Dr. Castellvi’s Invitation to Dr. Steffee
In 2008, Tony Castellvi invited Art Steffee to speak at his Duck Key meeting.
Stepping up to the podium at the meeting took some effort. He talked without notes.
What emerged was a story about how difficult it is to be an innovator in spine. While he could certainly have been referring to himself, he talked instead about other innovators, and how an academic vendetta from the 1950s has grown and even to this very day reverberates through this industry and the halls of the agencies that set reimbursement policy.
Dr. Steffee started his talk by recalling Dr. Paul Harmon’s work in 1952, when he implanted spheres in the disc space of patients suffering from degenerative disc disease. The spheres were manufactured by Austenal Corporation of York, Pennsylvania, and they were made from vitallium. Dr. Harmon was pilloried for trying something so innovative as spine arthroplasty and moved to South America to escape the attacks. He did eventually return to practice in California. In 1962, Dr. Harmon performed the first anterior lumbar fusion and published his results from 244 cases in Clinical Orthopaedics (26:107-27, 1963).
“Doing something new was not good for him,” said Dr. Steffee.
Then a gentleman from Sweden, Ulf Fernstrom, developed a stainless steel ball bearing that acted as a ball joint in the spine. Beginning in the late 1950s, Fernstrom implanted 191 of his “Fernstrom Balls” in 101 patients. It was an attempt to achieve arthroplasty in the spine and to create center of rotation that was truly mobile. President John F. Kennedy is rumored to have been a Fernstrom Ball patient.
Dr. Steffee put up some X-rays of two- and three-level Fernstrom Balls. I was sitting next to Dr. Lisa Ferrara, who is one of the leading experts on the biomechanics of the spine, and she noticed immediately how good the alignment of the spine was with the Fernstrom balls implanted.
The Fernstrom Balls were implanted with minimal disruption to the structures of the spine, including the ligamenture. Later Dr. McKenzie from Alberta, Canada, began implanting the Fernstrom Ball. Interestingly enough, he had two of them implanted in himself.
Dr. Steffee showed pictures of a patient who had had the Fernstrom Balls for 35 years and was doing fine.
Other reports in the literature are fairly positive about the Fernstrom Ball. Reitz and Joubert reported a total of 75 cervical disc arthroplasties performed with Fernstrom’s Ball in 32 patients. One year later there were no neurological complications or subluxations of the Balls. In two cases there was intrusion into adjacent bone, but the clinical results remained excellent in both cases. The authors cautioned about the need for a two-year follow-up period before a final assessment of this surgical technique could be made.
Unfortunately, Dr. Fernstrom had an academic enemy—Dr. Carl Hirsch from Uppsala University Hospital in Sweden. Dr. Hirsch was appalled at the idea of spinal arthroplasty and attacked the Fernstrom Balls relentlessly. Joining him in this campaign was Dr. Hirsch’s research assistant, Dr. Alf Nachemson.
Dr. Nachemson, who was born in Sweden in 1931 and died in 2006, called the use of the Fernstrom Balls “The Rape of the Spine” and, in the course of authoring more than 400 studies and articles became the dominant figure questioning spinal fusions and spinal arthroplasty.
His co-author on some of these studies was Dr. Richard Deyo of the University of Washington. Among his other accomplishments, Dr. Deyo petitioned the Center for Medicare and Medicaid Services (CMS) to deny coverage for the first spinal arthroplasty system approved by the FDA—the Charité.
Dr. Steffee, who has seen more and endured more in his efforts to innovate on behalf of patients, reminded the assembled surgeons at that 2008 meeting that spine arthroplasty actually started 55 years ago. The same group that attacked pedicle screws in the 1990s is attacking spine arthroplasty today and their animus, said Dr. Steffee, can be traced to the academic brawl between Dr. Ulf Fernstrom and Dr. Carl Hirsch.
Steffee’s Legacy
Here is what one of his patients said about him in a letter she sent to OTW:
“I was one of the patients that Dr. Steffee had in the ’80s. He actually traveled to Omaha, Nebraska to do the surgery. For me it was a process of three surgeries, and yes, a body cast. I had a fourth surgery when I slipped on the ice. I traveled to Cleveland and Dr. Steffee performed the surgery. I haven’t had any problems in nearly 35 years. I love Dr. Steffee. I was 16 years old when I had the surgeries and he gave me my life back”
John Evans, a physician based in Mississippi, sent OTW a note some years back about working with Dr. Steffee. Here is what he said:
“I was one of the first Orthopedic Surgeons in the State of Mississippi to perform a posterolateral interbody fusion in the lumbar spine. When I wanted to see a REAL surgeon on the cutting edge of the science, I elected to go to the Cleveland Clinic and operate along with Dr. Art Steffee. There I observed a true master at work!!!”
“He moved with amazing speed until he had elevated the muscles, when he got to the exiting lumbar nerves he slowed down dramatically to a meticulous thoughtful gentle surgeon, a master craftsman at his best!!! His anesthesia team was superb and very attentive to the slightest change in nerve conduction. Appropriate adjustments could be quickly made when the nerves indicated irritability. Very difficult cases were managed by a careful caring surgeon.”
“When I returned to Mississippi and encountered patients with severe complicated multiple level disease that no surgeon would touch, I now knew someone who would be willing to help…Art Steffee a surgeon far ahead of his time!”
“Yes, I am acquainted with the other side of the story; but I knew the man and I knew more about the motives behind the man; something difficult for the legal mind alone to encompass.”
In 2019, approximately 6,000 surgeons performed 700,000 instrumented spinal surgeries in the United States. Every one of them used the innovations that were pioneered by Steffee and an intrepid band of engineers, surgeons, and businesspeople—most of whom are still active members of the spine surgery community today.
