With a highly regarded career in spine surgery spanning throughout France, Dr. Vincent Cunin, who currently serves as the Deputy Chief of Service in the Spine Surgery department at Hospices Civils de Lyon (HCL), has witnessed first hand the progression taking place in the evolution of both spinal surgery technique and the specialized equipment required for the job.

Having worked directly with a multitude of innovations that include the early years of multisegmental spinal arthrodesis with Cotrel-Dubousset instrumentation, the ST2R technique, and the innovation of UNiD, we were especially curious to sit down and speak with Dr. Cunin about his views on the future of spine surgery and what he feels are the benefits of patient-specific surgeries.

 

Can you tell us a bit about your background as a surgeon and how you got started?

I started my medical studies in Paris around 1987 at the Pitié-Salpêtrière Hospital where Raymond Roy- Camille, father of the pedicle screw, was still head of the orthopedics department. I hesitated in my training between pediatrics, which thrilled me a lot during an internship at the Armand Trousseau Hospital, and orthopedic surgery, which had always attracted me, and so paediatric orthopedics surgery appeared as a natural choice for me. After a residency in Normandy at Rouen University Hospital and at Robert Debré Hospital, I returned to Paris at Trousseau Hospital.

My colleague there, having no attraction for spine surgery, allowed me to attend to all spinal surgeries of the department for two years. It was a privilege and an opportunity that undoubtedly shaped my professional destiny. It was also clear to me, during this training, that everything remained to be discovered in the field of scoliosis. Understanding the pathophysiology of this deformation and better deciphering the evolutionary profile are still very mysterious, and above all, finding an alternative to surgical spinal fusion, became for me the exciting challenge of my daily routine.
After ending my fellowship in 2003 and attracted by the Rhône-Alpes region where I grew up, I then happily joined Jérôme Berard’s team at Debrousse Hospital in Lyon. Later, in 2008, a large pediatric orthopedics department was created in the Femmes Meres Enfants University Hospital, which was a fusion of Rémi Kohler’s unit in Edouard Herriot Hospital and Jérôme Berard’s team.

“The best long-term results are those that have maintained the patient with a satisfactory sagittal balance.”

What has been the progression of the equipment you have used for surgery over the years?

My training took place in a service that saw the birth of multisegmental spinal arthrodesis from Cotrel-Dubousset. The reference technique of reducing the scoliosis was derotation of the rod and the main discussion during surgical preoperative meetings was surgical strategy and where to position implants that were still, at least in the thoracic region, only hooks. There was practically no reflection on the profile and the way to bend the rod during surgery was still very empirical.

A few years later, thanks to the multiplication of anchors by pedicle screws and progress of the devices available to us, especially of the PASS System and its evolution towards the ST2R technique, the correction of the deformity no longer posed significant intraoperative technique difficulties. The only limit being linked to the rigidity of scoliosis and not to the surgical device. This has allowed surgeons to focus on a much more complex target and restoring the most suitable profile for the patient. The arrival of the UNiD Rod on the market is totally in this evolution.

 

In your experience, what is the greatest benefit of using UNiD over other methods?

There are only advantages and we can really wonder how we operated without this system until now. I would say that the main advantage is to compel the surgeon to plan preoperatively and thus to reflect on the profile that is the most suitable for the patient. For a scoliosis surgeon, the objective is to correct the deformation in the coronal plane. It is what best characterizes the scoliosis in the eyes of young scoliosis patients and their parents. However, the best long-term results are those that have maintained the patient with a satisfactory sagittal balance, regardless of the result in the frontal plane. The pediatric surgeons have learned this from their colleagues operating on adult patients, who are more aware of the issues related to sagittal balance and for the future of our younger patients.

 

What do you and your peers see in the future for spine surgeries?

Spine surgery is developing rapidly, particularly around scoliosis, in which there are many things yet to be discovered. The dream of every scoliosis surgeon is to correct the deformity without the necessity of fusing the vertebrae together so that the function of the patient’s spine can be maintained.
Perhaps we’re not there yet to see this dream come true. The other major advance in spine surgery is undoubtedly the assistance of the computer and soon the robot. The surgeon does not want to leave his place, but this evolution is inevitable. It will help us, associated with customizing implants and with simulation of our planning, through modeling tools and to perform standardized and reproducible surgery tailored to each of our patients.

 

What do you think of personalized medicine and patient-specific technologies?

This is a development in line with our time. The synergy between the IT tools and modern imaging techniques now allows us to use in all medical fields, and especially in surgery, fully customized devices for each patient. New medical specialities will emerge from the field of biotechnology and medical imaging. Surgeons, in a probably not so distant future, will completely change their way of practicing surgery. Some gestures, that are still today handcrafted and empirical, as for example, intraoperative bending of rods, will completely disappear in favor of more reliable and standardized technologies.

“Some gestures that are still today handcrafted and empirical, as for example, intraoperative bending of rods, will completely disappear in favor of more reliable and standardized technologies.”

What do patients appreciate about personalized implants and what is their reaction to the technology after-surgery?

Patients are informed of new techniques through the Internet. They sometimes come and ask us to use one technology over another. This access to information is also a major upheaval, which doctors face.

So when we explain to them that we use technology like UNiD, it participates significantly in increasing their confidence and decreasing their anxiety. They immediately understand that this is not an untested and unproven implant but an evolution of an existing concept which will efficiently improve their care.

 

Have you seen any change in your daily workflow since using UNiD?

I spend more time planning the ideal rod curvature with the UNiD Lab team. This work is extremely satisfying and exciting. Planning, then comparing that planning with postoperative results, is a particularly exciting activity for me.

 

What are the advantages of scheduling patient-specific pediatric cases?

Unlike adult spinal deformity surgery, which often extends to the pelvis, the challenge with children is to save as much mobility as possible in the lumbar area. The fusion area often ends around the thoracolumbar junction. This is, for sagittal balance, a strategic area because it is at the transition point between two opposing curves in the spine: thoracic kyphosis and lumbar lordosis. There are many unanswered questions. Where should we position the transition point, what should be the amount of kyphosis to restore, and how will we adjust the lumbar left uninstrumented under the fusion area? We will gradually respond much better to these issues through the use of a reproducible and predictive digital surgical planning tool.

 

What is the value-add to the health care system, and can care truly be “value-based” without being personalized?

Personalized medicine, with tools for planning, simulation and customization, allow the surgeon to begin each surgery before stepping foot in the O.R.. The surgical procedure is then performed with greater ease, accuracy, and reproducibility from one surgeon to another. We expect this development, improvement, and rationalization of healthcare to allow optimizations in health costs.