US20060095028A1 - Devices and methods for tissue access - Google Patents

Abstract

Methods and apparatus are provided for selective surgical removal of tissue. In one variation, tissue may be ablated, resected, removed, or otherwise remodeled by standard small endoscopic tools delivered into the epidural space through an epidural needle. The sharp tip of the needle in the epidural space, can be converted to a blunt tipped instrument for further safe advancement. The current invention includes specific tools that enable safe tissue modification in the epidural space, including a barrier that separates the area where tissue modification will take place from adjacent vulnerable neural and vascular structures. A nerve stimulator may be provided to reduce a risk of inadvertent neural abrasion.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS
• This application claims the benefit of U.S. Provisional Application No. 60/619,306, filed 15 Oct. 2004 and U.S. Application No. 60/622,865, filed 28 Oct. 2004, each of which is incorporated by reference herein in its entirety.
FIELD OF THE INVENTION
• The present invention relates to methods and apparatus for selective surgical removal of tissue, such as for the treatment of spinal neural and neurovascular impingement, through selective resection, ablation, and remodeling of tissue in the lateral recess, neural foramina and central spinal canal, more particularly, for safely performing lateral recess and neuroforaminal enlargement of the spine.
BACKGROUND OF THE INVENTION
• Pathological compression of spinal neural and neurovascular structures is an age-related process, increased in prevalence and severity in elderly populations, with potential congenital anatomic components, that result in back, radicular extremity pain and both neurological (e.g., sensory) and mechanical (e.g., motor) dysfunction. Prevalence is also influenced by congenital spinal anatomy. Disease progression leads to increased neural irritation, impingement, and ischemia, and is frequently accompanied by progressively increased pain, often in conjunction with reflex, sensory and motor neurological deficits.
• In the United States, Spinal Stenosis occurs with an incidence of between 4 percent and 6 percent ofadults 50 years of age or older, and is the most frequent reason cited for back surgery inpatients 60 years of age and older.
• Spinal Stenosis often includes neural or neurovascular impingement, which may occur in the central spinal canal, the lateral recesses of the spinal canal, or in the spinal neural foramina. The most common causes of neural compression within the spine are spinal disc disease (collapse, bulging, herniation); ligamentum flavum buckling, thickening and/or hypertrophy; zygapophysial (facet) joint hypertrophy; osteophyte formation; and spondylolisthesis.
• Disease progression increases neural irritation, impingement, and ischemia, and is frequently accompanied by progressively increased pain, often in conjunction with reflex, sensory and motor neurological deficits.
• Current surgical treatments for Spinal Stenosis include laminectomy (usually partial, but sometimes complete) and/or facetectomy (usually partial, but sometimes complete), with or without fusion. While standard surgical procedures lead to improvements in symptoms for 6 months or more in approximately 60% of cases, there is an unacceptable incidence of long-term complications and morbidity.
• Several companies offer tools that facilitate surgical access to the areas of the spine where neural impingement is likely to occur, in order to allow the surgeon to decompress the impinged neural structures through the removal of vertebral lamina, ligamentum flavum, facet complex, bone spurs, and/or intervertebral disc material. These surgical resections are frequently (i.e., occurs in 15% to 20% of cases) accompanied by fusion (arthrodesis). Spinal arthrodesis is performed to fuse adjacent vertebrae and prevent movement of these structures in relation to each other. The fusion is commonly a treatment for pain of presumed disc or facet joint origin, for “unstable spines”, and for spines that have been rendered “unstable” by the surgical decompression procedures, as described above. The definition of “spinal instability” remains controversial in current literature.
• Spinal arthrodesis may be achieved through various surgical techniques. Biocompatible metallic hardware and/or autograft or allograft bone is commonly secured anteriorly and/or posteriorly in the vertebral column in order to achieve surgical fusion. These materials are secured along and between the vertebral bodies (to restore vertebral height and replace disk material) and/or within the posterior elements, typically with pedicle screw fixation. Autograft bone is often harvested from the patient's iliac crest. Cadaveric allograft is frequently cut in disc shaped sections of long bones for replacement of the intervertebral discs in the fusion procedure.
• Critics have frequently stated that, while discectomy and fusion procedures frequently improve symptoms of neural impingement in the short term, both are highly destructive procedures that diminish spinal function, drastically disrupt normal anatomy, and increase long-term morbidity above levels seen in untreated patients.
• The high morbidity associated with discectomy may be due to several factors. First, discectomy reduces disc height, causing increased pressure on facet joints. This stress leads to facet arthritis and facet joint hypertrophy, which then causes further neural compression. The surgically-imposed reduction in disc height also may led to neuroforaminal stenosis, as the vertebral pedicles, which form the superior and inferior borders of the neural foramina, become closer to one another. The loss of disc height also creates ligament laxity, which may lead to spondylolisthesis, spinal instability or osteophyte or “bone spur” formation, as it has been hypothesized that ligaments may calcify in their attempt to become more “bone-like”. In addition, discectomy frequently leads to an incised and further compromised disc annulus. This frequently leads to recurrent herniation of nuclear material through the expanded annular opening. It may also cause further buckling of the ligamentum flavum.
• The high morbidity associated with fusion is related to several factors. First, extensive hardware implantation may lead to complications due to breakage, loosening, nerve injury, infection, rejection, or scar tissue formation. In addition, autograft bone donor sites (typically the patient's iliac crest) are a frequent source of complaints, such as infection, deformity, and protracted pain. Perhaps the most important reason for the long-term morbidity caused by spinal fusion is the loss of mobility in the fused segment of the spine. Not only do immobile vertebral segments lead to functional limitations, but they also cause increased stress on adjacent vertebral structures, thereby frequently accelerating the degeneration of other discs, joints, bone and other soft tissue structures within the spine.
• Recently, less invasive, percutaneous approaches to spinal discectomy and fusion have been tried with some success. While these less invasive techniques offer advantages, such as a quicker recovery and less tissue destruction during the procedure, the new procedures do not diminish the fact that even less invasive spinal discectomy or fusion techniques are inherently destructive procedures that accelerate the onset of acquired spinal stenosis and result in severe long-term consequences.
• Additional less invasive treatments of neural impingement within the spine include percutaneous removal of nuclear disc material and procedures that decrease the size and volume of the disc through the creation of thermal disc injury. While these percutaneous procedures may produce less tissue injury, their efficacy remains unproven.
• Even more recently, attempts have been made to replace pathological discs with prosthetic materials. While prosthetic disc replacement is a restorative procedure, it is a highly invasive and complex surgery. Any synthetic lumbar disc will be required to withstand tremendous mechanical stresses and will require several years of development before it will achieve the longevity desired. Further, synthetic discs may not be an appropriate therapeutic approach to a severely degenerative spine, where profound facet arthropathy and other changes are likely to increase the complexity of disc replacement. Like most prosthetic joints, it is likely that synthetic discs will have a limited lifespan and that there will be continued need for minimally invasive techniques that delay the need for disc replacement. Even if prosthetic discs become a viable solution, a simpler, less invasive approach to restoration of functional spinal anatomy would play an important role in the treatment of neural impingent in the spine. The artificial discs in U.S. clinical trials, as with any first generation prosthesis, are bound to fail in many cases, and will be very difficult to revise for patients. The prostheses will, therefore, be best avoided, in many cases. Lumbar prosthetic discs are available in several countries worldwide.
• In view of the aforementioned limitations of prior art techniques for treating neural and neurovascular impingement in the spine, it would be desirable to provide methods and apparatus for selective surgical removal of tissue that reduce or overcome these limitations.
SUMMARY OF THE INVENTION
• In view of the foregoing, the present invention provides apparatus and methods for selective removal of tissue, e.g., soft tissue and bone, preferably in a minimally invasive fashion. An embodiment of the present invention provides apparatus and methods for safe and selective delivery of surgical tools into to the epidural space; and for apparatus methods that enable safe and selective surgical removal, ablation, and remodeling of soft tissue and bone, preferably in a minimally invasive fashion, with the apparatus delivered into the epidural space. In an important preferred variation of the methods and apparatus are used to treat neural and neurovascular impingement in the spine, through a novel approach to safe and selective enlargement of the pathologically narrow spinal neural foramen, the impinged lateral recess, and central canal.
• In a preferred embodiment, the methods and apparatus include the placement of a working backstop or barrier into the epidural space or neural foramina, to a location between the tool positioned for tissue alteration, and adjacent vulnerable neural or vascular structures, to help prevent neural or vascular injury during surgery. In a further preferred embodiment, the methods and apparatus utilize neural stimulation techniques, to enable neural localization, as a means of improving the safety of the procedure.
• In one variation of the present invention, an epidural needle may be converted to a working tool in order to resect or remodel spinal tissue, which is enabled by the use of herein described methods and apparatus:
• After placement of an epidural needle into the epidural space, a special epidural catheter is threaded through the needle into the epidural space. This catheter apparatus contains a needle tip cover in its distal end, which, after it is converted to an open position in the epidural space, is pulled back over the needle tip, by pulling on the proximal portion of the catheter. The catheter based cover blunts and thereby protects the vulnerable structures of the spine, such as the dura, from the sharp epidural needle tip. With the epidural needle tip covered, the needle may be more safely advanced into the epidural space, in a direction somewhat parallel to the dura, towards the contralateral or ipsilateral lateral recess and neural foramen. The needle may be advanced blindly; with image guidance; or with endoscopic guidance.
• The epidural catheter, with the cap or cover for the epidural needle, may or may not contain a rigid or flexible fiberoptic cable. With a fiberoptic element and a clear tip to the catheter, the epidural needle may be converted to an epidural endoscope or “needlescope”.
• One preferred embodiment of the epidural needle apparatus contains two adjacent lumens (“double barreled”), with a working channel adjacent to the epidural needle. The working channel may be fixed and permanent, or removable, as in with a rail and track connection. A removable working channel, in one embodiment, may be inserted or removed while the tip of the epidural needle remains in the epidural space. The distal beveled opening of the working channel, in a preferred variation, is located proximal to and on the same side of the needle as the epidural needle tip beveled opening faces, facilitating visualization of the working channel tools when a fiberoptic element has been placed in through the epidural needle lumen.
• The epidural needle or the working channel of the epidural needle may be a vehicle for insertion of a working backstop or barrier, another apparatus that facilitates safe tissue resection and remodeling in the epidural space. The barrier is a thin flat device that may be delivered into or adjacent to the epidural space or neural foramina, through the needle or working channel, or through an endoscope or open incision. Such a backstop may consist of a flexible, curved, thin and flat piece of material. This barrier will serve to protect neural and neurovascular structures from being damaged during tissue manipulation and resection, because it will be placed between the tissue to be ablated, resected, irritated, manipulated or remodeled, and the vulnerable neural and vascular structures or dura. The tools for tissue resection and ablation will be used on the side of the barrier opposite from the vulnerable neural and vascular structures, which will be safely protected from inadvertent injury.
• In one variation of the present invention, a tissue abrasion device is placed, either percutaneously or through an open surgical approach, through the neural foramina of the spine, around the anterior border of the facet joint, and anterior to the ligamentum flavum. The abrasion device alternatively or additionally may be placed through the neural foramen anterior to the facet joint, but through or posterior to the ligamentum flavum. After spinal neuroforaminal placement, the device is used to remove tissues that impinge on the neurovascular structures within the lateral recess and neural foramen, anterior to the facet joint.
• The abrasion device may, for example, include a thin belt or ribbon, with an abrasive, shaving, and/or cutting surface, which is placed through the neural foramina and is held firmly against the tissue to be removed. The belt optionally may be placed, at least partially, within a protective sheath or covering, with the treatment area exposed to the abrasive surface of the device somewhat limited to the area where tissue abrasion and removal is desired. The abrasive element may be provided in one or more of a variety of potentially interchangeable shapes, ranging from flat to curved; narrow to wide; or solid to perforated. The abrasive surface may also have various enabling designs, or surface patterns, or coarseness of abrasive material. The apparatus is placed with both free ends of the abrasive element, as well as the ends of the optional protective sleeve or covering, external to the patient for manipulation by a medical practitioner.
• When the optional protective sleeve or sheath is provided, both ends of the sleeve may be held under tension, external to the patient, such that the abrasive belt or ribbon may be pulled back and forth through the sleeve without causing significant friction against and/or trauma to adjacent tissues. Initially, both ends of the abrasive ribbon are pulled simultaneously, pulling the device in a posterior and/or lateral direction, thereby bringing impinging spinal tissue in contact with the abrasive and/or cutting surface of the ribbon. When one end of the ribbon is pulled with more force than the other, the ribbon moves in the direction of the stronger pull, while the lesser pull on the opposite end maintains force and creates friction with movement between the abrasive surface and the tissue to be resected.
• In an open surgical variation, the ribbon or belt and/or the protective covering or sleeve may be placed through the surgical incision. In a percutaneous variation, the device may be inserted through a needle or over a wire. As with the percutaneous approaches, placement may be aided by the use of image guidance and/or the use of an epidural endoscope.
• Once the surgical apparatus has been placed, the medical practitioner may enlarge the lateral recess and neural foramina via cutting, shaving, filing, rasping, sanding, ablating or frictional abrasion, i.e., by sliding the abrasive or cutting surface across the tissue to be resected. Impinging tissue to be targeted for abrasion may include, but is not limited to, lateral ligamentum flavum, anterior and medial facet, and osteophytes. The medical practitioner controls the force and speed of the abrasive surface against the tissue to be removed, while optional covers define the tissue exposed to the abrasive element.
• One variation of the abrasive element cover envelopes the abrasive surface and the backside of the belt or ribbon in areas where tissue removal is not intended. A nerve stimulator may be incorporated into the tissue removal surface and/or the protective cover or sleeve in order to verify correct placement and enhance safety by allowing the medical practitioner to ensure that neural tissue is not subject to inadvertent trauma or abrasion during the procedure.
• The present invention also describes methods and apparatus that may be used as a compression dressing, after tissue resection or ablation. Following neuroforaminal and lateral recess enlargement, one variation of the compression dressing is placed in a position where it is firmly wrapped against the abraded tissue surface around the facet and ligamentum flavum through the neural foramina. By tightly pressing against treated tissue surfaces, such a device serves to promote desired tissue remodeling; to prevent edema that may lead to impingement on neural or vascular tissue during early healing; to contain debris; to promote postoperative hemostasis; to block scar formation between the raw tissue surfaces and the adjacent neural and vascular structures; to avoid inflammation or irritation to neural and vascular structures from contact with adjacent resected tissue surfaces; and as a mechanism for sustained drug delivery, possibly as a depot, to the operative site post-operatively (e.g. steroids, procoagulants, adhesion barriers). Finally, the dressing would also present a smooth surface towards the nerve root during the immediate post-operative period.
• This neuroforaminal compression dressing may, for example, comprise the optional protective sheath, percutaneously held tightly in place against the abraded surface. Alternatively or additionally, a separate percutaneously removable compression dressing may be placed following tissue abrasion, with or without a biodegradable component. In a further alternative embodiment, an entirely biodegradable compression dressing may be placed tightly against the abraded surface, with the compression dressing remaining completely implanted following the procedure.
• Safe tissue removal, ablation and remodeling with these methods and devices are further enabled by complementary methods and apparatuses that assist with accurate neural localization. Neural localization will be performed by neural stimulation through electrically conductive materials located within the capped epidural needle tip; within the epidural tools that will be in contact with tissue to be modified; or one or both sides of the working barrier. Neural stimulation will be performed in conjunction with monitoring of the patient for sensory and/or motor response to the electrical impulses.
• Said backstop may also contain neural localization capabilities, including a conductive element on the working side and/or the non-working side. The conductive element may be used to ensure that the neural and their adjacent vascular structures are on the non-working side of the barrier. In the instance that the barrier is placed through the lateral recess or neural foramina, appropriate low intensity electrical stimulation on the non-working surface should result in the stimulation of sensory or motor nerves in the patient's extremity, while appropriate electrical conduction on the working surface should result in no neural stimulation. Neural stimulation may be monitored by monitoring somatosensory-evoked potentials (SSEPs), motor-evoked potentials (MEPs), and/or by looking for visual signs of muscular contraction within the extremities. (Somatosensory evoked potentials (SSEPs) are non-invasive studies performed by repetitive, sub-maximal, electrical stimulation of a sensory or mixed sensory and motor nerve. In response to the nerve stimulation the brain generates cerebral action potentials (electrical waves), that can be measured and recorded over the scalp and spine with surface electrodes. In many cases, needle electrodes are used for intraoperative SSEP monitoring, as they require less current, and reduce artifact. The recorded response is a series of waves that reflect activation of neural structures.) SSEP, SEP, MEP or EMG feedback may be monitored and/or recorded visually, or may be monitored audibly, potentially conveying quantitative feedback related to the volume or frequency of the auditory signal (e.g., a Geiger counter type of quantitative auditory feedback). Intensity of signal or stimulation may be monitored and used to localize the nerve during placement, as well.
• For example, the surgeon may use the neural stimulator to ensure that there is not stimulation of vulnerable neurons on the working side of the barrier, prior to initiating tissue manipulation with the working tools. For example, with the barrier in position in the lateral recess or neural foramina, the surgeon may send electrical current first along the working side of the barrier, then along the backside of the barrier. Low level stimulation of the working side would be expected to result in no neural stimulation, while the same stimulation on the backside of the barrier would be expected to stimulate2 dorsal roots, nerve roots, or ganglia.
• Neural localization may be further enabled by the addition of surgical instruments (e.g. cautery devices, graspers, shavers, burrs, probes, etc.) that are able to selectively stimulate electrically while monitoring nerve stimulation in similar fashions. Quantification of stimulation may enable neural localization. For instance, one might use a calibrated sensor input that recognizes stronger stimulation as the device is closer the neural structures. For added safety, a surgical device may be designed to automatically stimulate before or during resection, and may even be designed to automatically stop resection when nerve stimulation has been sensed.
• A method for modifying spinal anatomy is disclosed. The method includes delivering a surgical apparatus to an epidural space and surgically altering tissues that impinge neural or vascular structures in the lateral recess, neural foramina or central canal of the spine with the apparatus. Surgically altering tissues can include ablating tissue, resecting tissue, removing tissue, abrading tissue, retracting tissue, stenting tissue, retaining tissue, or thermally shrinking tissue. Surgically altering tissues can additionally include enlarging the lateral recess, neural foramina or central canal of the spine.
• Delivering the surgical apparatus to an epidural space can include delivering an epidural needle to the epidural space, and enlarging the lateral recess, neural foramina or central canal of the spine can include focally altering tissue with tools delivered through the epidural needle. Delivering the surgical apparatus to an epidural space also can include delivering an epidural needle to the epidural space, and enlarging the lateral recess, neural foramina or central canal of the spine also can include focally altering tissue with tools delivered through a working channel disposed adjacent to the epidural needle.
• Delivering the surgical apparatus can include converting the epidural needle to an endoscope within the epidural space. Delivering the surgical apparatus to an epidural space also can include delivering a working endoscope to the epidural space, and enlarging the lateral recess, neural foramina or central canal of the spine can also include focally altering tissue with tools delivered through the working endoscope. Delivering the surgical apparatus can also include converting the epidural needle into a blunt tipped instrument after placement of the needle's tip within the epidural space. Converting the epidural needle can also include threading an epidural catheter through the epidural needle into the epidural space, and covering the needle's tip with an epidural needle cover delivered via the catheter.
• Delivering the surgical apparatus can also include converting the epidural needle into an endoscope via a visualization element disposed within the epidural catheter. Delivering the surgical apparatus can include infusing fluid into the epidural space to improve visualization. Delivering the surgical apparatus can include inserting a removable working channel alongside the surgical apparatus. Delivering the surgical apparatus can include inserting a distal tip of a dual lumened epidural needle into the epidural space and using at least one of the dual lumens as a working channel for the delivery of instruments into the epidural space. Delivering the surgical apparatus can include inserting an instrument chosen from the group consisting of a tissue cauterization tool, a tissue laser device, a radiofrequency delivery device, a ronguer, a tissue grasper, a tissue rasp, a probe, a bone drill, a tissue shaver, a burr, a tissue sander and combinations thereof through the surgical apparatus.
• Delivering the epidural needle can include inserting the epidural needle to a position with a tip of the needle in proximity to where treatment will be directed. Delivering the epidural needle can include inserting the epidural needle at an interspace below the level of the spine where the treatment will be directed.
• Delivering surgical apparatus can include delivering the apparatus via an open surgical route. Delivering the epidural needle can include delivering the needle via a posterior, interlaminar percutaneous route. Delivering the epidural needle can include delivering the needle via a posterior, translaminar, percutaneous route. Delivering the epidural needle can include delivering the needle via a posterior, midline, interspinous, percutaneous route. Delivering the epidural needle can include delivering the needle via a percutaneous route through the neural foramen from its lateral aspect. Enlarging can include placing a mechanical barrier or backstop between tissue to be resected and adjacent neural or vascular structures. The barrier can be steerable.
• The method of modifying the spinal anatomy can include confirming proper placement of the surgical apparatus. Confirming proper placement can include confirming proper placement with a nerve stimulator. Confirming proper placement with a nerve stimulator further comprises confirming proper placement with stimulation leads placed on a tissue remodeling side of the surgical apparatus. The method of modifying the spinal anatomy can include confirming proper placement of the surgical apparatus or barrier with a nerve stimulator having stimulation leads placed on a tissue remodeling side of the barrier or on a back side of the barrier.
• The method of modifying the spinal anatomy can include monitoring nerve stimulation with the nerve stimulator via somatosensory evoked potentials (SSEPs). The method of modifying the spinal anatomy can include monitoring nerve stimulation with the nerve stimulator via motor evoked potentials (MEPs). The method of modifying the spinal anatomy can include monitoring nerve stimulation with the nerve stimulator via motor evoked patient movement. The method of modifying the spinal anatomy can include monitoring nerve stimulation via verbal patient sensory response to the nerve stimulator.
• The method of modifying the spinal anatomy can include monitoring enlargement via imaging. The method of modifying the spinal anatomy can include surgically altering the tissues under fluoroscopic imaging, MRI imaging, CT imaging, ultrasound imaging, radiological imaging, surgical triangulation, infrared or RF surgical triangulation.
• The method of modifying the spinal anatomy can include placing an element that provides tissue compression of surgically remodeled tissue or bone surface in order to enlarge the neural pathway or foramina post-surgical enlargement. The method of modifying the spinal anatomy can include placing an element that provides tissue compression and retention in order to remodel tissue or bone surface in order to enlarge the neural pathway or foramina de novo. Placing the element can include placing the element using a percutaneous technique via the epidural space, through a neural foramen at a level to be treated for spinal stenosis, and around a facet complex or a lamina adjacent to the facet complex. The method of modifying the spinal anatomy can include tightening the element to a determined tension. Placing the element can include placing an element having a posterior anchor that is a cord or tie looped through a hole that has been drilled in the cephalad lamina of the immediately adjacent vertebrae. The method of modifying the spinal anatomy can include tensioning the element to a determined level via a tension gauge or other measurement device element holding tension against the tissue to be remodeled.
• The method of modifying the spinal anatomy can include releasing a biologically active material for the purposes of decreasing inflammation, or promoting remodeling of soft tissue or bone growth from the element.
• Apparatus for focal tissue alteration are disclosed herein. The apparatus have an element configured for placement into an epidural space, and surgical tools configured for delivery through the element into the epidural space to remodel spinal anatomy that impinges upon neural, neurovascular or tendon structures. The element can include an epidural needle, and wherein the surgical tools further comprise a tissue remodeling device configured for placement via the epidural needle.
• The epidural needle can be configured for placement into the epidural space via an approach chosen from the group consisting of a posterior interspinal midline approach, a posterior paramedian interlaminar approach, a posterior translaminar paramedian approach through a hole in the lamina, a neural foramina approach around an anterior border of a facet joint, and combinations thereof. The epidural needle can include two adjacent lumens, the second lumen configured to act as a working channel for the delivery of the surgical tools into the epidural space.
• The apparatus can have an epidural catheter configured to convert the epidural needle into a blunt tipped instrument via an epidural needle tip cover that may be opened and then pulled back to cover the needle's tip. The epidural catheter can have a fiberoptic cable for visualization. The apparatus can have an insertable and removable working channel for tool access configured for placement alongside the needle.
• The tissue remodeling device can be chosen from the group consisting of a tissue cauterization tool, a tissue laser device, a radiofrequency delivery device, a ronguer, a tissue grasper, a tissue rasp, a probe, a bone drill, a tissue shaver, a burr, a tissue sander, and combinations thereof.
• The surgical tools can produce nerve stimulation. The apparatus can have a device for monitoring neural stimulation to identify when a working surface of the surgical tools is in close proximity to vulnerable neural tissue during tissue remodeling.
• An apparatus for protecting adjacent structures during remodeling of spinal anatomy that impinges upon neural, neurovascular or tendon structures is disclosed. The apparatus has a mechanical barrier configured for placement between tissue to be resected and the adjacent structures. The mechanical barrier can be configured for insertion through an open incision. The mechanical barrier can be configured for insertion through a working channel of an endoscope.
• The apparatus can be configured for use with a visualization element. The visualization element can be chosen from the group consisting of an epidural endoscope, a fluoroscope, ultrasound, XRay, MRI and combinations thereof. The apparatus can have a nerve stimulator to facilitate proper placement of the barrier. A conductive element can be included on a tissue modification side of the barrier or on a backside of the barrier to facilitate nerve localization. A working surface of the tissue remodeling device can have neurostimulation capabilities, thereby allowing for a positive and negative control in localizing neural tissue prior to tissue removal.
• The apparatus can include a monitoring technique for monitoring electrical nerve stimulation. The monitoring technique can be chosen from the group consisting of SSEPs (somatosensory evoked potentials); MEPs (motor evoked potentials); EMG; verbal inquiries of the patient's sensory experience to the electrical stimulation; visual techniques, mechanical techniques, tactile techniques monitoring neuro muscular stimulation and movement, and combinations thereof.
• The apparatus can include an element configured to provide tissue compression against surgically remodeled tissue or bone surface in a neural pathway or foramina post-enlargement. The element is configured for percutaneous placement via the epidural space, through the neuroforamen at the level to be treated for spinal stenosis, and around the facet complex or the lamina adjacent to the facet complex. The element is configured to release a biologically active material for the purposes of decreasing inflammation, or promoting remodeling of soft tissue or bone growth.
• The apparatus can be configured for tightening to a determined tension for purposes of relieving spinal stenosis. The element can include a posterior anchor having a cord or tie looped through a hole that has been drilled in the cephalad lamina of the immediately adjacent vertebrae. Tension of the element is configured to be set at a determined level by a tension gauge, or other measurement device element holding tension against tissue to be remodeled.
• The apparatus can have a neuro foraminal compression element configured to retract and hold pressure on spinal tissue when placed under tension, in order to relieve pressure on impinged neural and vascular structures and promote tissue remodeling. The apparatus can have a tensioning device for the neuro foraminal compression element configured to secure two ends of the element together at a posterior aspect of the vertebral lamina at a desired tension by pulling the element to the desired level of tension prior to locking the opposite ends of the element together at said tension.
• The apparatus can have a tensioning device configured to tighten a loop formed by the neuro foraminal compression element around the facet joint complex, within the lateral aspect of the lamina, and configured to tighten the compression element across a locking or crimping element to a specified tension, pulling the ligamentum flavum posteriorly in the spinal canal, in the lateral recess and in the neural foramen.
• The apparatus can have a tensioning device configured to tighten a loop formed by the neural foraminal compression element around the lamina, close to a facet joint complex, within a lateral aspect of the lamina, and configured to tighten the compression element across a locking or crimping element to a specified tension, pulling the ligamentum flavum posteriorly in the spinal canal, in the lateral recess and in the neural foramen.
• At least one free end of the neural foraminal compression element can be configured for subcutaneous placement to facilitate future removal of the element. The compression element can be biodegradable.
• The compression element can contain a therapeutic agent chosen from the group consisting of medications, bioactive compounds, steroids, depot steroids, anti-inflammatories, and combinations thereof. The agent can be configured for immediate release. The agent can be configured for sustained local delivery.
• A method of altering bone or soft tissue in a patient is disclosed. The method includes placing a tissue abrasion device through tissue to be altered, holding the tissue abrasion device under tension to bring an abrasive surface of the device firmly against the tissue to be altered, and sliding the abrasive surface of the abrasive element against the tissue to be altered, thereby altering bone or soft tissue immediately adjacent to the abrasive surface. Altering can include abrading, removing, or remodeling. Placing the tissue abrasion device through tissue to be altered can include placing the device through spinal tissue that impinges on neural, neurovascular or ligamentous structures in the patient's spine. Placing the tissue abrasion device can include placing the tissue abrasion device through a neural, neurovascular, or ligamentous pathway within the patient's spine, holding the tissue abrasion device under tension to bring the abrasive surface against tissue within the pathway, and where sliding includes enlarging the pathway via frictional abrasion of the tissue. Placing a tissue abrasion device through the pathway can include placing the tissue abrasion device through neural foramina of the patient's spine and around the anterior border of a facet joint. Placing the tissue abrasion device through neural foramina of the patient's spine and around the anterior border of a facet joint can include placing the device via a route chosen from the group consisting of an open surgical approach, a percutaneous approach, a posterior percutaneous approach, an interlaminar percutaneous approach, a translaminar percutaneous approach, an interspinous percutaneous approach, through the neural foramen from a lateral direction, and combinations thereof. Placing the tissue abrasion device can include placing the device within a protective sheath or cover.
• The method can include altering spinal tissues that impinge on neural, neurovascular, or ligamentous structures in the patient's spine.
• Enlarging the pathway can include enlarging a diseased pathway within the patient's spine.
• Holding the tissue abrasion device under tension against tissue within the pathway can include placing an abrasive surface of the tissue abrasion device against tissue chosen from the group consisting of an anterior surface of facet joint capsule, a medial surface of facet joint capsule, a superior articular process of the facet joint, ligamentum flavum, tissues attached to ligamentum flavum, extruded spinal disc material, scar tissue, and combinations thereof.
• Sliding the tissue abrasion device against the tissue can include sliding the abrasive surface of the tissue abrasion device against the tissue. Sliding the abrasive surface can include enlarging the lateral recess, neural foramina or central spinal canal via frictional abrasion. Sliding the abrasive surface can include preferentially abrading tissue chosen from the group consisting of ligamentum flavum, bone spurs, facet capsule, superior articular process, extruded spinal disc material, scar tissue and combinations thereof that impinge on neural or vascular structures.
• The method can include confirming proper placement of the tissue abrasion device. Confirming proper placement of the device can include confirming proper placement with a nerve stimulator. Confirming proper placement with a nerve stimulator can include confirming proper placement with a nerve stimulator having stimulation leads placed at a location chosen from the group consisting of a non-abrasive side of the tissue abrasion device, a back side of a protective sleeve or cover placed over the tissue abrasion device, an abrasive side of the tissue abrasion device, a working side of the tissue abrasion device, and combinations thereof. Confirming proper placement can include confirming placement via a modality chosen from the group consisting of fluoroscopic, MRI, CT, infrared, ultrasound imaging, surgical triangulation, and combinations thereof.
• The method can include monitoring nerve stimulation via somatosensory-evoked potentials (SSEPs) with the nerve stimulator. The method can include monitoring nerve stimulation via motor-evoked potentials (MEPs) with the nerve stimulator. The method can include monitoring nerve stimulation via verbal patient sensory response to the nerve stimulator.
• The method can include replacing the tissue abrasion device with a compression element that is held against altered tissue or bone.
• Apparatus for the removal of impinging soft tissue or bone within a patient are disclosed. The apparatus can have a tissue abrasion device configured for placement through impinged tissue pathways. The tissue abrasion device can have an abrasive surface configured for placement adjacent to the impinging tissue. The impinged tissue pathways can have pathways chosen from the group consisting of neural pathways, neurovascular pathways, ligamentous pathways, and combinations thereof. The tissue abrasion device can be configured for the removal of spinal structures that impinge neural or neurovascular tissues within the patient, and wherein the tissue abrasion device is configured for placement through neural foramina of the patient's spine and around the anterior border of a facet joint.
• The apparatus can have a protective cover disposed about the tissue abrasion device, where the protective cover is configured to limit exposure of an abrasive surface of the device to areas where tissue removal is desired. The apparatus can have a nerve stimulator in communication with the tissue abrasion device to facilitate proper placement of the device.
• The apparatus can have a conductive element disposed on an abrasive surface of the device to enable nerve localization by sending a small electrical current through the conductive element.
• The apparatus can have an epidural needle, where the tissue abrasion device is configured for placement through the epidural needle.
• The apparatus can have a visualization element for direct visualization of the neural foramina. The apparatus can have a neural foramina compression element.
• The compression element can be configured to promote hemostasis and desired tissue remodeling during healing. The element can be configured to be left in place after being secured with adequate tension against tissue abraded with the tissue abrasion device. The compression element can be configured to protect a tissue surface abraded with the device. The compression element can be configured to prevent adhesions during healing. The compression element can be configured to protect vulnerable structures adjacent to tissue abraded with the tissue abrasion device from an inflammatory response triggered by tissue abrasion.
• The tissue abrasion device can be configured for placement in front of, across, and then behind tissue to be abraded, such as through a naturally occurring or artificially created anatomical foramen or tissue pathway. The abrasive surface can be disposed on all or part of one side of the tissue abrasion device. The abrasive surface can be disposed on an element chosen from the group consisting of a length of ribbon, strap, cable, belt, cord, string, suture, wire and combinations thereof. The ends of the device can be configured for manual grasping. The apparatus can have a handle to which ends of the device are attached for manual grasping. The device can be configured for attachment to an electromechanical power-driven device.
• The device can be configured to be placed under tension in order to bring the abrasive surface into contact with tissue to be removed. The abrasive surface can be configured to be pulled against tissue to be removed. The abrasive device can have multiple abrasive elements with different abrasive surfaces, configured for interchangeable use. The multiple abrasive elements can have varying grades of abrasive material. The multiple abrasive elements can have different grooves, patterns of grooves, or material patterns on the abrasive surface to facilitate preferential abrasion of tissue at desired locations. The patterns of grooves can have diagonal parallel grooves that preferentially move the abrasive element towards one direction on the surface being abraded as the abrasive element is pulled in one direction, and towards an opposing direction as the abrasive element is pulled in a second direction. The multiple abrasive elements can have different shapes that guide the extent and location of tissue removal.
• The apparatus can be configured to carry debris away from the site of tissue removal.
• The tissue abrasion device can vary in profile along its length. The tissue abrasion device can have openings that facilitate passage of debris behind the device for storage or removal.
• The apparatus can have a monitor for monitoring electrical nerve stimulation with the nerve stimulator. The monitor can be configured to monitor a feedback chosen from the group consisting of SSEPs, MEPs, EMG, verbal communication of patient sensation, visual monitoring, mechanical monitoring, tactile means, monitoring of neuromuscular stimulation and movement, and combinations thereof.
• The compression element can be biodegradable. The compression element can contain a therapeutic agent configured for delivery to abraded tissue or adjacent neural and neurovascular structures. The therapeutic agent can be a medication, bioactive compound, steroid, depot steroid, anti-inflammatory, adhesion barrier, procoagulant compound, or combination thereof.
• The protective cover can be attached, external to the patient, to a suspension system that includes elements to firmly and individually grasp each end of the cover and hold it in position under tension against the tissue surface to be abraded, with an open portion of the cover exposing the abrasive element directly over tissue to be abraded. The protective cover can be configured to protect a non-abrasive side of the tissue abrasion device. The protective cover can have channels along its lateral aspects for the insertion and sliding of the tissue abrasion device. The protective cover can include channels along its lateral aspects for the insertion and sliding of a second protective cover configured for placement between an abrasive surface of the tissue abrasion device, and tissue adjacent to tissue to be abraded with the abrasive surface.
• Finally, the present invention also describes methods and apparatus that promote tissue remodeling, separate from the tissue resection or ablation. These devices tightly wrap, retract, or hold in position, under tension, impinging tissues within the spinous posterior elements.
• It is expected that the apparatus and methods of the present invention will facilitate a minimally invasive approach to the selective elimination of pathological spinal tissue, thereby enabling symptomatic relief in patients suffering from spinal stenosis.
BRIEF DESCRIPTION OF THE DRAWINGS
• The above and other objects and advantages of the present invention will be apparent upon consideration of the following detailed description, taken in conjunction with the accompanying drawings, in which like reference characters refer to like parts throughout, and in which:
• FIG. 1 is a cross section through the posterior aspect of the lumbar spine;
• FIG. 2 is a sagittal section through the lumbar spine;
• FIGS. 3a, b, care sagittal views through a patient's spine, illustrating a prior art method for epidural needle insertion, a loss of resistance method;
• FIG. 3aillustrates a needle inserted to an interspinal ligament.
• FIG. 3billustrates constant pressure applied on the syringe plunger.
• FIG. 3cillustrates saline injected into the epidural space.
• FIG. 4 is a cross-sectional view through a patient's spine, illustrating two prior art variations of the method ofFIGS. 3a, b, c;
• FIG. 5 is an illustration of standard Touhy epidural needle tips;
• FIG. 6 are schematic side views illustrating a method and apparatus, in accordance with the present invention, for covering with a cap and blunting the sharp tip of an epidural needle post-insertion;
• FIG. 7 are also a schematic side view of variations of the apparatus ofFIG. 6 with a method for also limiting the depth of insertion of cannula, access portal, or needle;
• FIG. 8 are schematic side views illustrating a method and apparatus in accordance with the present invention for covering with a cap and blunting the tip of the epidural needle post-insertion, and optionally converting the epidural needle to an epidural endoscope, for safe further advancement of the needle into the epidural space;
• FIG. 9 are also a schematic side view of variations of the apparatus ofFIG. 8;
• FIG. 10 are also a schematic side view of variations of the apparatus ofFIG. 6 or8;
• FIG. 11 are also a schematic side view of variations of the apparatus ofFIG. 8;
• FIG. 12a, b, care schematic side views of variations of the apparatus ofFIG. 6 or8;
• FIGS. 12d, eare schematic side views of an epidural portal over needle apparatus, as shown inFIGS. 12a, b, c; with a distal anchor engaged anterior to the ligamentum flavum, when the portal has been inserted over the needle, into the epidural space;
• FIG. 13 is a schematic side view of variations of the apparatus ofFIG. 6 or8;
• FIG. 14ais a schematic side view, partially in section, of variations of the apparatus, illustrating methods of safely utilizing the apparatus (e.g., safe tool access) for safe placement and use of surgical tools in or around the epidural space;
• FIG. 14bare side views, partially in section, illustrating a method and apparatuses for safe placement of a tool or working channel into the epidural space;
• FIG. 15 are side views illustrating apparatuses that include a double barreled epidural needle, with the epidural needle as the most distal point, and with the working channel the more proximal tip. This system may also be converted to an endoscope and may be used for safe placement of instruments into the epidural space;
• FIGS. 16-18 are cross-sectional views through a patient's spine, illustrating a method and apparatus for placement of a double barreled epidural needle or endoscope, the sharp tip of which has been covered inFIG. 17, and thereby blunted, for safe advancement towards the lateral recess and neural foramina. The blunted epidural needle apparatus may contain a fiberoptic cable for direct visualization, in a preferred embodiment;
• FIG. 19 is a cross-sectional view through a patient's spine that illustrates a method, followingFIGS. 16-18, for placement of a working backstop or barrier into the lateral recess and/or neural foramina. The barrier or backstop may contain elements for neural localization;
• FIGS. 20-21 are cross-sectional views through a patient's spine that illustrate alternative methods and apparatuses for placement of a working backstop or barrier to enable safe tissue resection, ablation, abrasion or remodeling;
• FIG. 22 is a cross-sectional view through a patient's spine that illustrates a tool inserted through the working channel (example shows a shaver or burr), with its tip in position for tissue removal or debridement, adjacent to a protective working backstop or barrier.
• FIG. 23 are schematic views of a working backstop or barrier apparatus, including an optional rail for controlled tool placement in relation to the barrier, and an optional conductive element for neural localization.
• FIG. 23bis a frontal view from above;
• FIG. 23cis a front view;
• FIG. 23dis a frontal view of the working backstop or barrier apparatus folded for compact delivery;
• FIG. 24 is a cross-sectional view through a patient's spine that illustrates a methods and apparatuses for providing neural stimulation and neural localization, within a working backstop or barrier, and/or within a tool (a bone burr placed adjacent to a spinal bone spur in the lateral recess, in this illustrative example), for safety in tissue resection, abrasion or remodeling;
• FIGS. 25-32 are cross-sectional views through a patient's spine, illustrating a method and apparatus for placement and use of elements for selective surgical removal of tissue;
• FIGS. 33-36 are cross-sectional views through a patient's spine, illustrating a variation of the method and apparatus ofFIGS. 25-32;
• FIGS. 37a-dare cross-sectional views through a patient's spine, illustrating another variation of the method and apparatus ofFIGS. 25-32;
• FIG. 38 are a detailed view and a close up of the cross section of a preferred embodiment of the apparatus used inFIG. 37d;
• FIG. 39 an alternative embodiment of the apparatus ofFIG. 38;
• FIGS. 40-45 are partial cross-sectional views through a patient's spine, illustrating a method for use with single or multiple lumen delivery systems, for placement of an abrasion apparatus through the neural foramina for selective surgical removal of tissue;
• FIGS. 46-58 are cross-sectional views through a patient's spine, illustrating a variation of the methods and apparatus ofFIGS. 40-45, which may also be used with single or multiple lumen delivery systems;
• FIG. 59 is a cross-sectional view through a patient's spine, illustrating a methods and apparatus that, under tension, anchors and suspends the working sheath or protective sleeve that covers the neuroforaminal abrasion device;
• FIG. 60 is a cross-sectional view through a patient's spine, illustrating a method and apparatus that, under tension, provides a percutaneous compression dressing over the abraded area. In this illustration, the compression dressing is the same working sheath or protective sleeve that had covered the neuroforaminal abrasion device;
• FIG. 61 is a schematic cross-sectional view through a patient's spine, illustrating a method and apparatus for achieving neural localization prior to or during use of the tissue removal apparatus;
• FIG. 62 are schematic views of additional apparatus, showing a spool or reel to reel configuration of a portion of the device that may be utilized for selective surgical removal of tissue;
• FIGS. 63-70 are schematic cross-sectional views through a patient's spine of a method and apparatus for a posterior midline or paramedian approach to placement of a posterior elements compression, retraction or retention device around the facet complex, through the neural foramina;
• FIG. 71 are schematic cross-sectional views through a patient's spine illustrating a posterior lateral approach to placement of the spinal compression, retraction or retention apparatuses;
• FIG. 72 are schematic cross-sectional views through a patient's spine of a fully implanted compression or retraction remodeling apparatus or compression dressing apparatus;
• FIG. 73 is a schematic cross-sectional view through a patient's spine of an apparatuses for a compression remodeling strap integrated with a working backstop or barrier.
• FIG. 74 is a cross-sectional view through a patient's spine that shows a facet drill with a ligament retraction device around a working backstop, and demonstrates a image guided drill used in conjunction with the backstop;
• FIGS. 75-78 are schematic views of cable strap configurations for temporary removable, permanent, or biodegradable compression dressings or remodeling tools;
• FIGS. 79-80 are schematic cross-sectional and lateral views through a patient's spine of apparatuses for temporary or permanent retraction and retention of the ligamentum flavum;
• FIG. 81 are sagittal cryosection images through 3 cadaveric spines (images courtesy of Wolfgang Rauschning, MD) that illustrate pathological anterior bulging and “buckling” of the ligamentum flavum, encroaching on the spinal canal or lateral recess, a frequent contributing factor in spinal stenosis. In circumstances when similarly protruding ligamentum flavum impinges neural and neurovascular structures in the spinal canal, lateral recess, or neural foramina, then retraction of said ligaments, as inFIGS. 79 and 80 may be beneficial to the patient;
• FIG. 82 are cross-sectional views through a protective sleeve or sheath, compact during insertion (b), and expanded (c) by passing the apparatus through its lumen;
• FIG. 83 are schematic cross section views of additional apparatus that may be utilized for selective surgical removal of tissue;
• FIG. 84 are schematic cross section views of additional apparatus that may be utilized for selective surgical removal of tissue, and subsequently as a compression dressing, with the ability to act as a therapeutic drug depot;
• FIG. 85 are schematic cross section views of additional apparatus that may be utilized for selective surgical removal of tissue;
• FIG. 86 is a schematic cross section views of additional apparatus that may be utilized for selective surgical removal of tissue;
• FIG. 87 are close-up schematic views of the resecting element inFIG. 86 that may be utilized for selective surgical removal of tissue;
• FIGS. 88-93 are schematic lateral views of additional apparatus that may be utilized for visualization in the epidural space, enabling the selective surgical removal of tissue;
• FIG. 88 illustrate an embodiment of an endoscope in a clear tipped cannula;
• FIG. 89 illustrate an embodiment of a 0-degree endoscope rotated in unison with a curved, clear tipped cannula;
• FIG. 90 illustrate an embodiment of a 30-degree endoscope rotated separately inside of a clear tipped cannula;
• FIGS. 91a-cillustrate various embodiments of a clear tipped cannula with a clear shaft;
• FIGS. 91d-fillustrate various embodiments of a clear tipped cannula with an opaque shaft;
• FIG. 92 illustrate an embodiment of a clear tipped cannula with a flexible neck;
• FIG. 93 illustrates an embodiment of an endoscope with a built-in clear cover (e.g., a combination device embodiment);
• FIGS. 94-99 are schematic lateral views of similar apparatus for visualization in the epidural space, along with additional method and apparatus that enable the safe placement and use of tools for selective surgical ablation, resection, abrasion and remodeling of tissue;
• FIG. 94 illustrate various embodiments of a clear tipped cannula with a free adjacent tool;
• FIG. 95 illustrate various embodiments of a clear tipped cannula with an attached adjacent tool;
• FIG. 96aillustrates an embodiment of a clear tipped cannula with a working channel for a tool;
• FIG. 96billustrates an embodiment of a clear tipped cannula with a nerve stimulator at a working channel exit;
• FIG. 97 illustrate various embodiments of cannulas with a nerve stimulator at the tip (e.g., EMG sensors peripherally placed);
• FIG. 98 illustrate various embodiments of a clear tipped cannula with a nerve stimulator at a tip of the free tool; and
• FIG. 99 illustrate various embodiments of a clear tipped cannula with a nerve stimulator at a tip of the free or attached tool.
DETAILED DESCRIPTION
• The present invention relates to methods and apparatus for the selective surgical removal or alteration of tissue that impinges upon spinal neural or vascular structures, with particular attention towards avoiding injury to the affected or adjacent neural and neurovascular structures. More particularly, a preferred embodiment of the present invention relates to methods and apparatus forlateral recess108 and neural foraminal enlargement of the spine, in cases of neurovascular impingement, through a novel approach to selective and safe enlargement of the pathologically narrow spinalneural foramen110, impingedlateral recess108 and/or compromised central spinal canal. Tissues that impinge the spine's central canal,lateral recess108, andneural foramen110 may include, but are not limited to,ligamentum flavum10; bone spurs or ligamentous calcifications; localized disc extrusions; enlarged facet joint complex12, facet capsule, and superior articular processes; and scar tissue or adhesions.
• The variations of the invention designed to treat spinal stenosis are summarized in this paragraph, and described in greater detail in the paragraphs that follow. The methods begin with insertion of anepidural needle2 apparatus, which is converted, after placement in the epidural space, from a sharp tipped instrument, into a blunt tipped tool. The blunt tool is manipulated within the epidural space. Accurate tool manipulation may be facilitated with the use of image guidance; direct vision via an accompanying epidural endoscope; or direct vision when the instrument itself is given endoscopic function. The same blunt tipped epidural instrument may have an attached fixed or removable working channel. An additional apparatus of the current invention, a working backstop orbarrier96 that serves to protect adjacent vulnerable structures during the procedure, may subsequently be inserted into the epidural space, as well as through the neural foramina, through the needle or endoscope or an adjacent working channel. Safe resection, ablation, and remodeling may be further ensured through integration into the invention of electrical neural stimulation and monitoring for localization, optionally available through nerve stimulation functionality in the epidural instrument; in the working tools used through the needle or working channel; and/or in either or both sides of the workingbackstop96. Finally, further variations of the device and method enable the surgeon to remodel stenotic spinal anatomy, either after tissue resection, cutting, or abrasion or as stand-alone procedures, through the placement of devices for holding, retracting or retaining anatomic structures away from vulnerable neural and neurovascular structures within the posterior elements of the spine.
• FIG. 1 shows the posterior elements of the spine in axial cross section. Theepidural space42 in the spine is consistently more accessible in its posterior most aspect, a fat filled zone most popular for safeepidural needle2 placement, posterior to thedura mater46. Thedura46 covers and contains the central neural elements of the spine, including the spinal cord,cauda equina140,nerve roots62, and spinal fluid.FIG. 2 illustrates the spine in sagittal section.FIGS. 1 and 2 show two of the most important anatomic structures involved in the impingement of neural and neurovascular tissue in spinal stenosis—theligamentum flavum10 and the facetjoint complex12.FIG. 2 illustrates spinous processes80.
• For posterior approaches to thelateral recess108 andneural foramen110, theneedle2 is inserted at or one level below the spinal interspace where tissue abrasion and removal is desired. Theepidural needle2 may be inserted into theepidural space42, midline, ipsilateral, or contralateral to the area where the spinal canal,lateral recess108 and/or neuroforaminal stenosis or impingement is to be treated. Referring now toFIG. 3, a prior art method forepidural needle2 insertion is shown, comprising a standard loss-of-resistance technique. Needle based device placement may be approached from either the medial or the lateral side of theneural foramen110.FIG. 3 illustrate a midline interspinous approach to the posteriorepidural space42. Using this technique, a large bore (e.g. 12 to 18 gauge)epidural needle2 is inserted into interspinal ligaments, and is directed towards the posteriorepidural space42, while fluid (e.g. sterile saline) or air is compressed within thesyringe60, meeting resistance to injection. Upon entry of the needle tip into theepidural space42, perhaps through theligamentum flavum10, there is a manually perceptible “loss of resistance” to the continued pressure on the plunger of thesyringe60, as the compressed fluid or air easily enters theepidural space42, without resistance, signifying correct needle tip position (i.e., placement). The epidural space has a slight negative pressure.
• Alternative posteriorepidural needle2 entry approaches into the epidural space are illustrated inFIG. 4, including interlaminar paramedian and midline interspinous techniques, a preferred approach to the medial side of theneural foramen110. An alternative posterior translaminar approach, where the needle is placed through a hole in the lamina122 [LA], is not shown. The epidural space may also be entered via a more lateral, neuroforaminal approach to needle placement, as shown inFIG. 71. With any percutaneous epidural approach, after a sterile prep and drape, the epidural needle's2 sharp tip is inserted through the skin to perform a loss-of-resistance technique.
• When a midline approach is used, the epidural needle's2 sharp tip is inserted through the skin until it begins to engage theinterspinous ligaments78. Subsequently, a fluid or air filled (loss of resistance)syringe60 is depressed and will meet resistance to injection, until the needle tip is advanced, through theligamentum flavum10, entering theepidural space42, which actually has a slight negative pressure. There is a clear “loss of resistance” to the pressurized contents of thesyringe60, which occurs upon entering theepidural space42, signifying correct needle tip placement.
• When interlaminar access is not possible (e.g. unusual cases whenlaminae122 are too tightly approximated, even with flexion of the back), the epidural space may be entered via a translaminar burr hole, using a drill176 (e.g., an image guided drill) designed for safe epidural entry. Each of these approaches allows placement of theepidural needle2 tip in the posteriorepidural space42, poised for access to thelateral recess108 andneural foramen110.
• After the epidural needle's distal tip has been placed in the posteriorepidural space42, a specially designedepidural catheter24 is threaded through theneedle2. Once threaded into theepidural space42, the epidural catheter's unique epidural needle tip cap or cover36, located in the distal end of the epidural catheter24 (with needle tip covering capabilities) is opened and pulled back to cover the sharpepidural needle2 tip, locked in place, and thereby converts the needle to a non-sharp (e.g., blunt) instrument. The needle, thus converted, may be manipulated and more safely advanced in the epidural space. The blunted needle is subsequently advanced in a direction parallel to thedura46, in a gentle manner, taking care to avoid inadvertent dural, neural or vascular trauma. With reference toFIGS. 6, 8,9,10,11,12, and13, methods and apparatus for protecting, covering and blunting the sharp tip of theepidural needle2 post-insertion, and optionally converting theepidural needle2 to anepidural endoscope132, are described. Thecatheter apparatus24 is inserted through the needle, and into theepidural space42, as inFIGS. 6b,8b,9a,10b,11b,12a, and13c. The catheter tip may be converted to the open position by one of several mechanisms, for example, the catheter illustrated inFIG. 9 has aport34 for injection of air or liquid to the open the epidural needle tip cover. The injected air or liquid drives (e.g., opens) the actuator for the catheter's tip (needle cover). By forcing air or fluid intoport34 in theepidural catheter24, a portion of the catheter'stip36 may be expanded, as inFIGS. 6b,8c,9b,11c,12b, or13e, to inflate or otherwise open the needle's protective cover orcap36. In another variation, an alternative means of actuation of the cap system on theepidural catheter24 may be a wire or string that pulls the cap into a new shape. For example,FIG. 12 demonstrate a sliding umbrella-like mechanism for actuation of the distalepidural catheter24 basedneedle tip cover36.FIG. 9B shows the epidural “needle cap” or “fiber cap”36 in the opened position. In certain embodiments, the catheter may next need to be pulled back proximally through theneedle2 until, as inFIG. 9C, until theepidural needle cover36 is engaged over the distal needle tip, protecting thedura46, neural and vascular structures from the sharp point of theneedle2, which is no longer exposed. Markings on the catheter may be used to demonstrate to the surgeon that the catheter is in the correct position, allowing the blunted epidural instrument to be safely advanced.
• Once the tip of theepidural needle2 has been blunted or capped, and no longer has a sharp exposed portion, the needle may be safely advanced within the epidural space, preferably in a direction parallel to the dura46 (FIG. 13). In one variation, theepidural needle2 tip is covered by the catheter based device, then is advanced through the epidural space under image guidance (e.g. fluoroscopy, CT, x-ray, MRI, Ultrasound, etc.), towards the area where tissue resection, ablation or remodeling is to be performed.
• In an alternative variation of the method and device, as inFIGS. 8, 9,11, and13, theepidural catheter24, in addition to a needle tip cover, also contains a fiberoptic cable38 (or clear cover over the distal end of the fiberoptic cable within the epidural catheter), which enables conversion of theepidural needle2 into anepidural endoscope132. Thefiberoptic component38 of the catheter provides the surgeon with an ability to directly visualize theepidural space42. In a further variation of the method, both fiberoptic visualization and image guidance may be used concurrently.
• In this apparatus and method for enabling safe manipulation of the apparatus in the epidural space, anepidural needle2 is first placed in the posteriorepidural space42 in a similar manner to what was described above. With the needle tip in theepidural space42, anepidural catheter24 apparatus is used to deliver a cover to the sharpepidural needle2 tip, converting the needle to a blunt instrument for further atraumatic advancement of the apparatus into the epidural space, as shown inFIGS. 6, 9,11, and12. After thecatheter24 is advanced through theepidural needle2 into theepidural space42, as inFIGS. 6aand9a, a distal portion of the catheter is converted to a shape that will be used to cover the sharpepidural needle2 tip, as illustrated inFIG. 6b.
• Once thecover36 in thedistal catheter24 is opened, thecatheter24 is gently pulled back until the needle tip is covered and thereby blunted. The capped needle is next carefully advanced within theepidural space42, between the ligamentum flavum10 and thedura46, somewhat parallel to both, towards one of theneural foramen110, with much less risk of inadvertent dural puncture. In order to further facilitate safe advancement of the capped needle in the epidural space, image guidance may be used. Additionally or alternatively, theepidural needle2 may be converted to an epidural endoscope. Conversion to an endoscope may be performed by either converting theepidural needle2 to an endoscope directly (“needlescope”), or by utilizing theepidural needle2 to enable placement of an endoscope cannula or portal56, which will replace theneedle2. Theneedle2 may be converted to an endoscope directly through use of thecatheter24 that is used to cover, blunt, or “safe” theepidural needle2 tip. Theepidural catheter24 optionally may contain a rigid or flexiblefiberoptic element38, through which the surgeon may view theepidural space42, thereby converting theepidural needle2 into an epidural endoscope. The tip of the fiberoptic catheter would, in such a case, be clear38.
• FIG. 7 illustrates a distalepidural anchor40. The distal epiduralportal anchor40 can, in its engaged position, hold the distal portion of the epidural apparatus in the epidural space, anterior to the ligamentum flavum.FIG. 7 also illustrates that the portal, needle, or endoscope may include a proximal epidural anchor, stopper or lock28 (e.g., to anchor on the skin) that may be advanced from the proximal end of the device (skin side), in order to help to prevent the percutaneous device from advancing further into the epidural space than is desired (as inFIG. 7b). Thelock28 can be inserted over the portal and against the skin when the portal is at a desired depth.
• In a further variation of the apparatus and method, anepidural portal56 would allow interchangeable epidural endoscopes to be used to view or work within the epidural space. Anepidural needle2 may be used to place anendoscope portal56, using one of the three following general approaches: (a) In one variation, a portal is an expandable catheter (e.g.FIG. 82) that is delivered as a catheter through theepidural needle2; (b) In another preferred embodiment, anepidural needle2 may be inserted into the epidural space, with a thin walled epidural cannula or portal56 already in place over it, similar to the method and apparatus of standard intravenous cannulation with IV catheters used today. This technique would ideally be used in conjunction with theepidural needle2 method and apparatus, so that the needle may be advanced far enough to safely also place the neck of the cannula or portal56, which is a short distance proximal to the distal tip of theepidural needle2, into the epidural space. In order be able to safely advance the portal56 into the epidural space, the needle may be covered or blunted, as described above, using a catheter that does not contain a fiberoptic element, as inFIG. 6. With the sharp tip covered, the needle may be subsequently advanced a few millimeters, until the distal tip of the portal has also been advanced into theepidural space42; (c) In a third embodiment of the method and apparatus, the portal56 may be inserted over a soft tipped flexible guidewire that has been placed through theepidural needle2, analogous to the popular “Seldinger Technique” (a standard cannula over needle insertion approach to vascular access).
• With reference toFIG. 14, additional variations of the apparatus ofFIG. 9 are described, illustrating methods of safely utilizing the apparatus, in combination with additional surgical tools. Safe tool access, for example, may be facilitated by the inclusion of either a workingchannel50 on an epidural endoscope, or by sliding the tool along arail52 andslot58 interface on the epidural cannula or “needlescope”56.FIG. 14A shows tool54 (illustratively a grasper) fitted withrail52 that mates with aslot58 of epidural endoscope, so that it may be inserted directly into theepidural space42 and placed in the “safe zone”, without the need for a working channel along endoscope/needle.
• InFIG. 14B, workingchannel50 is disposed alongepidural needle2, “needlescope”, or endoscope, e.g., is integrally formed with the endoscope or is positioned via a rail and slot mating, or a similar removable fastening mechanism, with the endoscope.FIG. 14B illustrates anepidural working channel50 in place, connected to the cannula, needle, or endoscope, with its tool-presenting end adjacent to the “safe zone”.
• In order to further facilitate working in theepidural space42, the epidural portal orcannula56 may have, preferably close to its distal tip, ananchor system40 to prevent said apparatus from inadvertently slipping out of theepidural space42, as illustrated inFIG. 7. Theanchor40 may be engaged towards the distal tip of the cannula or portal56, anterior to theligamentum flavum10. The portal56 may also be anchored external to theepidural space42, e.g., to the patient's skin70 (e.g., of the patient's back), or withininterspinous78 or supraspinous ligaments.
• Referring now toFIG. 15, an additional method and apparatus for placement of the tissue modification elements is illustrated. A twin (i.e., double) lumenepidural needle84 is illustrated, comprising a workingchannel50 adjacent to theepidural needle2. The second lumen serves as a workingchannel50, or for the delivery of tools into or adjacent to theepidural space42. Note that the distal beveled aperture of the working channel is proximal to theepidural needle2 tip, and opens onto the side of theepidural needle2 that the epidural bevel faces. The double lumenepidural needle84 can have a proximal bevel representing a working channel and a distal bevel representing an epidural access needle and, potentially, an endoscopy port or an additional working channel.
• Referring now toFIGS. 16-19 and42-45, an additional method and apparatus for placement of a tissue abrasion apparatus for selective surgical removal or remodeling of tissue is described. InFIG. 16, the double lumen epidural needle apparatus is positioned for advancement into theepidural space42.FIGS. 17 and 18 show how the covered and blunt tip of theepidural needle2, double lumenepidural needle84, or the blunt end of the epidural endoscope, may be advanced into the ipsilateral or contralaterallateral recess108, towards theneural foramen110, in a direction parallel to both the adjacent ligamentum flavum10 and thedura46. In the illustrated example of the apparatus and method labeledFIG. 17, afiberoptic element38 has been placed withinepidural needle2, providing both a means for fiberoptic visualization of theepidural space42 and a means to blunt the needle and thereby protect the tip of the needle from damaging thedura46 or neural or vascular structures. InFIG. 18, the endoscope has been advanced along ligamentum flavum10 (visually yellow, otherwise known as “the yellow ligament”) to thelateral recess108. “Safe zone”44 designates the area in which a medical practitioner may resect, ablate, or otherwise modify tissue safely, directly visualizing the are of tissue modification through the fiberoptic element. Thesafe zone44 is the area posterior to the apparatus in the epidural space, where dura is known to be on the other side of the apparatus, and is therefore a safe zone for tissue alteration without damaging dura or central nervous system structures, particularly when using fiberoptic visualization through the distal lumen. The second lumen of the twolumened needle84 or endoscope may be used as a workingchannel50, or to dispense theabrasive element14 and/or itsprotective sleeve6, or the working barrier described in the primary patent referenced herein. After theneural foramen110 has been cannulated with a non-sharpcurved needle16 or catheter, and after the flexible, sharp, straight needle or wire4 (e.g., a guidewire) has been passed through thecurved needle16 until its tip is advanced through the skin in the patient'sback70, theabrasion apparatus14 and/or its sleeve orcover6 are pulled through theneural foramen110, as illustrated inFIGS. 43-45. Thecurved needle16 or tube may, for example, be fabricated from a spring steel, Nitinol, or other memory material that will allow it to be inserted through a straight needle, but to return to a fixed curve upon exiting the straightepidural needle2 or workingchannel50. Thecurved needle16 optionally may be steerable. Preferably, the curved needle tip is not sharp, but is rounded or designed in other fashions less likely to cut tissue, in order to reduce a risk of neural or vascular damage.
• In yet an additional embodiment of the invention (“portal over epidural needle” variation), anepidural portal56 may be inserted into theepidural space42 as a catheter over the epidural needle2 (as inFIG. 12), similar to the design for placement of standard intravenous catheters used today. With such an approach, advancing the blunted needle (sharp tip covered) by several millimeters will also bring the distal tip of the portal into theepidural space42. Subsequently, the needle may be withdrawn from the portal, which is held in place by the surgeons other hand, leaving the epidural portal in theepidural space42 as a working channel or endoscope guide.
• In one variation, theepidural needle2, needle based endoscope, flexible or rigid endoscope, or portal56 (for placement over an epidural needle2) may have, preferably close to its distal tip, an (e.g., distal)anchor mechanism40 and48 (in its un-engaged position) that may be inflated or otherwise opened (e.g., in the epidural space42), to help prevent inadvertent removal of the device from theepidural space42. It is expected that utilization of an anchor to, or within, theligamentum flavum10, will prevent the portal from being pulled inadvertently through the ligamentum flavum, and will enhance the reliability and safety of epidural access for minimally invasive endoscopic surgery.
• FIG. 14 illustrates additional methods of safely utilizing a blunted epidural apparatus in conjunction with additional surgical tools. Safe tool access may, for example, be facilitated with either a fixed workingchannel50, as shown inFIG. 15, or by the creation of arail52 andslot58 interface on the tool or epidural endoscope, cannula or “needlescope”132, as shown inFIG. 14b. The workingchannel50 can be insertable and removable and can be for attachment to the epidural apparatus. Therail portion52 of the epidural instrument can be for guiding the epidural tools along the blunted epidural apparatus into the epidural space. Theslot portion58 of the epidural instrument or portal can be for guiding the epidural tool or working channel into the epidural space. Note therail52 andslot58 may be reversed, with therail52 on the sleeve or scope and theslot58 on the tool or working channel.
• FIG. 14ashows a tool54 (illustratively a grasper) fitted with arail52 that mates with aslot58 ofepidural endoscope132, so that it may be inserted directly into theepidural space42 and then advanced until it is placed in the “safe zone”44 (e.g., for tissue resection or modification, on an opposite side of the epidural tissue), without the need for a working channel along endoscope/needle132. The part of the epidural tool that is expected to be in direct contact with the impingingspinal tissues124 that the surgeon intends to modify provides an ideal location for neuralstimulator lead placement130. In the example illustrated inFIG. 14a, an insulated tool shaft is combined with aconductive surface130 on the tip of the graspingtool54, to be used for neural stimulation. (note: the use of neural stimulation with sensorimotor monitoring, for neural localization, in conjunction with the current invention, will be discussed later in this document)
• In one variation, theepidural needle2 is curved towards its distal end, e.g into a hockey stick shape. In a curved configuration, the lumen exits the bevel, distal to, and on the concave side of the bend in the needle's distal shaft. With such a configuration, a “safe zone”44 is created by inserting the needle so that the side opposite the bevel (convex side of the bend) is in direct contact with the dura, and the lumen, on the concave side of the bend, faces the ligamentum flavum. This configuration provides a “safe zone”44, where tools, or a workingchannel50, may be reliably placed on the needle side opposite thedura46.
• InFIG. 14b, a removable workingchannel50 is disposed along epidural needle/endoscope132, e.g., is integrally formed with the endoscope or is positioned via arail52 andslot58 mating with theendoscope132.FIG. 14billustrates an epidural “needlescope”132 or endoscope cannula with the workingchannel50 in place, with its tool-presenting end adjacent to the “safe zone”.
• Referring now toFIGS. 16-19, an additional method and apparatus for selective surgical removal of tissue is described. InFIG. 15, a double barrelepidural needle164 is illustrated, comprising a workingchannel50 adjacent to theepidural needle2. InFIG. 16, the double lumen epidural needle apparatus is positioned for advancement into the epidural space42 (e.g., a safe triangle, an area at the most posterior aspect of theepidural space42, whereepidural needle2 tip insertion is most consistently safely performed). InFIG. 17, a catheter basedfiberoptic element38 has been placed withinepidural needle2, providing both a means for fiberoptic visualization of theepidural space42 and a means to blunt the needle and thereby protect the tip of the needle from damaging thedura46 or neural or vascular structures. InFIG. 18, the endoscope has been advanced along the ligamentum flavum10 to thelateral recess136. “Safe zone”44 designates the area in which a medical practitioner may resect, ablate, or otherwise modify tissue safely, under direct visualization. The second barrel or lumen of the double barreledneedle164 or endoscope may be used as a workingchannel50, or to dispense a tissue modification barrier or working barrier or backstop134.
• In addition to the insertion of tools through theepidural needle2, or through an adjacent workingchannel50, the same channels may be utilized to insert abarrier134, or “working backstop”134 (FIGS. 19, 20b,21b,22,23,24), into the spine. In a further variation of the present invention, a flexible, flat, thin mechanical barrier (“working backstop”)134 is placed between the tissue to be resected and adjacent vulnerable neural or vascular structures that are desired to be left intact and uninjured. The barrier provides protection for thedura46,nerve root62, dorsal root ganglia, and/or vasculature, by providing insulation and/or preventing direct contact between the tools and these vulnerable structures during tissue manipulation, resection, abrasion, or remodeling. The protective barrier may be placed between the needle based or endoscopically delivered tools and thedura46 in the central spinal canal; in thelateral recess136; or between the tools and the neural and neurovascular structures within theneural foramen110. Thebarrier134 may be placed through theneural foramen110 anterior to the facet joint77, either anterior to the ligamentum flavum10 (epidural space42) or within or posterior to the ligamentum flavum10 (posterior to the epidural space42). Tools that may be used in conjunction with this barrier include, but are not limited to, cautery devices (monopolar or bipolar), lasers (erbium, etc.), rasps, ronguers, graspers, burrs, sanders, drills, shavers, or probes.
• The barrier or backstop134 may be placed percutaneously via aneedle2,endoscope132, or double barreledneedle164. In addition to epidural endoscopy, image guidance may be combined with the use of straight, curved, or steerable guidewires for the proper placement of the barrier or backstop134. In an open surgical variation, the barrier orbackstop device134 may be placed through the surgical incision.
• Thebarrier134 may be synthesized from one of several possible materials, for example, it may be partially fabricated from a spring steel, Nitinol, polymers, or other memory material that will allow a thin, flat barrier to be reconfigured into a more condensed configuration for passage through a straight needle [23d], after which it returns to its desired shape [23c] upon exiting theneedle2. Thebarrier134, optionally, may be steerable.
• As is illustrated inFIG. 24, correct anatomic placement of thebackstop device134 may be validated via monitored electrical neural stimulation through thebarrier device134. Electrical nerve stimulation function may be added to the apparatus via dual conductive elements, the firstconductive element104 for neural stimulation and localization placed on the working side (e.g., on the surface) of the backstop (or the tool used on the working side or the epidural endoscope tip), where tissue remodeling and resection will occur. The neuralstimulation delivery box114 can be attached to theground electrode116. In the example illustrated inFIG. 23, the working nerve stimulator on the working side of the barrier may be integrated with therail128, through which nerve stimulation may be tested before sliding the tool or sleeve over the rail for tissue modification. A conductive element (e.g., for neural stimulation) may also be placed on the non-working side of thebackstop130. To gain accuracy in neural localization, the stimulation leads on the device are separated by insulation material within the backstop material.
• The patient may be kept awake and responsive throughout this procedure, with no neuraxial anesthetics and no systemic analgesia. In this manner, the medical practitioner may, through verbal questioning, elicit responses from the patient in order to ensure that any severe pain that would accompany undue pressure on thenerve root62 during placement of the tissue modification device and/or during tissue removal or remodeling is immediately recognized prior to nerve injury. Alternatively, for a deeply sedated patient, or one under general anesthesia, nerve stimulation may be monitored via SSEPs or SEPs; visually (motor movement of extremities); via MEPs; and/or via EMG (motor stimulation). In one embodiment of the device, one might use a calibrated sensor, combined with computer analysis, to accurately quantify neural stimulation at different locations, in order to more accurately localize neural structures.
• As is illustrated inFIG. 24, there should be nonerve root62 or dorsal root ganglion stimulation in the exact location where tissue alteration is intended to take place, when one sends appropriate small electrical current through an insulated electrode that is located on the working side of an insulated working barrier, prior to tissue modification tool placement. Correct neural location, relative to the tissue modification tools and barrier may further be ensured by the addition of focused neural stimulation functionality to accompanying surgical instruments. For example, tools used for probing, tissue resection, tissue cauterization, thermal treatment, tissue lasering, tissue manipulation, tissue retraction, and tissue abrasion may contain conductive elements forneural localization104. The nerve stimulation capabilities may be used to ensure that the neural elements are not in dangerous proximity, or they may be used to assist with more concise neural localization. For instance, a probe fitted with neural stimulation capabilities in its tip may be used to identify neural structures, through monitoring of sensory or motor stimulation. However, electrical stimulation on the non-working surface of the working barrier, which is in direct or indirect contact with neural structures, should result in motor and/or sensory action potentials, which may be monitored as described above, thereby providing a positive control and assurance of proper barrier placement. For added safety, a surgical device may be designed to automatically stimulate before or during resection, and may even be designed to automatically block resection when nerve stimulation has been sensed.
• In a preferred variation, impinging spinal tissue is removed using tissue abrasion apparatus and method. Variations of the apparatus and method may be utilized during an open surgical procedure(s); during an endoscopic surgical procedure(s); or via a percutaneous (needle delivered) surgical approach. Use of a needle-based posterior interlaminar or interspinous approach, a posterior-lateral neuroforaminal approach or a minimally-invasive surgical approach for placement of the neuroforaminal abrasive tissue removal device avoids unnecessary tissue resection and minimizes tissue injury. In addition, further embodiments of the device include nerve stimulation and monitoring capabilities, which, when added to a spinal tissue alteration device, may enable the surgeon to more safely perform the procedure.
• FIG. 25 shows the needle tip anterior to theligamentum flavum10, but still posterior to thedura46 in the posteriorepidural space42.FIG. 26 illustrates a preferred method of cannulating the neural foramina, where a blunt, curved needle composed ofmemory material16 is passed through the straight epidural needle2 (alternatively, a stiffepidural catheter24, or steerable guidewire may be inserted through the needle for this step). Thecurved needle16 is flexible enough to be passed through the straightepidural needle2, but is made of a memory material that returns it to its curved configuration upon when it is passed into tissue. The second needle18 (alternatively, a steerable, stiff catheter, needle or guidewire), is advanced through theepidural space42, possibly passing through a portion of the ligamentum flavum10, towards and then through the ipsilateral or contralateralneural foramen110. The surgeon may use any combination of tactile feel, image guidance, direct visualization, and/or fiberoptic visualization to ensure that thecurved element16 is driven through theneural foramen110, anterior to the facet (zygapophysial)joint complex12, but posterior to thenerve root62 or ganglion. Once the curved element is in position through theneural foramen110, the surgeon subsequently passes a smaller gauge straight and sharp flexible wire4 (or needle), as inFIG. 27 through the lumen of the larger curved needle that is in position through theneural foramen110, until it exits into the tissue lateral to the neural foramen110 (FIG. 27). Thisstraight wire4 or straight needle exits the curved element with its tip facing in a posterior or posterior-lateral direction. It is advanced further in this direction, passing to, and then through the skin of the patient'sback70, as inFIG. 27.
• Studies and tests may be performed to ensure that the transforaminally placed apparatus has been properly positioned between thenerve root62 or ganglia and the facetjoint complex12. For example, imaging of the abrasion element and spinal anatomy (fluoroscopic or other imaging modalities); monitored neural stimulation through the apparatus; or direct (endoscopic or open) visualization may be utilized.
• After proper placement has been confirmed, thecurved element16 that was used to initially cannulate theneural foramen110 is removed, by pulling it back out of the hub of theepidural needle2, leaving thetransforaminal wire4 in place, as illustrated inFIG. 28. Next theepidural needle2 may also be removed, if desired, again leaving thewire4 in its position, through theneural foramen110. As shown, both ends of the element remain external to the patient, having exited the skin (percutaneous procedure) or exited the tissue through the surgical wound (open procedure).
• With the wire in position through the neural foramina, there are multiple possible methods for replacing the wire with the abrasion apparatus. One method is illustrated inFIGS. 43-45, where thewire4 is used to pull into position theabrasion element14; the abrasion element sleeve orcover6; or theabrasion element14 andcover6 together, as is described in greater detail below. Alternatively, as shown inFIGS. 29 and 30, separate protective sleeves or covers6 may be passed over both the proximal and distal ends of thetransforaminal wire4. Each sleeve or cover may be advanced to theneural foramen110. Next, the neuroforaminally placedwire4 is connected distally, or proximally, to theabrasive element14, with an abrasive surface on one side. Theabrasive element14, connected by one end to thetransforaminal wire4, is pulled through theneural foramen110, and through the protective sheaths or covers6, as inFIGS. 31 and 32, until theabrasive element14 has completely replaced the initially placed wire4 (or needle). Passage of a tissue dilator over thetransforaminal wire4 or needle, may be helpful, either before or after placement of the sleeve. Protective sleeve(s)6 illustratively are disposed over both ends of thetransforaminal wire4, in order to protect non-surgical tissues from the abrasive or cutting portion of the device, when it is pulled into place. Alternatively, a protectiveabrasive element sleeve98, which may be expandable, as illustrated inFIG. 83, may be attached to the end of the wire and pulled through the neural foramina, thereby replacing the initial transforaminally placed element. Theabrasive element sleeve98 covers the abrasive element in tissue and is a conduit for insertion and exchange of abrasive elements.
• In an alternative preferred embodiment, theabrasive element14 is positioned within theprotective sleeve cover6, before or after placement of the abrasive element in position through the neural foramina. Please note that the terms “protective sleeve” and “protective cover” are used interchangeably in these descriptions of several examples of the apparatus and methods for protecting vulnerable tissue from the abrasion apparatus. Embodiments of the protective methods and apparatus are illustrated inFIGS. 82-85. With theabrasive element14 already inside theprotective apparatus6 or96, with or without an opening over the abrasive surface where tissue abrasion is to be performed the protective covering, with the abrasive apparatus already inserted within it, may be connected to one end of the needle or guidewire that remains in place through theneural foramen110. In this preferred method, the combined protective sleeve and6 theabrasive element14 are then pulled simultaneously through theneural foramen110, by pulling from the opposite end of the preliminarily placed neuroforaminal element, while it is removed. Aconductive element90 for neural stimulation can be on the working side of the apparatus.
• Once the abrasion apparatus has been properly positioned through the neural foramina, with its protective cover in place, it is ready to be tested to ensure it has been properly located. The apparatus may subsequently be utilized for tissue abrasion, tissue removal, and tissue remodeling, as will be described in detail below. Before describing tissue modification in further detail, however, we will describe alternative approaches for placement of the abrasion device into position through the neural foramina.
• Referring now toFIGS. 33-36, a variation of the method and apparatus ofFIGS. 25-32 is described comprising an alternative approach for placement of the tissue modification device, wherein theapparatus14 is placed from the lateral side of theneural foramen110. As seen inFIG. 33, a steerable orneedle wire18 is placed through theneural foramina110 from the lateral towards the medial side of theforamen110. This lateral to medial neuroforaminal approach may begin with a curved, blunt wire through a straight needle (as described in the previous technique), or using a curved needle technique, a steerable guidewire technique, a needle-through-a-needle technique, or common variations thereofFIG. 36 illustrates that theprotective sleeve6 or cover can have aneural barrier portion8 for the abrasion element. While a loss of resistance technique is not as helpful with this transforaminal approach to theepidural space42, as it was in the previously described posterior approach to theepidural space42, the method is, in many other aspects, otherwise similar to the method illustrated inFIGS. 25-32.
• With reference toFIGS. 37a-e, another variation of the method and apparatus ofFIGS. 25-32 is described. InFIG. 37a, theapparatus20 is placed from an interlaminar; a translaminar, interspinous; or a transforaminal insertion, illustratively via a paramedian, ipsilateral approach. A lateral to medial transforaminal approach with the same type of apparatus may alternatively be used. The blunt or rounded distal tip ofapparatus20 optionally may be somewhat sharper, to facilitate placement. Theapparatus20 may be preceded by a guidewire, a dilator, or a needle introducer (possibly with or followed by an expandable sheath). This variation of the apparatus and method, as seen inFIG. 37b, contains a rigid, curved wire orneedle22, which may be steerable, which is driven from the tip of theapparatus20, laterally through theneural foramen110 and then posteriorly, around the facet joint complex12 and back towardsapparatus20, where the needle may be received once again by the apparatus.Arrow26 inFIG. 37dillustrates the direction of movement of the abrasive element.FIG. 38 provides a cross section throughapparatus20 that illustrates an exemplary geometry for the apparatus comprising a feature that facilitates receiving of the distal end of the needle or rigid guidewire back within the apparatus. Alternative geometries will be apparent. Once received back withinapparatus20, thewire22 completely encircles the facet joint12, as inFIGS. 37c, d. InFIGS. 37d,38, and39, guidewire22 has been replaced bytissue abrasion device32, e.g., a belt, strap or ribbon, preferably within a protective sheath or cover, with the abrasive surface of the device in contact with the anterior-medial facet complex.Apparatus 20 is pulled back, bringing the working surface (exposed abrasive portion) of the instrument into firm contact with operator controlled pressure against the surface from which tissue removal will occur. Neuroforaminal enlargement begins with the movement of theabrasive surface30 against the anterior and medial portion of thefacet complex12, in the lateral recess andneural foramen110. Theabrasive surface30 can be of an abrasive element in an electromechanical abrasion device.
• With reference toFIG. 38, an enlarged view of the mechanical portion ofapparatus20 is described. Anabrasive surface30 is disposed along the inside side of tissue abrasion element. The abrasion device may be actuated, e.g., via rotation of agear106 within theapparatus20. The gear orknob106 engages with the abrasive element, and is turned to provide movement of the abrasive element within the apparatus. Debris may be captured withinapparatus20, and stored in the shaft and/or handle68, or removed continuously during the procedure. The debris can be sent in the direction ofarrow180 for removal or storage.
• Referring now toFIG. 39, a variation of the apparatus ofFIG. 38 is described comprising an additionalprotective cover32 that covers one or more sides of theabrasive elements14 of thedevice20 in all regions except for the area covering the tissue where abrasion is to take place. This cover may contain a conductive element in order to enablenerve stimulation130 and/or to facilitateneural localization104. Nerve stimulation capabilities may be present on the internalabrasive surface30 of deviceabrasive element14, and/or on the external side (non-tissue abrading) of the device, as an added safety measure. For example, the user may send an electric impulse through a conductive element within the back-side (external surface) of the device, expecting to achieve neural stimulation when the device is in place through the neural foramina, while neural stimulation should not be achievable with a similar electrical impulse conducted across a portion of the abrasive side of the device. In this manner, information from monitoring the nerve stimulation may ensure proper placement of the abrasion device and reduce a risk of inadvertent neural or perineural vascular abrasion.
• InFIG. 40, straight wire orneedle4 is driven throughcurved needle16 disposed in workingchannel50 of double barrelepidural needle164. This straight wire or needle is advanced until it has penetrated through the skin and out of the patient's body. The straight wire preferably has a sharp tip. InFIG. 41, thecurved needle16 has been withdrawn from workingchannel50, leaving straight wire orneedle4 in place. Then, as seen inFIG. 42, theepidural needle2 and working channel may be withdrawn from the patient, or, in an alternative embodiment (FIG. 14b), when using a detachable workingchannel50, the working channel alone may be withdrawn from the patient, leavingstraight wire4 in place. InFIG. 43,straight wire4 has been hooked toabrasion device14 and/or the abrasion device'sprotective sleeve6. InFIG. 44, theabrasion device14 and/or the device's protective sleeve are pulled into position bywire4 as the wire is removed. InFIG. 45,wire4 has been completely removed, and theabrasion device14 and itsprotective sleeve6 are properly positioned for tissue resection, anterior to thefacet12 andligamentum flavum10.
• In an open surgical variation, theabrasive element14 and itscover6 may be placed through the surgical incision, from a interlaminar, translaminar, or neuroforaminal approach. Visualization and placement may be aided via partial or complete laminectomy, facetectomy, or ligamentectomy. Methods for threading the neural foramina include, but are not limited to the use of a wire, blunt needle, probe, endoscope, or suture. After spinal neuroforaminal placement, theabrasion device14 is used to selectively remove tissues that impinge on the neurovascular structures within thelateral recess108 andneural foramen110, on the anterior side of the facet joint12. In an open approach, as with a percutaneous approach, the device may be inserted through a needle, optionally under image guidance or with the aid of an epidural endoscope. Once placed through theneural foramina110 of the spine, around the anterior border of the facet joint12, and anterior to theligamentum flavum10, the medical practitioner may enlarge the lateral recess and neural foramina via frictional abrasion, i.e., by sliding the abrasive surface across the tissue to be resected (e.g., far lateral ligamentum flavum10, anterior and medial facet, osteophytes). The abrasion device alternatively or additionally may be placed through theneural foramen110 anterior to the facet joint12, but through or posterior to theligamentum flavum10. The medical practitioner controls the force and speed of the abrasive surface against the tissue to be removed, while optional protective covers, tubes orsleeves6 help limit the area exposed to the abrasive element for treatment.
• Referring now toFIGS. 46-61, a variation of the method and apparatus ofFIGS. 40-45 is described, comprising another preferred approach for placement of the abrasion device. This series begins withFIG. 46, in which a double lumen, blunt tipped,epidural device84, has already been advanced to thelateral recess108, using a technique similar toFIG. 18. Next,FIG. 47 shows a curvedflexible needle16, preferably with an atraumatic tip, that has been advanced, via the working channel50 (FIG. 15), through theneural foramina110.FIG. 48 illustrates threading of the straight, flexible, sharp tippedwire4athrough thecurved needle16, and advanced posteriorly until it exits the skin of the back70. InFIG. 49, the curved needle has been withdrawn, leaving thestraight wire4ain place. InFIG. 50, the double lumenepidural apparatus84 is slightly withdrawn, from the patient, so that the workingchannel50 is directed towards the medial side of thefacet complex12.FIG. 51 shows thecurved needle16 advanced through the working channel again, adjacent to thefirst wire4a, this time advancing the same or a different curved,flexible needle16, towards the opposite side of thefacet complex12.FIG. 52 shows where a second straightflexible wire4bis advanced through the second placement of acurved needle16, this time on the medial side of the facet joint. The second sharp, flexible,straight wire4bis threaded through this second curved needle, and subsequently advanced posteriorly, until the sharp tip of thewire4bexits the skin.FIG. 53 next shows both the curved needles and the double lumen apparatus removed, leaving thewires4aand4bin place.FIG. 54 shows that both wires have been attached to the two ends of the abrasive element and/or thecover32 of the abrasive element. Alternatively, the twowires4aand4bmay be opposite ends of the same continuous wire, with thecover32 for the abrasive element already placed over the mid-portion of thewire4. Alternatively, theabrasive element14 may already have been placed inside saidcover32, and attached at each end to thewires4aand4b.FIGS. 55 and 56 show the twowires4aand4bpulled and bringing the abrasive element cover, possibly with theabrasive element14 already placed inside saidcover32, into position through the neural foramina.FIG. 57 illustrates the step that follows placement of the abrasion element cover alone. InFIG. 57, with the wire in place inside theabrasion element cover6, theabrasive element14 is now seen to have been attached to the end of the wire. Subsequently, thecover32 is held open at each end by a grasping device, which also holds the cover under tension against the tissue to be abraded. With the cover anchored thus, the abrasive element is pulled into place by the wire, replacing the wire, as has occurred forFIGS. 58 and 59. With the abrasive element in position and the abrasive element cover tightly held open and against the tissue to be abraded, theabrasion element14 may be pulled back and forth, under tension, against the tissue to be abraded, as inFIG. 59. Alternatively, the abrasive element may be pulled in a single direction across the tissue to be abraded.FIG. 60 illustrates the cover following removal of the abrasive element. Said cover may remain in placed as acompression bandage168, under tension against the freshly abraded surface, in order to promote hemostasis, promote tissue remodeling, and trap debris post operatively. Thecompression bandage168 can be a percutaneous retention and compression dressing or tissue remodeling strap, or a retention strap or belt.
• A nerve stimulator may be incorporated into the abrasive surface of the abrasive element, and/or incorporated into theprotective cover88 or sheath for the abrasive element, in order to verify correct placement and enhance safety by allowing the medical practitioner to ensure that neural tissue is not subject to inadvertent abrasion.FIG. 61 illustrates a neural stimulation apparatus.FIG. 61 also illustrates anabrasion element14, disposed inside of a sheath orcover6, and held in place by tension retaining elements112 (shown inFIG. 60). Theskin anchor112 for the abrasive element cover or sheath can hold the cover under tension, allowing the abrasive element to be moved freely within. The stimulation apparatus114 (e.g., the neural stimulation delivery box) delivers a small electrical current through the working surface and/or the non-working surface (backside) of either the tools used in theepidural space42, the abrasive element, and/or the protective cover of the abrasive element. Preferably, one electrode, orwire120 to the electrode, would be connected to each side (abrasive and non-abrasive) of the entire device and sheath complex, along the full distance where tissue abrasion is planned to occur, in the lateral recess, central canal, orneural foramen110. Neural stimulation may be monitored via verbal response to stimulation in an awake or lightly sedated patient, or SSEP, MEP, EMG, or motor evoked muscular movement in an asleep or sedated patient. One possible mechanism for avoiding inadvertent neural damage may be to ensure that there is no neural stimulation when stimulating the working surface of the device. A positive control should be obtainable in the lateral recess andneural foramen110, when stimulating the non working surface (back side) of the device or, preferably, the backside of the device cover or sheath172 (e.g., first portion of locking mechanism).
• After the abrasion element, and possibly its protective sheath or cover [3,49,50], have been placed through theneural foramina110 the abrasive surface is brought into firm contact with the tissue to be abraded by pulling tension simultaneously on each end of the abrasion element. When both ends of theabrasive element14 are pulled simultaneously, the abrasive surface of the device is brought under tension and into firm contact with the impinging spinal tissue on the anterior and medial sides of the facetjoint complex12. Subsequently, one end of the abrasive element is pulled more forcefully than the other, sliding the abrasive surface is across the target tissue. When one end of the abrasive element is pulled with more force than the other, the ribbon moves in the direction of the stronger pull, while the lesser pull on the opposite end maintains force and creates friction with movement between the abrasive surface and the tissue to be resected. When the optionalprotective cover6 or sheath is provided, both of its ends of the are, in one variation, pulled under traction and anchored in place, such that theabrasive element14 may be pulled in either or both directions through thecover6 or sheath without significant friction against and/or without causing trauma to adjacent tissues.
• Alternatively, theabrasive element14 may be pulled in a single direction across the tissue. The abrasive belt, strap or ribbon may be a single length, pulled alternately in each direction, or it may be dispensed from a spool, as inFIG. 62a, or from a reel to reel configuration, as inFIG. 62b, and pulled in both directions or pulled in a single direction, across the tissue to be abraded. An alternative variation of the apparatus and method utilize an electromechanical, belt driven abrasive tool, an example of which was described previously inFIGS. 38 and 39.
• In one variation of the invention, a tissue retention or compression dressing (FIGS. 60, 70,72) method and apparatus are utilized immediately following the tissue removal, ablation and remodeling procedures described previously. For example, following neuroforaminal and lateral recess enlargement, it may be advantageous to leave, as a surgical dressing, a thinflat element150 pulled tightly against the resected, abraded, or remodeled tissue surface (e.g., around the facet complex12). The neuroforaminal compression element can be placed around the facet complex. It is expected that a compression dressing of this nature will enhance hemostasis, promote healing and promote subsequent tissue remodeling with theneural foramen110 widely open. Furthermore, thesurgical dressing150 would provide a barrier to trap tissue debris away from neural or neurovascular structures, while providing an optional technique for delivering medication, possibly as a depot, to the operative site. The dressing150 would also present a smooth surface towards thenerve root62 in the immediate post-operative period.
• As inFIG. 60, this neuroforaminal compression dressing may be percutaneously held tightly in place against the resected, abraded, or otherwise remodeled surface (e.g., zygapophysial (facet) joint)77. In certain embodiments, the compression dressing may be either percutaneously removable (as shown inFIGS. 60 and 70), either by pulling the dressing through theneural foramen110, or by the inclusion of a biodegradable central component of the dressing, such that the two ends may be removed, with the dressing separating at its biodegradable portion in the middle. Other variations such a compression dressing include a totally implanted and completely biodegradable dressing, as illustrated inFIG. 72aorb.FIG. 72aalso illustrates the transverse processes.
• FIGS. 46-56 and60, andFIGS. 63-70 illustrate midline or paramedian approaches to percutaneous placement of a neuroforaminal compression device (e.g., percutaneous retention compression dressing or tissue remodeling strap)155 that is wrapped around thefacet complex12 and retracts the posterior aspect of the neural foramina, effectively dilating the space available for the neural and vascular structures.FIGS. 67aandbillustrate the first steps in a posterior lateral neuroforaminal approach to placement of a compression element (subsequent steps would share similarities with the approach illustrated inFIGS. 46-56 and60). A grasper, loop or hook146 can be for grabbing an end of the guidewire.
• An additional embodiment of the method and apparatus may combine both the workingbackstop134 and thecompression element150,155, as illustrated inFIGS. 73 and 74. In these illustrations, thecompression element150,155 serves to keep the workingbarrier134 in proper position. Subsequently, image guidance may be used to guide tools used in open or percutaneous procedural approaches to neuroforaminal and lateral recess enlargement. The example inFIG. 74 illustrates an image guideddrill176 removing a portion of the impingingfacet complex12. With the barrier in place, possibly further aided by neural stimulation/localization capabilities, selective and safe tissue removal may be more readily performed.
• FIGS. 75-78 illustrate some of thecompression element embodiments150,155.FIG. 76 also contains an area (e.g., a drug depot in a retention strap or compression dressing)162 for storage of medications for delivery to the tissue retracted by thecompression element150,155. The compression element can have a locking mechanism that can have afirst portion172 that can insert through a second portion. The compression element can have a locking mechanism that can have asecond portion174 that can receive afirst portion172.
• FIGS. 79 and 80 demonstrate additional methods and apparatus for enlargement of the central spinal canal and lateral recess, by retracting the posterior spinal anatomy, in particular the ligamentum flavum10 (FIGS. 79 and 80 illustratetranslaminar ligamentum10 retraction), in a further posterior direction, away from thedura46,cauda equina140,nerve roots62, and dorsal root ganglia. Such a device would both serve both to retract the spinal tissue posteriorly, and to prevent the posterior elements, particularly theligamentum flavum10, from buckling anteriorly138 into the spinal canal or lateral recess.FIG. 79 illustrates an apparatus with ananchor126 anterior to or within theligamentum flavum10, a second (e.g., laminar)anchor166 posterior to the lamina122 (e.g., for posterior retention) and a mechanism for maintaining tension in order to retract the tissues posteriorly, towards thelamina122.FIG. 80 illustrates a rivet type device that is placed through a hole that has been drilled through thelamina122. Such a rivet has ananchor126 placed anterior to theligamentum flavum10, which is retracted posteriorly in order to enlarge the central spinal canal and/or lateral recess. Spinal endoscopy may be used as a tool to place aligamentum flavum10 retraction system, or in order to confirm that correct placement and efficacy has been achieved.
• Most of the safety issues related to the methods and apparatus described herein are similar to those associated with any surgical procedure, e.g., infection and/or bleeding. Some safety issues are more specific to surgery in and around the spine or spinal cord, and are therefore given special consideration below. These generally relate to spinal nerve injury. Morbidity could result from instruments inadvertently passed through thedura mater46, and creating a cerebrospinal fluid leak and/or damaging the cauda equina140 (below T12-L1) or spinal cord (above T12-L1) when entering theepidural space42. Potentially traumatized structures further includenerve roots62, adjacent vasculature, or dorsal root ganglia.
• FIG. 81 are sagittal midline cryosections of the lumbar spine, provided courtesy of Wolfgang Rauchning, MD, that demonstrate the ligamentum flavum10 protruding (“buckling”) anteriorly, a potential mechanism for central or lateral recess neural or neurovascular impingement. The ligamentum flavum10 is a potential target for abrasive tissue resection using the herein described methods and apparatus.
• FIGS. 82, 83,84,85,87 illustrate preferred embodiments of the protective cover or sheath for the abrasion element, in which the abrasive surface is covered98 and the backside of the abrasive element may also be shielded48, to prevent tissue damage in areas where tissue abrasion is not intended. The abrasive element'sprotective cover6 is ideally shaped to provide optimal protection of vulnerable tissues, at the same time maintaining both a very small profile, for easy threading of the stenoticneural foramen110; and atraumatic edges (e.g. rounded), in order to prevent cutting of or trauma to neural, vascular or other tissue during placement, use or removal of the device. For example, in certain preferred embodiments, the abrasion device may be tubular (FIG. 82), with an opening over the tissue to be abraded; or may be flat (FIGS. 83, 84,85,87) with atraumatic railings or tracks that facilitate passage of the abrasion element, abrasion surface cover, or other instruments. Side channels82 (e.g., the edge of the backing for the abrasive element), through which the edges of the abrasion element may be maintained or held but are able to slide freely may be of an atraumatic shape. Said side channels may also hold theprotective cover94 for the abrasive side of theabrasion element14. Note that neural stimulation and localization may be performed through aconductive element86 in the back cover, the front cover (e.g., a strap tension element170), or in the abrasive side of the abrasive element itself14. Both free ends of the device, as well as the ends of the optional protective sheath or cover, are positioned external to the patient for manipulation by a medical practitioner.
• FIG. 84 show a similar protective cover and abrasive element configuration to that described inFIG. 83, this time withneural stimulation element92 only illustrated in the non-abrasive (e.g., non-working) side of the apparatus (e.g., protective cover). In addition,FIGS. 84eand84fshow that theabrasive element14 has been replaced by an alternative element for drug deposition88 (e.g., a drug depot strip for insertion into the compression strap, working backstop or barrier device; a retention strap or belt, or a compression bridge), and/or to serve as part of the compression dressing, when the elements are left under tension against the abraded surface, after the operative procedure.
• FIG. 85 illustrate an additional similar embodiment of theabrasive element14 withprotective covers94,96: theremovable cover94 for the abrasive (i.e., working) side of the of the abrasive element, and the protective working barrier96 (i.e., the working backstop) for the abrasive element. This time, no neural stimulation elements are illustrated.
• Referring now toFIGS. 86 and 87, cross sections through the abrasive apparatus are illustrated. Theabrasive element14 is seen, housed within the protective covers. As shown, the abrasion element may, for example, be structured as a thin belt or ribbon, with an abrasive102 and/or cuttingsurface100 on one of its sides. The cuttingsurface100 can be an abrasive surface of the apparatus with a miniature blade design. Theabrasive surface102 can be an abrasive surface of the apparatus with a sandpaper design. The abrasive element7 may exist in a variety of shapes, ranging from flat to curved; from narrow to wide; and from a solid to perforated. The abrasive surface of the abrasive element may, in one variation, containdeep grooves118 or perforations for the transport, collection and removal of (tissue) debris away from the operative site. Alternatively, the pattern of abrasive may be designed to control the direction and speed of movement of the surface across the tissue to be abraded (e.g.deep grooves118, at a diagonal to the edge of the straps, may be used to facilitate lateral movement of the abrasive element). The width and shape of the abrasive elements may also be varied, in further effort to control the area of tissue to be resected. Finally, in one preferred variation, the surgeon would begin with a coarser grade of abrasive material, in order to gain more aggressive tissue removal. Sequential use of less and less aggressive surfaces would serve to smooth the abraded tissue surface, with the aim of creating an atraumatic surface for contact with neurovascular structures.
• Placement of atissue abrasion device86 through protective sleeve(s) and48 into position for selective tissue removal, brings the abrasive surface into contact with the tissue to be removed. A medical practitioner may remove tissue in contact with abrasive surface (FIGS. 87a, b, c) by applying a reciprocating or unidirectional motion to the ends ofdevice86 exterior to the patient. In one variation, a spool or reel to reel configuration may be designed that begins with a coarse grade of abrasive material, and progresses towards less abrasive materials as the spool or reel unwinds.
• In one variation, the device includes a compression dressing as illustrated in the percutaneous embodiment described above inFIGS. 60 and 61. Following neuroforaminal and lateral recess enlargement, it may be advantageous to leave, as a surgical dressing, a belt or ribbon pulled tightly against the abraded tissue surface. It is expected that a compression dressing will enhance hemostasis, promote healing and promote subsequent tissue remodeling with theneural foramen110 widely open. Furthermore, the surgical dressing would provide a barrier to trap tissue debris away from neural or neurovascular structures, while providing an optional technique for delivering medication, possibly as a depot, to the operative site. The dressing would also present a smooth surface towards thenerve root62 in the immediate post-operative period.
• The neuroforaminal compression dressing may, in one preferred embodiment, comprise the optional protective sheath, percutaneously held tightly in place against the abraded surface, after the abrasive apparatus has been removed from its lumen, for a period of time. Alternatively or additionally, a separate percutaneously removable compression dressing may be placed following tissue abrasion. The abrasive material may be followed by a length of compression dressing material on the same reel or spool, or a subsequent reel or spool. Alternatively, a compression dressing may be delivered through theneural foramen110 as a separate element. The compression element may also be used to deliver medications or other bioactive components (e.g. steroid, biodegradable adhesion barriers, etc.), to the surgical site. The compression dressing material may be, in one variation, partially or completely biodegradable. An entirely biodegradable compression dressing may be placed tightly against the abraded surface, and left completely implanted following the procedure.
• Whether placing the apparatus with anepidural needle2; through the working channel of an epidural needle e.g.50; with an epidural endoscope; or during an open surgical procedure; image guidance may be used to facilitate safe and accurate placement. If theepidural needle2 has been replaced by, or converted to, an endoscope, direct visualization of theepidural space42 may be accomplished. In this case, as illustrated inFIGS. 88-99, the clear tip of the fiberoptic scope will facilitate visualization through the fat present in theepidural space42. The fiberoptic cable may be rigid or flexible. The endoscope fiberoptic cable tip may be straight or angled, with the flat surface of itsdistal tip66 perpendicular (0°, for straight ahead viewing) or at an angle (e.g. 30°, 45°, or 60°). The cannula or portal (e.g., an epidural endoscope) may be closed at its tip or end76, as inFIGS. 88-99, covering and protecting the distal end of the fiberoptic cable with aclear tip74 which may be solid, fluid, or gas filled, potentially sized and shaped to expand the area of viewing within the fat filledepidural space42. Additionally the endoscope or “needlescope” may contain an additional channel or space for infusion of fluid into theepidural space42, in order to facilitate visualization, to create a space for visualization, and/or to decrease bleeding by increasing pressure, towards or above venous pressure, within the viewing area.
• FIGS. 88 through 99 illustrate several embodiments of closed tip portals for epidural fiberoptic visualization. Some description of these portals may be found in the text above. Basically, the portals show several preferred variations of designs that enable visualization through the fat that exists in theepidural space42. The clear tips of the portals may be solid and clear, or may contain air or clear liquid. The volume of the tip creates a space for improved perspective during visualization.
• Referring now toFIG. 88, a hockey stick shaped portal facilitates steering of the portal by rotation of the device. Such a design may be used with a flexible, partially flexible, or rigidfiberoptic element64. Besides steering the portal tip, the fiberoptic element may be rotated separately in order to direct visualization, when angled scope tips are used (e.g. 30°, 45°, 60°). Alternative embodiments, as illustrated inFIG. 92, may allow the flexible neck (i.e., tip)72 of the instrument (e.g., the clear tipped epidural endoscope portal) to be steered.FIGS. 94-96,98, and99 illustrate means of delivering tools along with the epidural endoscopic portals. Finally,FIG. 97 show a couple of different shapes of the many possible variations that may be helpful in improving visualization and access to the central canal, lateral recesses,neural foramen110 and posterior annulus of the spine.
• Many of the safety issues related to the methods and apparatus described herein are similar to those associated with any surgical procedure, e.g., infection and/or bleeding. Some safety issues are more specific to surgery in and around the spine or spinal cord, and are therefore given special consideration below. These generally relate to spinal neural and neurovascular injury. Central Nervous System injury could result from instruments inadvertently traumatizing thedura mater46 when entering theepidural space42, injuring the nerve root(s)62, the adjacent vasculature, or the dorsal root ganglion as the apparatus is advanced and utilized towards and through theneural foramen110.
• Several techniques may be used to reduce a risk of dural, neural or neurovascular injury, including potentially traumatizing structures includingnerve roots62, adjacent vasculature, or dorsal root ganglia. For example, the tissue alteration (e.g., abrasion) devices may be placed under direct visualization when utilizing an open surgical approach or technique. Likewise, image guidance may be provided during placement or to confirm correct placement. Candidate image guidance techniques include fluoroscopy, fluoroscopy alone, fluoroscopy with additional technology for triangulation and tracking of instruments (e.g. infrared, RF, etc.), MRI, CT, OCT, ultrasound, etc. Catheters or guidewires may include their own image guidance capabilities such as catheter or guidewire-based image guidance, e.g., fiberoptic visualization, catheter-based ultrasound, catheter-based MRI, optical tomography, etc. Alternatively or additionally, endoscopic visualization may be utilized (e.g. flexible fiberoptic endoscope as in Epiduroscope, or via rigid surgical endoscopes), during placement and/or post-placement confirmation of correct placement.
• In addition to epidural endoscopy, image guidance may be combined with the use of straight, curved, or steerable guidewires for the proper placement of the neuroforaminal abrasive element. Placement may be achieved percutaneously or through a surgical incision. Such a device may be implanted as an adjunct to an open surgical procedure(s); as an adjunct to an endoscopic surgical procedure(s); or as a separate open, image-guided percutaneous or endoscopic surgical procedure. Percutaneous approaches will enable the surgeon to perform the procedure under local anesthetic in awake or sedated patients, if desired. As discussed, nerve stimulation and localization capabilities may be added to the device in order to enable the surgeon to more safely perform the procedure in an anesthetized, but un-paralyzed patient.
• It is expected that the apparatus and methods of the present invention will facilitate a minimally invasive approach to the selective elimination (e.g., alteration, ablation, removal) of pathological spinal tissue, thereby enabling symptomatic relief in patients suffering from spinal stenosis. Spinal neural and neurovascular impingement cause tremendous pain and disability, with symptoms that include back and leg pain, weakness, and decreased sensation. Neural ischemia and injury caused by compression and inflammation may result in a wide range of symptoms or degrees of nerve damage. Symptoms range in severity from mild to severe, and from intermittent to permanent. For example, neurogenic claudication, which is exacerbated by back extension (as occurs when one stands erect and places the spine in extension), may be mild or severe. Symptoms of neurogenic claudication are usually improved by changes in posture that lead to back flexion, such as sitting. The most severe cases of spinal stenosis may lead to permanent neurological damage, including the possibility of the development of cauda equina syndrome.
• Spine surgeons lack safe and effective techniques or tools to minimally invasively or percutaneously reduce neural and neurovascular impingement in the spine, while minimizing collateral tissue damage. It is expected that the apparatus and methods of the present invention may be utilized for lateral recess and neuroforaminal enlargement to provide adequate bone and soft tissue resection, while reducing unnecessary destruction of functional bone, ligament or muscle in order to gain access to the tissues to be resected or modified.
• Because critical neural and neurovascular structures are in close proximity to the areas where surgical manipulation, dissection, resection, ablation and remodeling would be therapeutically valuable in the spine, safety at each step in the procedure is of critical importance in order to avoid disabling neurological damage to the patient. For this reason, safety measures, such as working barriers and nerve localization via an integrated nerve stimulator, are described.
• Although preferred illustrative embodiments of the present invention are described hereinabove, it will be apparent to those skilled in the art that various changes and modifications may be made thereto without departing from the invention. It is intended in the appended claims to cover all such changes and modifications that fall within the true spirit and scope of the invention.

Claims (30)

1. A method to achieve access to target tissue in a patient, with minimal tissue damage, the method comprising:

advancing a cannulated access device into tissue at a first location;

inserting a portion of a cannulated instrument through the access device, where on exiting from the cannulated access device the portion of the cannulated instrument assumes a curved shape;

advancing the cannulated instrument until the curved portion of the cannulated instrument is immediately adjacent to the target anatomy;

inserting a sharp, substantially straight, flexible element through the curved portion of the cannulated instrument, where the flexible element substantially straightens upon exiting the from the curved portion of the cannulated instrument; and

advancing the flexible element, away from the target anatomy until a distal tip of the flexible element exits the patient at a second location.

2. The method ofclaim 1, where the cannulated instrument is preconfigured with a curved shape.

3. The method ofclaim 1, where the cannulated instrument is of a different shape than the cannulated access device.

4. The method ofclaim 3, where the cannulated access device is substantially straight and the cannulated instrument is substantially curved.

5. The method ofclaim 1, where the anatomy comprises spinal anatomy and where advancing the cannulated access device comprises advancing the cannulated access device in a substantially anterior direction.

6. The method ofclaim 5, where advancing the cannulated instrument comprises advancing the curved portion of the cannulated instrument around an anterior aspect facet joint by advancing the curved portion through a neural foramen.

7. The method ofclaim 2, where advancing the cannulated instrument comprises inserting the cannulated access device into the epidural space and then advancing the distal portion of the cannulated instrument through the neural foramen.

8. The method ofclaim 1, where the anatomy comprises spinal anatomy and where advancing the cannulated access device comprises advancing the cannulated access device laterally towards a medial side of a neural foramen and then advancing the instrument through the neural foramen.

9. The method ofclaim 1, further comprising advancing a tissue modifying device into the tissue at the first location, until a distal portion of the tissue modifying device extends out of the patient at the second location, while a proximal portion of the tissue modifying device remains extended out of the patient at the first location and modifying an anatomy in the patient with an intermediate working portion of the tissue modifying device.

10. The method ofclaim 9, further comprising advancing the second portion of the tissue modifying device out of the patient at the first location, where the first and second portions of the tissue modifying device extend out of the patient at substantially the first location.

11. The method ofclaim 9, where the working portion of the tissue modifying device comprises an element selected from the group consisting of an abrasion element, a cutting element, a shaving element, a rasp element, a filing element, an ablation element.

12. The method ofclaim 9, further comprising moving the working portion of the tissue modifying device across a portion of the anatomy to remove tissue.

13. The method ofclaim 9, further comprising coupling the tissue modifying device to an apparatus having a gear adapted to move the working portion of tissue modifying device.

14. The method ofclaim 9, further comprising simultaneously applying a force on both the distal and proximal portions of the tissue modifying device to create a force against the anatomy being modified.

15. The method ofclaim 9, further comprising inserting a first protective sleeve over the proximal portion of the tissue modifying device.

16. The method ofclaim 15, further comprising inserting a second protective sleeve over the distal portion of the tissue modifying device and advancing the second protective sleeve within the patient towards the first protective sleeve such that a gap between the first and second protective sleeves within the patient defines a surgical area.

17. The method ofclaim 15, where the first protective sleeve further includes at least one opening, where the method further comprises advancing the first protective sleeve towards the distal portion of the tissue modifying device, such that the opening in the protective sleeve defines a surgical area.

18. The method ofclaim 9, where advancing the tissue modifying device into the tissue at the first location comprises attaching the tissue modifying device to the flexible element and withdrawing the flexible element from the patient to pull the tissue modifying device into the patient.

19. The method ofclaim 9, where advancing the tissue modifying device into the tissue at the first location comprises advancing the tissue modifying device over the flexible element and out of the patient.

20. The method ofclaim 1, where the cannulated access device comprises more than one lumen.

21. The method ofclaim 1, where the second location is substantially the same as the first location.

22. The method ofclaim 1, further comprising withdrawing the cannulated instrument from the target anatomy and advancing a second sharp, substantially straight, flexible element through the opposite side of the anatomy.

23. The method ofclaim 1, further comprising using a guidance system to assist in advancing the cannulated instrument until the curved portion of the cannulated instrument is immediately adjacent to the target anatomy, where the guidance system is selected from a group consisting of a portal, an endoscope, a fiberoptic visualization device, a ultrasound device, a catheter-based MRI device, an optical tomography device.

24. The method ofclaim 1, where the cannulated instrument is steerable.

25. The method ofclaim 1, where at least one of the cannulated access device or cannulated instrument are removed from the patient leaving the flexible element in place as a working platform.

26. A method to achieve access to target tissue in a patient, with minimal tissue damage, the method comprising:

inserting a cannulated instrument into the patient in a first direction, where a distal portion of the cannulated instrument is made to assume a curved shape in the patient to advance in a second direction;

advancing the curved distal portion of the cannulated instrument immediately adjacent to the target anatomy;

inserting a sharp, substantially straight, flexible element through the cannulated instrument, where the flexible element substantially straightens upon exiting from the curved portion of the cannulated instrument; and

advancing the flexible element away from the target anatomy until a distal tip of the flexible element exits the body.

27. The method ofclaim 26, where the cannulated instrument is steerable.

28. A method to access target tissue anatomy in a patient, with minimal tissue damage, the method comprising:

advancing a cannulated access device into tissue at a first location towards the targeted anatomy;

inserting a distal portion of an instrument through the cannulated access device, where on exiting the cannulated access device the distal portion assumes a curved shape;

advancing the distal portion of the instrument until immediately adjacent to the target anatomy;

substantially straightening the distal portion of the instrument;

advancing the substantially straightened distal portion of the instrument away from the target anatomy and out of the tissue until a distal tip of the instrument exits the body.

29. The method ofclaim 28, where the instrument comprises an instrument selected from the group consisting of a needle, an epidural catheter, and a steerable guidewire.

30. A method to achieve access to the epidural space of a patient whose spine contains tissue which impinges on a neural or neural vascular tissue, the method comprising:

advancing a cannulated access device having a sharp distal end to the epidural space;

inserting a cannulated instrument with a substantially blunt distal end through the cannulated access device,

advancing the distal end of the cannulated instrument out of the distal end of the cannulated access device and through a neural foramen and anterior to a facet joint;

inserting a element having a sharp distal end through the cannulated instrument; and

advancing the element out of the distal end of the cannulated instrument and away from the neural foramen until a distal tip of the flexible element exits the patient.

Images