOSPITALYR LAENNEC 

DEPARTEMENT D’ORTHOPEDIE, BP 72 

60109 CREIL — FRANCE 

+33 344 616 667 

Dr HOVORKA Etienne 

CHU DE L’ARCHET II 

151 ROUTE STE GINESTIÈRE 

CEDEX 3 

6202 NICE — FRANCE 

hovorka@wanadoo.fr 

+33 492 036 126 

Pr ILLES Tamas 

SZOLOS UTCA 26 

7625 PECS — HUNGARY 

illes@clinics.pote.hu 

+36 72 32 41 22 

Dr ISLA GUERRERO Alberto 

HOSPITAL LA PAZ 

SERVICIO DE NEUROCIRURGIA 

PSO. DE LA CASTELLANA 261 

28046 MADRID — SPAIN 

division.neurotrauma@¬ 

primhospitales.com 

+34 91 729 25 98 


Dr JABY Yves 

CLINIQUE TOUS-VENTS 

19, RUE RENÉ COTY 

76170 LILLEBONNE — FRANCE 

y.jaby@free.fr 

+33 235 39 67 60 

Dr JEANNERET Bernard 

ORTHOPADISCHE 

UNIVERSITATSKLINIK 

KANTONSPITAL BASEL 

4031 BASEL — SWITZERLAND 

jeanneretbernard@bluewin.ch 

+41 61 265 78 10 

Dr JELMONI Gian Paolo 

POLICLINICO SAN MATTEO 

P. LE GOLGI 19 


PR JIANU Mihai 

HOPITAL GR. ALEXANDRESCU 

BDL IANCU DE HUNEDOARA 30-32 

78942 BUCHAREST — ROMANIA 

mjianu@yahoo.com 

+40 21 650 4194 

Dr JONES Eric T 

200 ORTHOPAEDIC WAY 

WW 26505 MORGANTOWN — USA 

erictjones@adelphia.net 

+1 304 599 07 20 

Dr JUDET Henri 

CLINIQUE JOUVENET 

6, SQUARE JOUVENET 


h.judet@gsante.fr 

+33 142 154 121 

Dr KAECH Denis Laurent 

NEUROCHIRURGIE 

KANTONSSPITAL GRAUBUNDEN 

LOESTRASSE 170 

CH 7000 CHUR — SWITZERLAND 

denis.kaech@ksgr.ch 

+41 81 256 62 30 

Dr KASIPPILLAI Parameshwaran 

GLENEAGLES MEDICAL CENTRE 

1 JALAN PANGKOR, PENANG 

10050 GEORGETOWN — MALAYSIA 

k_paramesh14@yahoo.com 

+60 42202128 

Pr KEHR Pierre 

25, RUE SCHWEIGHAEUSER 

67000 STRASBOURG — FRANCE 

kehrpier@aol.com 

pierre.kehr@argospine.org 

+33 388605037 

Dr KOROVESSIS Panagiotis † 

GENERAL HOSPITAL AGIOS 

ANDREAS 

26224 PATRA — GREECE 

korovess@otenet.gr 

+30 2610 227 202 


140

PR KORRES Dimitrios 

HOSPITAL KAT 

DPT ORTHOPAEDIC 

2, NIKIS STREET KIFISSIA 


dkorres@med.uoa.gr 

+30 10 82 32 241 

Dr KRAPPEL Ferdinand 

DAUFFENBACHSTRASSE 9 

D 52080 AACHEN — GERMANY 

fkrappel@yahoo.com 

+49 240 562 3323 

Dr KROKOS Antonios 

49, VOULIAGMENIS AVENUE 


6972843981@mycosmos.gr 

+30 210 92 23 300 


Dr KUMANO Kiyoshi 

FUJI TORANOMON HOSPITAL 

ORTHOPAEDIC DEPT. 

1067-1 KAWASHIMADA GOTENBA- 

SHI 

412-0045 GOTENBASHI — JAPAN 

office@jpstss.com 

+81 550 89 7872 

Dr KUNOGI Jun-Ichi 

JAPAN RED CROSS MEDICAL 

CENTER, DEPT OF ORTHOPAEDIC 

SURGERY AND REHAB. 4-1-22 

HIROO - SHIBUYA-KU 

TOKYO — JAPAN 

ANB38407@nifty.ne.jp 

+88 3 3400 1311 

Dr LAAGER Charles-Marc 

SHOWA IKA EUROPE 

VIA CAPECELATRO, 81 

20148 MILAN — ITALY 

charlesmarc.laager@fastwebnet.it 

+39 02 40 77 308 

Dr LAREDO Jean-Denis 

HÔPITAL LARIBOISIÈRE 

SERVICE DE RADIOLOGIE OSTÉO- 

ARTICULAIRE 

2 RUE AMBROISE PARÉ 


jean-denis.laredo@lrb.aphp.fr 

Mr LAVASTE FranÇois 

ENSAM, LABORATOIRE DE 

BIOMÉCANIQUE 

151, BOULEVARD DE L’HÔPITAL 


francois.lavaste@paris.ensam.fr 

+33 144 246 364 

Dr LEGAYE Jean 

CLINIQUES UNIVERSITAIRES 

MONT-GODINE 

AVENUE G. THERASSE 

5530 YVOIR — BELGIUM 

jean.legaye@orto.ucl.ac.be 

+32 81 42 30 91 

Mr LEMAIRE Jean-Philippe 

POINT MÉDICAL 

ROND POINT DE LA NATION 

21000 DIJON — FRANCE 

jean.philippe.lemaire@cegetel.net 

+33 380 703 834 

Dr LEONARD Philippe 

HÔPITAL DE LA CROIX ST SIMON 

125, RUE D’AVRON 


p.leonard@noos.fr 

Dr LEONE Vincent 

289 MILL SPRING ROAD 

NY 11030 MANHASSET — USA 

vinleone@optonline.net 

Mr LEONG John 

THE OPEN UNIVERSITY OF HONG 

KONG LEVEL 11 

30 GOOD SHEPHERD STREET 

HOMANTIN KOWLOON — CHINA 

+852 2768 6089 

Dr AGUILAR FERNANDEZ Lluis 

CLINICA TEKNON DESP 10 

MARGUESA DE VILALLONGA 12 

8017 BARCELONA — SPAIN 

24604laf@comb.es 

+34 932906410 

PR LOGROSCINO Carlo 

POLICLINICO GEMELLI DI ROMA 

LARGO GEMELLI 8 

168 ROME — ITALY 

mf4792@mclink.it 

Mr LOUIS René 

4 BIS IMPASSE ROC FLEURI 

13008 MARSEILLE — FRANCE 

+33 491 537 457 

Dr LUITJES Willem F. 

WILLEMSBOS 45 

2134 EA HOOFDDORP — THE 

NETHERLANDS 

fen-a-flor@hetnet.nl 

+31 20 512 4418 

Dr MACCHIAVELLO Nicolas 

WILFERDINGER STR. 29/1 

76307 KARLSBAD — GERMANY 

nmacchia@yahoo.com 

Dr MARTIN BENLLOCH Antonio 

HOSPITAL UNIVERSITARIO DR. 

PESET, ORTHOPAEDIC SURGERY 

DEPARTMENT 

AV. GASPAR AGUILAR, 90 

46017 VALENCIA — SPAIN 

antonio.martin@uv.es 

+34 96 386 1906 


Dr MARUENDA Jose Ignacio 

HOSPITAL CLINICO UNIVERSITARIO 

VALENCE — SPAIN 

division.neurotrauma@¬ 

primhospitales.com 

+34 91 33 42 412 

Pr MAZEL Christian 


MONTSOURIS 


ORTHOPÉDIQUE 

42 BOULEVARD JOURDAN 


cristian.mazel@imm.fr 

+33 156 61 64 01 

Dr M’BAREK Mondher 

HOPITAL AZIZA OTHMANA 

PLACE DU GOUVERNEMENT - LA 

KASBAH 

1008 TUNIS — TUNISIA 

+216 9830 6306 

Dr MELCHER ROBERT P. 

SRH-GRUPPE, KLINIKUM 

KARLSBAD-LANGENSTEINBACH 

GUTTMANST. 1 

76307 KARLSBAD- 

LANGENSTEINBACH — GERMANY 

robert.melcher@kkl.srh.de 

+49 7202 610 

Dr MILADI Mongi 

POLYCLINIQUE ETTAOUFIK 

BLVD DU 7 NOVEMBRE 1987 


miladi.mg@planet.tn 

+216 7184 62 85 

Dr Ing MITULESCU Anca 

33 BOULEVARD HOPKINSON 


a.mitulescu@argos-europe.com 

Dr MOULIN Patrick 

SWIWW PARAPLEGIC CENTRE 

NOTTWIL 

HEAD OF DIVISION ORTHOPAEDICS 

ABD SPINE SURGERY 

6207 NOTTWIL — SWITZERLAND 

patrick.moulin@paranet.ch 

+41 41 939 558 77 

Dr NAZARIAN Serge 

CENTRE HOSPITALYR 

UNIVERSITAIRE 

HOPITAL DE LA CONCEPTION 

147 BLVD BAILLE 


serge.nazarian@ap-hm.fr 

+33 491 776 551 

Dr ONIMUS Michel 

CLINIQUE ST VINCENT 

SERVICE D’ORTHOPÉDIE 

3, CHEMIN DES ÉCOLES DE 

TYLLEROYES 

25001 BESANÇON — FRANCE 

michelle.onimus@wanadoo.fr 

+33 381 472 140 

PR PARISINI Patrizio 

RIZZOLI ORTHOPAEDIC INSTITUTE 

1 G.PUPILLI 

40136 BOLOGNE — ITALY 

patrizio.parisini@ior.it 

Dr PATERAKIS Konstantinos 

UNIVERSITY HOSPITAL OF LARISSA 

DEPT OF NEUROSURGERY 

411 10 LARISSA — GREECE 

hpaterakis@yahoo.com 

+30 2410 682 739 

Pr PATSIAOURAS Thomas 

204, MESSOGHION AVENUE 

ATHENS — GREECE 

kkatsogridakis@carlsonwagonlit.gr 

+30 2106509400 

PR PERRIN Gilles 

HÔPITAL PIERRE WERTHEIMER, 

CHU DE LYON, 59, BLD PINEL 

69394 LYON CEDEX 03 — FRANCE 

gilles.perrin@chu-lyon.fr 

+33 472 11 89 02 

Dr PIANCASTELLI Marco 

VIA FORNACI 9B 

47023 CESENA FORLI — ITALY 

mpianca@usa.net 

Dr POINTILLART Vincent 

CHU PELLEGRIN TRIPODE 

SCE DU PROF. VITAL 

PLACE AMÉLIE RABA LÉON 

33076 BORDEAUX CEDEX — 

FRANCE 

vincent.pointillart@chubordeaux.fr 

+33 556 79 87 18 

PR PRIES Pierre 

CHU LA MILETRIE, SERVICE 

ORTHOPÉDIE 

RUE DE LA MILÉTRIE, BP 577 

86021 POITIERS CÉDEX — FRANCE 

p.pries@chu-poitiers.fr 

+33 549 44 38 60 

Dr RAKOVER Jean-Patrick 

CLINIQUE DU PRÉ 

72000 LE MANS — FRANCE 

j-p.rakover@wanadoo.fr 

+33 243 77 54 20 

PR RAMADAN Aymen 

22 CHEMIN BEAU SOLEIL 

1206 GENEVA — SWITZERLAND 

aymenram@yahoo.com

Dr RAMARE Stéphane 

CLINIQUE AGUILERA 

SERVICE DE CHIRURGIE 

ORTHOPEDIQUE 

21, RUE DE L’ESTAGNAS 

64200 BIARRITZ — FRANCE 

+33 559 22 46 22 

Dr RIBEIRO Carlos Henrique 

HOSPITAL SALGADO FILHO 

RUA VISCONDE DE PIRAJ·, 547 

SALA 517 

22410-002 IPANEMA — BRAZIL 

chribeiro@globo.com 

+55 21 2274-3226 

Dr RICART Olivier 

CLINIQUE AMBROISE PARÉ 

21 ROUTE DE GUENTRANGE 

57100 THIONVILLE — FRANCE 

olivrica@pt.lu 

+33 382 82 27 09 

Dr RICHARD Bertrand 


MONTSOURIS 



+33 156 61 64 01 

Dr RODA FRADE Enrique 

HOSPITAL RAMON Y CAJAL/ SAN 

CAMILO 

SCIO DE NEUROCIRURGIA 

CTRA COLMENAR VIEJO KM 9,100 


+34 91 33 42 412 

Dr RODIO Dario 

AIUTO AZ. OS SS. ANNUNZIATA 

VIA ROMA 66, CASTELLANA 

GROTTE (BA) 

70013 BARI — ITALY 

0804961998@iol.it 

+39 080 49 61 998 

Mr ROKEGEM Pascal 

SPINENETWORK 

18 RUE ROBESPIERRE 

BP 23 

62217 BEAURAINS — FRANCE 

Pr SAILLANT Gérard 

HÔPITAL PITIÉ SALPÉTRIÈRE 

CHIRURGIE ORTHOPÉDIQUE 

83, BLD DE L’HÔPITAL 


gerardsaillant@psl.ap-hop-paris.fr 

Dr SAMAHA Dominique 

CLINIQUE INTERNATIONALE DU 

PARC MONCEAU 

21 RUE DE CHAZELLES 


samaha.dominique@wanadoo.fr 

Dr SANO Shigeo 

DEPT OF ORTHOPAEDIC SURGERY, 

SANRAKU HOSPITAL, 2-5 KANDA 

SURUGADAI CHIYODA-KU 

101-0062 TOKYO — JAPAN 

shigeosanoshop@sanraku.or.jp 

+81 3 32 93 3981 

Dr SAPKAS George 

MEDICAL SCHOOL, ATHENS 

UNIVERSITY 

ORTHOPAEDIC DEPARTMENT 

ATHENS — GREECE 

gsapkas1@hol.gr 

+32 10 723 3967 

Dr SCHIZAS Constantin 

HÔPITAL ORTHOPÉDIQUE 

1011 LAUSANNE — SWITZERLAND 

cschizas@hotmail.com 

+41 797109637 

Dr SCHULZ Ronald 

JOHNSON & JOHNSON 

AV KENNEDY 5454 P12 

SANTIAGO — CHILE 

avillar@andinadelsud.cl 

+56 23880159 

Dr SCHWAB Frank 

MAIMONIDES MEDICAL CENTER 

927 49TH STREET 

NY 11219 BROOKLYN, NEW YORK — 

USA 

fschwab@worldnet.att.net 

Dr SCHWARTZE Amy 

200 ST. MARY’S MEDICAL PLAZA, 

STE 301 

MO†65101 JEFFERSON CITY — USA 

julia@spinemidwest.com 

Dr SENEGAS Jacques 

C.H.U. PELLEGRIN TRIPODE 

PLACE A. RABA LÉON 

33076 BORDEAUX — FRANCE 

jsenegascad@aol.com 

+33 557 020 000 

Pr SEYDINA ISSA LAYE Seye 

ORTHOPÉDIE TRAUMATOLOGIE 

BP 2239 

18522 DAKAR — SENEGAL 

silseye@mac.com 

+221 77 638 21 23 

Pr SHOHAM Moshe 

TECHNION ISRAËL INSTITUTE OF 

TECHNOLOGY 

DEPT OF MEDICAL ENGINEERING 

32000 HAÔFA — ISRAEL 

shoham@tx.technion.ac.il 

+972 482 932 64 

Dr. SILVA Alvaro 

CLINICA ALEMANA DE SANTIAGO 

AV. MANQUEHUE NORTE 1410 

7650567 SANTIAGO — CHILE 

silva.alvaro@yahoo.com 

+56 89031030 

PR SKALLI Wafa 

ENSAM, LABORATOIRE DE 

BIOMÉCANIQUE 

151, BOULEVARD DE L’HÔPITAL 


wafa.skalli@paris.ensam.fr 

+33 144 24 63 68 

Dr SOLA Carlos A. 

HOSPITAL ITALIANO 

SERVICIO DE COLUMNA, POTOSI 

4215 

1199 BUENOS AIRES — ARGENTINA 

+54 11 47 42 37 36 

Mr SOLA Carlos Alberto 

HOSPITAL ITALIANO 

ROTOSI 4215 

BUENOS AIRES — ARGENTINA 

carlos.sola@hospitalitaliano.org 

PR STEIB Jean-Paul 

HÔPITAL CIVIL DE STRASBOURG, 

PAVILLON CHIRUGICAL B 

1, PLACE DE L’HÔPITAL BP 426 

67091 STRASBOURG CEDEX — 

FRANCE 

Jean-Paul.STEIB@chrustrasbourg.fr 

+33 388 11 68 27 

Dr Ing TEMPLIER Alexandre 

9, AVENUE DU COLONEL DRIANT 

78700 CONFLANS STE HONORINE 

— FRANCE 

a.templier@gmail.com 

Dr TERRACHER Richard 


MONTSOURIS 



r-terracher@imm.fr 

+33 156 61 64 19 

Dr TRABELSI Mohsen 

HOPITAL AZIZA OTHMANA 

PLACE DU GOUVERNEMENT 


mohsen.trabelsi@yahoo.fr 

+216 71 521 363 

Dr TSAFANTAKIS Emmanouil 

KAT HOSPITAL 

2 NIKIS ST 

14561 KIFISSIA — GREECE 

kalitravel17@yahoo.gr 

+32 103646262 


Dr UEYAMA Kazumasa 

HIROSAKI MEMORIAL HOSPITAL 

NISHIDA 59-1, SAKAIZEKI 

036-8076 HIROSAKI-SHI — JAPAN 

kuzkinen@jomon.ne.jp 

Dr ULLRICH Christopher G. 

2623 LEMON TREE LANE 

NC 28211-3643 CHARLOTTE — USA 

chris.ullrich@worldnet.att.net 

+1 704 365 4714 

Dr VILLAREJO Francisco 

CLINICA LA LUZ 

C/ GENERAL RODRIGO 8 


+34 914530200 

Pr VITAL Jean-Marc 

CHU BORDEAUX - TRIPODE 

PLACE AMÉLIE RABA LÉON 

33200 BORDEAUX — FRANCE 

vita;.jean-marc@wanadoo.fr 

+33 556795529 

Dr Ing WARDEN Karen E. 

8202 SHERMAN ROAD 

OH 44026 CHESTERLAND — USA 

kxw15@po.cwru.edu 

+1 440 729 8457 

Dr WASSERMAN Johan 

PO BOX 3352 

2040 HONEYDEW — SOUTH AFRICA 

wassie@mweb.co.za 

+27 11 794 2664 

Dr WELK Thomas 

SRH KARLSBAD 

LANGENSTEINBACH 

76307 KARLSBAD — GERMANY 

juergen.harms@kkl.srh.de 

+49 720 261 3892. 

Dr WILES David 

ETBS 

310 NORTH STATE OF FRANKLIN 

ROAD 

SUITE 103 

TN 37604 JOHNSON CITY — USA 

DAWiles@aol.com 

+1 4232328301 

Dr ZACHARIOU Konstantinos 

KAT HOSPITAL 

2 NIKIS ST 

14561 KIFISSIA — GREECE 

kalitravel17@yahoo.gr 

+90 32103646262 

Dr ZILELI Mehmet 

EGE UNIVERSITY 

FACULTY OF MEDICINE 

DEPT OF NEUROSURGERY, 

BORNOVA 

35100 IZMIR — TURKEY 

zileli@med.ege.edu.tr 


142


DePuy Spine is headquartered in Raynham, Massachusetts. 

Focus on 

DePuy Spine, Inc 

DePuy Spine, Inc. is an operating 

company of DePuy, Inc., a Johnson & 

Johnson company, one of the world’s 

leading designers, manufacturers, 

and suppliers of orthopaedic devices 

and supplies. The company is known 

throughout the medical world for the 

development, manufacture, and 

marketing of innovative solutions for 

a wide range of spinal pathologies. 

Historical background : 

1895 : DePuy was founded in Warsaw, 

Indiana : the 1st orthopaedic manufacturer 

in the world. 

1993 : DePuy jointly forms a new 

company with Biedermann Motech, a spinal 

products manufacturer located in 

Schwennigen, Germany. The new company, 

DePuy Motech Inc., develops, manufactures 

and markets spinal implants. This marks 

DePuy’s entry into the spinal implant market. 

1998 : DePuy purchases Clevelandbased 

AcroMed, the second largest spinal 

DEPUY AND ITS LEADING PARTNERS 

DePuy Spine has worked and partnered with 

leading clinicians, researchers, and thought 

leaders to develop products to treat spine 

disorders for over 20 years. Many world-wide 

recognized key opinion leaders have built 

philosophies in the past and today in close 

corporation with DePuy Spine to surgically 


company. This acquisition makes the newformed 

entity, DePuy AcroMed the second 

largest spinal company. 

1998 : Johnson & Johnson buys DePuy, 

including DePuy AcroMed 

2003 : DePuy AcroMed renamed into 

DePuy Spine 

The company is committed to advancing the 

knowledge of all health care professionals and 

their patients in addressing spinal pathologies. 

DePuy Spine achieved many 

milestones over the past years : 

Variable Screw Placement 

Poly-Axial Screw 

Harms cage 

Brantigan Cage 

Charite Disc 

World Wide President of DePuy Spine is 

Gary Fischetti. The International Office is 

based in Leeds, England. Vice President of 

DePuy Spine International is Mike 

Thompson. 

treat spinal disorders. To name a few : From left to right : Professor Harms, Doctor Steffee, Doctor Brantigan, Professor Kaneda, Doctor Asher. 

DePuy Spine is scheduled to introduce new 

products in cervical, minimally invasive spine 

surgery, deformity, degenerative disease and 

interbody fusion this year. In addition, DePuy 

Spine is laying the clinical, educational and 

economic foundation for investments it made 

last year in diagnostic testing for scoliosis, 

vertebral body augmentation for fractures 

from osteoporosis, total facet arthroplasty 

and annulus repair. 

Last year DePuy Spine acquired the 

Confidence System, a proprietary delivery 

system and novel polymethylmethacrylate 

(PMMA) bone cement that is injected directly 

into vertebral bodies to treat compression 

fractures, a painful condition that occurs when 

one or more vertebrae collapse, usually as a 

result of osteoporosis. The treatment results in 

significant pain reduction and the restoration 

of mobility in many patients. More than 

200.000 surgical interventions for vertebral 

compression fractures are performed 

worldwide each year. 

DePuy Spine has the resources, 

portfolio, focus and long-term 

commitment to meet the 

new challenges facing 

health professionals and 

their patients”, said Gary 

Fischetti. “Our solutions 

will focus on the patient 

and be backed by solid clinical 

and economic data, coupled 

with extraordinary education, 

service and support. 

The major product lines in DePuy 

Spine’s portfolio today are : 

Bengal Charite Confidence 

Devex Discover Expedium 

Healos Leopard Monarch 

Mountaineer Saber Summit


DePuy Spine is headquartered in Raynham, Massachusetts. 

Focus on 

DePuy Spine, Inc 

DePuy Spine, Inc. is an operating 

company of DePuy, Inc., a Johnson & 

Johnson company, one of the world’s 

leading designers, manufacturers, 

and suppliers of orthopaedic devices 

and supplies. The company is known 

throughout the medical world for the 

development, manufacture, and 

marketing of innovative solutions for 

a wide range of spinal pathologies. 

Historical background : 

1895 : DePuy was founded in Warsaw, 

Indiana : the 1st orthopaedic manufacturer 

in the world. 

1993 : DePuy jointly forms a new 

company with Biedermann Motech, a spinal 

products manufacturer located in 

Schwennigen, Germany. The new company, 

DePuy Motech Inc., develops, manufactures 

and markets spinal implants. This marks 

DePuy’s entry into the spinal implant market. 

1998 : DePuy purchases Clevelandbased 

AcroMed, the second largest spinal 

DEPUY AND ITS LEADING PARTNERS 

DePuy Spine has worked and partnered with 

leading clinicians, researchers, and thought 

leaders to develop products to treat spine 

disorders for over 20 years. Many world-wide 

recognized key opinion leaders have built 

philosophies in the past and today in close 

corporation with DePuy Spine to surgically 


company. This acquisition makes the newformed 

entity, DePuy AcroMed the second 

largest spinal company. 

1998 : Johnson & Johnson buys DePuy, 

including DePuy AcroMed 

2003 : DePuy AcroMed renamed into 

DePuy Spine 

The company is committed to advancing the 

knowledge of all health care professionals and 

their patients in addressing spinal pathologies. 

DePuy Spine achieved many 

milestones over the past years : 

Variable Screw Placement 

Poly-Axial Screw 

Harms cage 

Brantigan Cage 

Charite Disc 

World Wide President of DePuy Spine is 

Gary Fischetti. The International Office is 

based in Leeds, England. Vice President of 

DePuy Spine International is Mike 

Thompson. 

treat spinal disorders. To name a few : From left to right : Professor Harms, Doctor Steffee, Doctor Brantigan, Professor Kaneda, Doctor Asher. 

DePuy Spine is scheduled to introduce new 

products in cervical, minimally invasive spine 

surgery, deformity, degenerative disease and 

interbody fusion this year. In addition, DePuy 

Spine is laying the clinical, educational and 

economic foundation for investments it made 

last year in diagnostic testing for scoliosis, 

vertebral body augmentation for fractures 

from osteoporosis, total facet arthroplasty 

and annulus repair. 

Last year DePuy Spine acquired the 

Confidence System, a proprietary delivery 

system and novel polymethylmethacrylate 

(PMMA) bone cement that is injected directly 

into vertebral bodies to treat compression 

fractures, a painful condition that occurs when 

one or more vertebrae collapse, usually as a 

result of osteoporosis. The treatment results in 

significant pain reduction and the restoration 

of mobility in many patients. More than 

200.000 surgical interventions for vertebral 

compression fractures are performed 

worldwide each year. 

DePuy Spine has the resources, 

portfolio, focus and long-term 

commitment to meet the 

new challenges facing 

health professionals and 

their patients”, said Gary 

Fischetti. “Our solutions 

will focus on the patient 

and be backed by solid clinical 

and economic data, coupled 

with extraordinary education, 

service and support. 

The major product lines in DePuy 

Spine’s portfolio today are : 

Bengal Charite Confidence 

Devex Discover Expedium 

Healos Leopard Monarch 

Mountaineer Saber Summit

Editorial BY JEAN-PAUL STEIB p112 - ArgoSpine

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