Virginie Lafage entered the world of spinal research by chance, after an engineering project drove her to a biomechanics lab in Paris, France. Since then, she has moved to the USA, become an executive member of the International Spine Study Group, and now directs the Department of Spine Research at the Hospital for Special Surgery (New York City, USA). She speaks to Spinal News International about the current state of spinal research, and where she believes its future lies.
Why did you decide to become a researcher in the field of spinal surgery?
In fact, spinal surgery was not part of my initial career plan. I was interested in technology, so pursued mechanical engineering at university. To complete a project in my final year of study, I needed to use specific software only available at the Laboratory of Biomechanics in Paris. It was there that I fell in love with the engineering methodology used to understand the human body. So, I came back for a Master’s, and ultimately a PhD.
Mechanical engineering provided a mental framework for problem solving. Looking for a field to make use of this tool, I was fortunate to be surrounded by the right people at the right time.
Who have been your career mentors and what wisdom did they impart?
My PhD was directed by Wafa Skalli, who has been a great mentor. She taught me how to be rigorous and cautious in the interpretation of results. I continue to work with her today, co-directing PhD students.
During my Master’s degree, I met Jean Dubousset, who codirected my PhD. He is an incredibly passionate man, inspiring me to continue into his field. He not only pushed me to my current career, but shared his passionate attitude and taught me how to focus on the entire body instead of just a focal pathology. Jean Dubousset ultimately encouraged me to move to New York to work with Frank Schwab and Jean-Pierre Farcy, as I had completed engineering school, a Master’s, a PhD and post-doctoral training at the same place. I did not know who they were, but I went!
Farcy, too, has a real passion for his patients. I spent many hours learning about the clinical aspects of spinal surgery and patient evaluation from him. I was also introduced to Frank Schwab, who then became my research partner and closest collaborator for my entire US career. Schwab has amazing analytical skills and the brilliance to understand the future of spinal surgery and deformity research. He also provided me with abundant opportunities to take on leadership roles. Now, all of our work comes from a place of shared passion and decision-making.
You moved from Paris to New York City, in 2005. What have been the biggest differences for your work?
I intended to stay in New York for a few months, but now it has been 11 years! In the USA, I have found that collaborative work is really embedded in the culture. This approach to projects is extremely pragmatic. We develop a concept, publish it with others, and then welcome people to build upon this concept. We also use study groups more than in France. When you put ten people together, you are more likely to move forward.
I think, in France, we try to do things as perfectly as possible ourselves. We refine our concepts again and again, sharing them only once they are fully mature. Sometimes this is a good approach, and sometimes perhaps the team-based approach is better.
I enjoy New York because it is extremely dynamic in the way people think and the way people work. And from a logistical standpoint, it is easy to travel between New York and Europe, which is important to me–I can maintain relationships with my friends, family, and colleagues in Europe.
What do you think has been the biggest development in spinal surgery during your career?
The biggest development in the past 10 years has been the use of data. Analyses of large data sets have led to identifying best practices by looking at what works and what just does not. We can start using big data to guide the transformation of surgery from an art to an applied technical science.
Of course we are also learning that general rules and algorithms do not apply evenly to all patients. Data has in fact led to a more personalised understanding of patients.
Outside of your own work, what has been the most interesting paper that you have seen in the last 12 months?
Probably a project investigating the impact of adult spinal deformity on quality of life (Pellisé et al, Eur Spine J, 2015) developed by the European Spine Study Group, led by Ferran Pellisé (Barcelona, Spain). The authors compare the disease burden of adult spinal deformity (ASD) to other chronic conditions. We used to think about ASD as a bigger brother of idiopathic scoliosis. But, we now realise that it is associated with a high level of disability, and can be as disabling as conditions like diabetes and heart disease. We cannot simply dismiss ASD as merely low back pain and a crooked spine—we must consider the real impact on quality of life for the patient. People seek treatment because they cannot function any more.
Of your own research, what are you most proud of, and why?
I am most proud of our efforts to understand the clinical impact of sagittal alignment and the importance of preoperative planning. While the concept is not new, ten years ago it was perceived as just an academic exercise. Collaboratively, we have been able not only to demonstrate its clinical impact on patient-reported outcomes, but also to identify patient-specific thresholds that were subsequently integrated into the Scoliosis Research Society (SRS)-Schwab classification. People are now taking over the project, refining it, and asking us to offer an operating-room solution This is a new challenge. It started as a clinical question, and now it is a technical one.
What has been your most memorable project?
When I first arrived in New York, Frank Schwab and I were working on a porcine model of fusion-less adolescent idiopathic scoliosis surgery. We operated on small pigs, inducing deformities that resembled the condition. We then applied corrective surgery, using a tethering technique to redirect the force of the animal’s growth to three-dimensionally realign the spine. Schwab and I operated on about 50 pigs. What makes it so memorable is how unexpected it all was. I went from finite element modelling in Paris to chasing pigs, taking X-rays, and performing surgeries right after landing in New York. Thinking back to it still makes me shake my head in disbelief. But, more importantly, this project shaped my understanding of the clinical side of spine surgery and its implications in spine surgery research.
You have been involved in the International Spine Study Group (ISSG) for several years—how has this group developed?
The ISSG started in 2008, and has evolved into an extremely productive academic group. Originally focused on thoracolumbar deformity, the ISSG expanded to cervical deformity, and later to multiple subgroups. One group focuses on “best practice”. In the field, not everyone will agree on a single technique, but it does not mean that they will produce different results. We are currently developing a platform where each surgeon can compare his or her results to the rest of the group. We are also working with the SRS on a risk stratification element to characterise the complexity of each patient and surgery, and then compare how surgeons perform the same procedure.
As a team, we are all very passionate about the ISSG and its future. One key element to its success is the camaraderie between all the researchers. We truly enjoy working together, debating ideas and sharing goals for the future of spinal research. In addition, it provides an excellent avenue for young clinicians or researchers to become involved in research.
What are your current main research interests?
The most important endeavour now is to make sure that research findings are available at the point of care. For that, we need to develop the infrastructure to bring updated information to the key decision-makers.
We are also interested in soft tissues, muscles and ligaments. When you take an MRI slice of a patient and look at it in the transverse plane, the vertebrae are tiny compared to the rest of the body. Perhaps soft tissue differences—the mechanical behaviour of the muscles, for
example—will have an impact on postoperative compensation and behaviour.
Another interest is in taking a closer look at the blurry line that divides “deformity” and “degenerative” pathologies. In extreme cases, there are surely distinct differences between the two; in moderate cases, the separation is less clear. Where exactly does deformity start and degeneration end? If there is overlap, perhaps there is a global principle that we need to identify.
You have been appointed as Director of Spine Research at the Hospital for Special Surgery. What has this entailed?
The transition to the Hospital for Special Surgery has brought new opportunities, allowing us to expand and apply our research to the concepts of degenerative conditions, paediatrics and soft tissue analysis. In addition to academic collaborations with other clinical, biomechanical, radiological, and statistical departments in the hospital, we also have the opportunity to work with internal administration. This provides a base for us to examine and research what needs attention from the academic, administrative, and patient-centred point of view.
You have been involved in many spinal societies. Why do you think that societies are important?
Societies have a big role that changes over one’s career. As a young researcher, the main purpose of a society is to present work, and to disseminate your research. When you get older, you attend society meetings to learn from other people. Societies allow you to get feedback on your work and to network with people with interesting perspectives that may lead to future collaborations. We also have to give back to societies—to take part in committees and direct the future of research.
What are the three questions in spinal medicine that still need an answer?
- What is the best treatment for each patient? We have enormous amounts of data on thresholds and standards for populations, but we are now realising that the ideal treatment result for each patient depends on a multitude of factors.
- How do we make intraoperative adjustments based on our preoperative plans? There have been major advancements in planning technology, but there is a lack of intraoperative technology to give real-time feedback.
- How do we utilise a multidisciplinary approach to the patient to achieve the best continuum of care, long after the operation is over?
What advice would you give to someone who was starting their career in spine medicine research?
Firstly, I would advise them to get training in non-medical fields, and to travel to meet people with different approaches. Then they need to find a good partner. I was very fortunate to meet Frank Schwab. Our different skills complement each other; he has clinical knowledge, and I have engineering knowledge. It is very important to find someone who will care about your career, who will push you, and train you and vice versa. Those people are not around every corner!
Outside of medicine, what are some of your interests?
I enjoy spending time with my colleagues abroad as well as the members of my lab. Nothing compares to the simple joy of sharing a meal and great conversation with friends. Some of these have led to wonderful and innovative projects. My long-term partnership and friendship with Frank Schwab led to our development of SurgiMap, a cross-platform software for surgical planning. It allowed us to channel our creative energy into a program combining research, surgery, and novel uses of technology.
1995–1998 Mechanical Engineering degree, Ecole Nationale Supérieure d’Arts et Métiers (ENSAM), Paris, France
1998–1999 Master’s degree in Biomechanical and Medical Engineering, ENSAM
1999–2002 PhD in Biomechanics, Laboratoire de Biomécanique”, ENSAM
2005–2006 Research Associate, Maimonides Medical Center, Brooklyn, USA
2006–2008 Research Scientist, NYU Hospital for Joint Diseases, New York City, USA
2008–2009 Director of Spinal Biomechanics Laboratory, NYU Hospital for Joint Diseases, New York City
2010–2015 Director of Spine Research, Spine Service, NYU Hospital for Joint Diseases
2015– Director Spine Research, Spine Service, Hospital for Special Surgery, New York City
International Spine Study Group – Executive committee
Scoliosis Research Society (SRS) – Active member
North American Spine Society (NASS) – member
Congress of Neurological Surgeons (CNS) – Member
Spine Arthroplasty Society (SAS) – Member
AO Spine – Member
Editorial review positions
The Spine Journal
Spine Deformity Journal
European Spine Journal
Journal of Musculoskeletal Research
Journal of Orthopedic Research