US20050182412A1 - Transverse cavity device and method - Google Patents

Abstract

A surgical instrument for creating and preparing a cavity in a bony intervertebral body is provided with asymmetrical cutting structures. These asymmetrical cutting structures selectively open a cavity which has a relatively large surface area in the vertical direction. In one embodiment, the cutting structure includes a shearing element that sweeps out a cutting arc that is larger than the instrument delivery area.

Description

CROSS-REFERENCE TO RELATED CASES
• The present case claims the benefit of, and incorporates by reference the following US provisional applications:
• US Provisional Patent Application Ser. No. 60/227,050 filed Aug. 21, 2000, entitled “Vertebroplasty Cavity Creation using an Expanding Tube” and, US Provisional Patent Application Ser. No. 60/225,191 filed Aug. 14, 2000, entitled “Vertebral Body Expander.”
FIELD OF THE INVENTION
• The present invention relates generally to the treatment of compression fractures in bones, and more specifically to a device and a method for cutting a “transverse” cavity in the bone as one part of a therapy.
BACKGROUND OF THE INVENTION
• The human spine consists of a complex set of interrelated anatomic elements including a set of bones called vertebral bodies. Intervertebral discs separate most vertebral bodies. These discs includes a “spongy” nucleus pulpous surrounded by an annulus fibrosis “membrane.” The annulus fibrosis connects the opposed endplates of adjacent vertebral bodies. All of these structures together with muscles act to provide motion, stability and protection for the spinal cord. When healthy, these structures effectively protect the spinal cord and allow for normal motion.
• However, there are many disease states and aging processes that impact the patient. Osteoporosis and metastatic disease reduce the structural integrity of the vertebral bodies, predisposing them to fracture. Vertebral fractures can lead to loss of vertebral height, which can exacerbate existing neurological conditions or predispose the spine to other symptoms. Back pain often results from these conditions.
• Vertebroplasty is an effort to stabilize these fractures and to alleviate this source of pain. Generally, if not treated, fractures and loss of height result in a cascade of injury which is undesirable. For this reason, various efforts have been directed at stabilizing and restoring the natural vertebral bodies of the back.
• Many surgeon experts suggest that it is desirable to intervene and restore the height of the vertebral body and natural biomechanics of the spine, in addition to stabilizing the spine to provide pain relief. As an initial step to fracture reduction, which for vertebral compression fractures restores anatomic vertebral height, it may be desirable to cut a cavity that is approximately transverse to the vertical axis of the vertebral body. This cavity is intended to create a large, uniform, initial surface area for fracture reduction devices. The transverse cavity reduces contact stress in supporting bone and decreases the likelihood of cancellous compaction associated with prior art techniques. Thus, this step increases the likelihood that the fracture will be reduced rather than simply creating a large cavity within a bony structure. In general, it may be desirable to locate this transverse cavity near the fracture, which is generally located in the anterior portion of the vertebral body. It is important to create a shallow cavity at the correct location to minimize disruption of cancellous bone and to facilitate further therapeutic intervention.
• The presently available techniques and devices expand along a path of least resistance within the cancellous bone. As a result, these devices do not expand in a predictable manner, often expanding vertically before expanding horizontally (transverse). Rather than consistently reducing the fracture, these techniques often crush the cancellous bone, creating an expanded cavity without necessarily reducing the fracture or restoring the natural anatomy.
• Another reason for creating a narrow cavity is to impart known fracture zones in the bone. These fracture zones enable controlled movement of the bone during other therapeutic procedures. These fracture zones also create flow channels for various injectable materials that may be used in a further therapeutic intervention.
SUMMARY
• In contrast to the prior art, the devices and methods of the present invention are used to create an initial cavity in the vertebral body that has a controlled shape and location.FIG. 13 represents a prior art procedure where a narrow andsmall cavity17 is filled with a balloon and the overall “footprint” is small so that the total distraction force is also small.FIG. 14 represents a cavity created according to the invention filled with a balloon to apply distraction force. In this figure, the increased area of the “footprint” of thetransverse cavity18 permits greater distraction force per unit balloon pressure.
• The vertebral body is entered through either a transpedicular or extrapedicular location with a needle, trocar or other access devices. The cavity creation tool of the invention is inserted into the cancellous bone of the vertebral body through the relatively small area aperture created by the trocar or needle. The cavity creation tool is then activated and manipulated.
• In general, the tool is directed to a site near the bone fracture. In the context of a vertebral compression fracture, the fracture is typically located in the anterior portion of the vertebral body. Once positioned at the desired site, the device is used to create a cavity. Although several related embodiments of the cavity creation tool are contemplated and illustrated, each of them defines a cutting or shearing plane. Each device limits its action to a controlled area of the bone. The controlled area both defines and is a portion of the “transverse” cavity.
• Once the preferred transverse cavity is created, any number of interventions can be performed. For example, a device that “expands” may be introduced to reduce the fracture. Typically, the reduction is intended to restore the normal anatomy. This expansion device may be removed or permanently implanted.
• Once a fracture is reduced, the bone cavity may be filled with a bone filler material such as bone cement, allograft, or synthetic bone substitutes. The filler acts to increase the stability and strength of the bone. In some interventions, the filler may be combined with bone growth factors (BMPs, cell therapy, autologous growth factors) to accelerate bone remolding and increase the amount of bone remodeling. Likewise, other drugs or therapies (including but not limited to antibiotics, chemotherapy, and other drug therapies) may be combined with the bone filler.
• Although the invention is illustrated within the vertebral body compression fracture treatment context, other secondary interventions or operations can be contemplated for using the shaped cavity.
• Although the invention is particularly useful for the treatment of vertebral bodies, it should be understood that similar bone fracture geometries exist in other parts of the body. For this reason, the devices and methods of the invention may be used in the treatment of any compaction fracture, such as but not limited to the tibial plateau fractures, distal radius fractures, calcaneous, distal tibial fractures, and humeral fractures.
BRIEF DESCRIPTION OF THE DRAWINGS
• Illustrative embodiments of the inventions are shown throughout the several views of the drawings. For ease of illustration, the inventions are disclosed in the context of the repair of a vertebral body, however the device and method can be applied in other compression fracture applications including, but not limited to tibial plateau, distal radius, calcaneous, distal tibial fractures, and humeral fractures.
• In these illustrative but not limiting drawings, like reference numerals indicate equivalent structure, wherein:
• FIG. 1 is a phantom view of a vertebral body showing a transverse cavity, certain tool features and a coordinate system;
• FIG. 2 is a cross section of a vertebral body illustrating a portion of a cavity creation tool;
• FIG. 3 is a cross section of a vertebral body illustrating a portion of a cavity creation tool;
• FIG. 4 is a cross section of a portion of a cavity creation tool;
• FIG. 5 is a cross section of a portion of a cavity creation tool;
• FIG. 6 is a cross section of a vertebral body illustrating a portion of a cavity creation tool;
• FIG. 7 is a cross section of a vertebral body illustrating a portion of a cavity creation tool;
• FIG. 8 is a cross section of a vertebral body illustrating a portion of a cavity creation tool;
• FIG. 9 is a cross section of a vertebral body illustrating a portion of a cavity creation tool;
• FIG. 10 is a cross section of a vertebral body illustrating a portion of a cavity creation tool;
• FIG. 11 is a cross section of a vertebral body illustrating a portion of a cavity creation tool;
• FIG. 12 is a cross section of a vertebral body illustrating a portion of a cavity creation tool;
• FIG. 13 is a cross section of a vertebral body illustrating a portion of a hydraulic lifting device of the Prior Art; and,FIG. 14 is a cross section of a vertebral body illustrating a portion of a hydraulic lifting device.
DETAILED DESCRIPTION
• FIG. 1 is a phantom view of a vertebral body showing atransverse cavity18 and a coordinatesystem16. This figure shows avertebral body10 in isolation. Two possible surgical entry points into the vertebral body contemplated within the scope of the invention are illustrated. One entry point is “transpedicular.” This approach is indicated by the physical location oftube12, traveling through the pedicle into thevertebral body10. Another approach is “extra-pedicular.” This access approach is illustrated bytool14 entering the vertebral body at a location lateral of the transpedicular approach on the posterolateral corner of the vertebral body.
• The typical surgery will include a small incision in the back adjacent to the vertebral body. Next, a small gauge needle or guide-wire is introduced to confirm proper positioning under fluoroscopy. Physicians typically utilize an 11-gauge needle for the transpedicular approach and a larger needle or tube (up to 6 mm ID) for the extra-pedicular approach. Many physicians advance cannulated tools over a small gauge needle to successively increase the size of the working channel.
• Other physicians may prefer to place a guide catheter at the site and to introduce tools though the lumen of the guide catheter. In general, the tools described herein can be used either over the wire or through a guide catheter or alone at the election of the physician.
• In this figure, a coordinatesystem16 identifies a vertical direction Z, which points along the spine. The Y-direction is generally anterior. It is the purpose of the invention to create a cavity with a fixed and controlled vertical extent (Z-axis height) and a controlled shape in the X-Y plane. For the purposes of this disclosure, the term transverse cavity will be used interchangeably with a cavity created parallel to the surface that is to be reduced or restored to its normal anatomic position, and generally normal to the force applied. The surface that is reduced or displaced defines the X-Y plane. This definition holds for other procedures performed with the invention.
• Returning to the figure, thecavity18 is typically ovaloid in shape as projected in the X-Y plane. The ovaloid shape has an approximately uniform height in the Z direction. This “shape” is referred to throughout the specification as a “transverse cavity” for the vertebral body application illustrated in these figures. Therefore the X-Y plane is defined as the “transverse plane” and the Z-axis direction may be referred to as the “vertical axis.” It is a characteristic of all the embodiments of the tools shown in the application that the cross sectional area of the tool at the entry point into the bone is smaller than the transverse cavity created with the tool.
• To facilitate description of the invention, the distal “working” structures of the cavity creation tools are illustrated in isolation while the proximal manipulation handles as contemplated are shown generically ashandle20 andfinger loop21. In each embodiment, ahandle structure20 can be moved with respect to the tool sheath ortool body14. In each embodiment, the relative motion betweenhandle20 andsheath14 activates the distal working surfaces of the device. Thehandle20 or thefinger loop21 is indexed to the distal working surfaces to provide confirmation of the orientation of the working surfaces with respect to the bone structures.
• It is contemplated that in addition to direct manual manipulation, other power sources can be used to actuate the working surfaces, including hydraulic or pneumatic cylinders and electromechanical actuators shown generically inFIG. 1 aspower source23. In general, purely manual mechanical mechanisms are preferred because they improve tactile feedback to the physician.
• The tools may be made of conventional materials, with stainless steel preferred for “blade” embodiments and Nitinol or other super elastic alloys adopted for the flexible arm embodiments. The tools may be reusable or disposable. Materials choices do not appear critical for carrying out the invention.
• The overall length of the cavity creation tool from thehandle structures20 and21 to the working distal tip may vary to facilitate the particular surgical procedure. For example, a length of 220 cm is useful for the vertebral application, while a length of60 cm is a practical value for a tibial plateau procedure.
• FIG. 2 shows an embodiment of thecavity creation tool30 that includes ablade38 mounted on thetool body14 for rotational motion around thepivot34. Therod32 is coupled to a proximal handle20 (FIG. 1) and a push-pull motion between the handle and the finger loop21 (FIG. 1) causes the blade to sweep out anarc40. The blade may be blunt or it may include a cuttingsurface42. In operation, theblade38 laterally loads cancellous bone, breaking or cutting the bone in the X-Y plane of the cavity. The pivot and blade are confined to a transverse plane so this action creates the transverse cavity. By advancing the tool along theaxis36, the cavity may take an approximately oval shape in the X-Y plane.
• FIG. 3 shows acavity creation tool62 having a distal end that is positioned in a vertebral body. The distal end includes two arms. Afirst arm52 is anchored to thetube14 with ahinge point mechanism56 at a first end. The second end of thearm52 is coupled to thepull rod64. Relative motion between thetube14 and thepull rod64 expands the first arm in a transverse plane. This particular embodiment of the tool is asymmetric and the tool includes asecond arm58 that is anchored to thetube14 with ahinge mechanism60. The first and second arms define a plane for the operation of the device in the transverse plane.
• FIG. 4 shows a cross section of thetool body14 having a notch or groove15 for locating and restraining apull rod32. The tool body cross section defines the tool body area for the cavity creation tool. In general, the tool may be inserted into a bone through a hole of the size of the tool body area. This parameter or area is always smaller than the “footprint” of the transverse cavity in the X-Y plane. The cross section of this portion of the tool defines the tool body area.
• FIG. 5 shows apull rod32 is constrained in a groove in thetool body14. In this embodiment the pull rod actuates a blade or other structure. The cross section of this portion of the tool defines the tool body area.
• FIG. 6 shows an embodiment of the tool that has two pull or pushrods100 and106. Pullrod106 operates afirst arm108 while thesecond arm102 is activated by theindependent pull rod102. The asymmetrical operation of the two independent arms can be used to control the shape of the cavity by directing expansion of the cavity to preferred areas within the vertebral body.
• FIG. 7 shows an embodiment of thetool70 where acontainer72 surrounds a pair ofarms52 and58. The container interacts with the cancellous bone as the pull rod activates the arms and moves them against the cancellous bone. The container prevents debris from interfering with the retraction of the arms. Thecontainer72 can be subsequently inflated to reduce the fracture and restore the natural anatomy. Finally, the container may be detached and left behind.
• In this particular embodiment, the first and second arms are identical, and will normally create a symmetric cavity. Thecontainer72 is optional and the arms can be used alone in a fashion analogous to other versions of the tool.
• In this particular embodiment, the first and second arms have blunt dissection surfaces on the exterior of the arms to interact with cancellous bone. In this embodiment, the first and second arms may also have different mechanical properties for the creation of an asymmetric cavity.
• FIG. 8 shows an embodiment of thecavity creation tool80 that includes saw-like teeth on thefirst arm88 and thesecond arm82. Once again, traction on thepull rod64 causes the teeth on the arms to cut through the cancellous bone. In a fashion similar to related embodiments, the arms lie in and define a cutting plane that creates a transverse cavity. The saw teeth typified bytooth90 can be moved by manipulating both the pull rod and the tube.
• FIG. 9 shows a cable-actuated device with acable200 wrapping a spindle oraxle202 mounted on thetool body214. Cable motion results in sweeping out anarc210 as seen inFIG. 10.
• FIG. 10 shows theblade38 can sweep through 360 degrees because of cable actuation. An arc of less than 360 degrees may be used when a non-circular cavity is required.
• FIG. 11 is a cable-operated version with thepull rod232 coupled tocable200. In this device, the pull on the cable forces theflex arms202 and208 in an outward direction to form the transverse cavity.
• FIG. 12 shows the cable-operated version ofFIG. 9 with the arms deployed, creating a transverse cavity.
• FIG. 13 which represents the prior art is a schematic of a balloon or other hydraulic lifting device as it is initially inserted into the vertebral body.
• FIG. 14 is a schematic of the increased lifting force generated by a balloon or other hydraulic lifting device which immediately reaches a broad surface area because of the transverse cavity that has been prepared before deploying the balloon or hydraulic lifting device.
• Although the invention has been illustrated in one context, it should be apparent that the device features maybe modified or combined in alternate configurations.

Claims (47)

1-8. (canceled)

9. A tool for creating a cavity in a bone comprising:

an elongated body having a distal end and having a proximal end, said body having an exterior diameter defining a tool body area for the tool;

a shearing element anchored to said distal end of said delivery tube by an anchor element; said anchor element and said distal end of said delivery tube together forming a hinge to permit and to restrict said shearing element to move in a transverse plane;

whereby the motion of said shearing element in said transverse plane sweeps out a cutting arc, said cutting arc defining an area larger than said delivery area; an actuator located within said delivery tube and connected to said shearing element;

whereby motion imparted to said actuator rod moves said shearing element through said cutting arc.

10. The tool ofclaim 9 wherein said shearing element is a blade.

11. The tool ofclaim 9 wherein said blade is blunt.

12. The tool ofclaim 9 wherein said blade includes a cutting surface.

13. The tool ofclaim 9 wherein said actuator includes a push-pull element coupled between said proximal end and said distal shearing element.

14. The tool ofclaim 9 wherein said actuator includes a cable pull element coupled between said proximal end and said distal shearing element.

15. The tool ofclaim 9 further including: a handle indexed to said shearing element coupled to said elongate body at said proximal end.

16. The tool ofclaim 9 further including: a finger loop handle indexed to said shearing element coupled to said elongate body at said proximal end.

17. The tool ofclaim 9 further including: an electrical solenoid to provide power to said actuator.

18. The tool ofclaim 17 further including: a high frequency forcing function superimposed on the solenoid drive signal generating an impacting force to said actuator.

19. The tool ofclaim 9 further including: a pneumatic cylinder to provide power to said actuator.

20. The tool ofclaim 19 further including: a high frequency forcing function superimposed on the pneumatic cylinder drive signal generating an impacting force to said actuator.

21. The tool ofclaim 9 further including: an electro mechanical actuator to provide power to said actuator.

22. The tool ofclaim 21 further including: a high frequency forcing function superimposed on the electro mechanical actuator drive signal generating an impacting force to said actuator.

23. A tool for creating a cavity in a bone comprising:

an elongated body having a distal end and having a proximal end, said body having an exterior diameter defining a tool body area for the tool;

at least one shearing element anchored to said distal end of said delivery tube by an anchor element; said anchor element and said distal end of said delivery tube together forming a hinge to permit and to restrict said shearing element to move in a transverse plane;

whereby the motion of said shearing element in said transverse plane sweeps out a cutting arc, said cutting arc defining an area larger than said delivery area; an actuator located within said delivery tube and connected to said shearing element;

whereby motion imparted to said actuator rod moves said shearing element through said cutting arc.

24. The device ofclaim 23 wherein said shearing element is a flexible bow element.

25. The device ofclaim 24 wherein said flexible bow element has a cross section that varies along its length.

26. The device ofclaim 23 wherein said bow has a sharp exterior edge for shearing bone.

27. The device ofclaim 23 wherein said bow has a set of sharp teeth members on said exterior edge for shearing bone.

28. The device ofclaim 23 wherein said bow element is blunt.

29. The device ofclaim 23 wherein said bow element is connected to said delivery tube at the distal end of said tube and said bow element is anchored to said actuator rod at the distal end of said actuator rod; whereby relative motion of said actuator rode toward said distal end of said tube forces said bow outwardly in said transverse cutting plane.

30. The device ofclaim 23 wherein said flexible element is located within a cover, which moves to accommodate the motion through an arc.

31. The device ofclaim 23 wherein said flexible bow element has a proximal end and a distal end wherein said flexible element has a constant mechanical strength from its distal end to its proximal end.

32. The device ofclaim 23 wherein said flexible element has a proximal end and a distal end and wherein said flexible element varies in mechanical strength from its distal end to its proximal end.

33. The device ofclaim 23 wherein said flexible element has a proximal end and a distal end and wherein said flexible element is constant in cross sectional area from its distal end to its proximal end.

34. The tool ofclaim 23 further including: a handle indexed to said shearing element coupled to said elongate body at said proximal end.

35. The tool ofclaim 23 further including: a finger loop handle indexed to said shearing element coupled to said elongate body at said proximal end.

36. The tool ofclaim 23 further including: an electrical solenoid to provide power to said actuator rod.

37. The tool ofclaim 23 further including: a pneumatic cylinder to provide power to said actuator rod.

38. The tool ofclaim 23 further including: an electro mechanical actuator to provide power to said actuator rod.

39. The tool ofclaim 23 wherein the shearing element is constructed of a superelastic material.

40. A tool for creating a cavity in a bone comprising:

an elongated body having a distal end and having a proximal end, said body having a exterior diameter defining a tool body area for the tool;

a pair of shearing elements including a first shearing element and a second shearing element anchored to said distal end of said delivery tube by an anchor element;

said anchor element and said distal end of said delivery tube together forming a hinge to permit and to restrict each of said shearing elements to move in a transverse plane;

whereby the motion of either of said shearing elements in said transverse plane sweeps out a cutting arc, said cutting arc defining an area larger than said delivery area;

a first actuator rod located within said delivery tube and connected to said first shearing element;

a second actuator rod located within said delivery tube and connected to said second shearing element;

whereby motion imparted to said actuators rods moves said shearing elements through said cutting arc independently.

41. The device ofclaim 40 wherein said shearing elements are flexible bow elements.

42. The device ofclaim 41 wherein said bow elements have a sharp exterior edge for shearing bone.

43. The device ofclaim 41 wherein said bow elements have a set of sharp teeth members on said exterior edge for shearing bone.

44. The device ofclaim 41 wherein said bow elements are blunt.

45. A kit of parts for use in treating compression fractures of a bone, comprising:

a tool adapted to form a transverse cavity within said bone, said tool having an extent configured for moving within said bone in a transverse plane; and

an expandable device adapted for insertion into said transverse cavity and for applying a force within said bone upon expansion in a direction substantially normal to said transverse plane.

46. The kit ofclaim 45, wherein said tool is configured to have a cross- sectional area upon insertion less than the cross-sectional area of said transverse cavity.

47. The kit ofclaim 46, wherein said tool comprises a tool body and a blade pivotally mounted therein for rotation in said transverse plane about a pivot axis.

48. The kit ofclaim 46, wherein said tool comprises a tool body and a flexible element configured to swing outwardly in said transverse plane.

49. The kit ofclaim 48, wherein said flexible element comprises two flexible arms configured to swing outwardly in opposite directions.

50. The kit ofclaim 45, wherein said expandable device comprises a hydraulic lifting device.

51. The kit ofclaim 45, wherein said expandable device comprises a balloon.

52. The kit ofclaim 45, further including a bone filler material for introduction into said transverse cavity.

53. The kit ofclaim 52, wherein said bone filler material is selected from the group consisting of bone cement, allograft and synthetic bone substitutes.

54. The kit ofclaim 52, wherein said bone filler is combined with additional materials selected from the group of bone growth factors consisting of BMP, cell therapy and autologous growth factors.

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