US20120215229A1 - Curvilinear spinal access method and device - Google Patents

Abstract

A system for performing a procedure on a spine of a patient includes a curved tissue distractor, a curved housing, and an exterior channel. The curved tissue distractor includes a first distractor ramp and a second distractor ramp. The curved housing is configured to slide between the first and second distractor ramps. The curved housing includes a distal end, a proximal end, and an interior channel disposed between the distal end and the proximate end. The exterior channel is disposed on an outside surface of the curved housing and between the distal end and the proximal end. The curved housing is configured to slide between the first and second distractor ramps to provide access through the interior channel to the spine.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS
• The present application claims priority to U.S. Provisional Application No. 60/900,554, to Garcia-Bengochea, filed Feb. 9, 2007, and titled “Guided Lumbar Interbody Fusion Method and System” and incorporates its entire disclosure hereby by reference.
BACKGROUND OF THE INVENTION
• 1. Field of the Invention
• This invention relates generally to the field of spinal surgery. In particular, the present invention relates to the field of surgical access to the spine.
• 2. Background of the Invention
• Surgical techniques that are considered to be minimally invasive utilize instrumentation and implant design that allow the site to be prepared and the implant to be introduced through one or several small incisions in the patient. For example, in the lumbar spine, surgical procedures known as lumbar interbody fusion (“LIF”) have become common over the past ten years. Particular techniques are typically designated by the direction of approach relative to the spine—anterior (“ALIF”), posterior (“PLIF”), transverse (“TLIF”), and extreme lateral (“XLIF”). While these procedures are an improvement over conventional surgery in that muscular disruption and trauma are minimized, difficulties in the techniques have limited widespread adoption in the medical community.
• For example, anterior approaches require the use of an access surgeon in addition to the spinal surgeon to navigate through the abdomen and require mobilization of the abdominal viscera and great vessels. Anterior approaches also do not safely allow for revision or re-exploration and can incur additional complication such as ileus and abdominal pain. Should further fixation be required these approaches do not allow posterior fixation without repositioning the patient. This procedure is commonly called a360 operation where the operation begins with the patient in the supine position for the ALIF procedure and then flipped, re-sterilized and posterior fixation is applied with the patient in the prone position. These procedures increase the time of the operation which directly relates to blood loss, recovery time and hospital fees.
• Posterior and transverse approaches provide some advantages over anterior approaches, yet still require some exposure of the nerves or thecal sac, making placement of large (and therefore more stable) implants difficult. Therefore posterior and transverse approaches require the use of fixation devices that are smaller than those used in anterior approaches.
• Extreme lateral approaches still provide some advantages over previously discussed procedures yet require cumbersome positioning, long operating distances and provide no access to the spinal canal. In these approaches the patient is placed on their side which allows a larger access area to implant a bigger device but does not overcome the setback of repositioning the patient should posterior fixation be required. Thus, there is a need for a minimally invasive method and device that allows access to the lateral spine while the patient is placed in a prone position. This configuration would be advantageous because it also allows posterior access without repositioning the patient should posterior fixation be required. Disclosed herein is a specialized curvilinear device and method wherein the lateral spine is access through a curved access portal which may or may not comprise a slot/rail combination.
SUMMARY OF THE INVENTION
• The present invention is directed to a device and a methodology for access to the spine, including devices and methodologies in the lumbar interbody fusion (“LIF”) field, that address some of the actual or perceived problems with other known spinal access procedures. The present invention's equipment and implant design enable the present invention's procedure, which allows an advantageous access to the spine.
• In some embodiments, the techniques disclosed herein are directed to a semi-automated posterior approach to perform a lateral spinal procedure, such as discectomy, bony removal, tissue removal, implant placement and/or fusion. In some embodiments, the present invention relates to a method and instrumentation for performance of the method, wherein the pathway or approach to the spine is through curved portals of varying angles.
• The instrumentation for performance of the procedure is curved, allowing the procedure to be performed on a prone patient. In this manner, the approach to the spine is initially posterior and finally lateral or transverse at the spine, the arc in the instrumentation altering the direction of approach approximately about 45 to about 90 degrees, alternately about 55 to about 80 degrees, alternately about 65 to about 75 degrees, within the body. The instrumentation is inserted through a small incision located laterally from the spinal midline a distance approximately equal to the distance from the center of the vertebral body to just outside the skin. A rail/slot combination in a curved portal is provided such that instrumentation and the implant remain oriented in the proper direction during insertion. A representative portal may have an inner diameter of approximately 22 mm, with the rail or slot having a depth or diameter of approximately 3 mm. Those skilled in the art will recognize that the portal does not have to be circular.
• In some embodiments, the device will comprise an implant. When used, the implant possesses a curved longitudinal axis and curved side walls matching that of the portal and other instrumentation. The implant can also include a slot or rail that cooperates with a rail or slot of the portal such that the implant remains in a controlled orientation during insertion. Multiple embodiments for the implant are possible, such as bone screws, plates, interbody devices, and/or artificial discs. While dimensions will vary dependent on the size of the patient, a representative implant may have a height ranging from approximately 8 to 18 mm, an anterior-posterior depth of approximately 22 mm and a lateral width of approximately 45 to 55 mm.
• In some embodiments, additional instrumentation such as trocars, dilators and guides that possess a circular, rectangular or elliptical cross-section. The guide rail or slot in the portal can be configured in such fashion that instrumentation used subsequent to positioning of the portal are each provided corresponding slots or rails that allow for relative telescoping or axial movement between the instrumentation and the guide retractor, such instrumentation including an annulotomy chisel, a disc whisk, and the implant inserter.
• Some of the objects and advantages of the present invention include: providing an approach to the spine maintaining the patient in a prone position and avoiding complications of other approaches discussed above; allowing multiple procedures and treatments in the operating room without repositioning the patient; providing a larger sized, more stable implant previously not availably implanted from a posterior angle; and allowing implantation of supplemental instrumentation posteriorly.
• The conventional LIF procedures relate to direct, linear approaches, whereas the present invention's procedure provides for a curvilinear guided approach. In some embodiments, instrumentation can be configured to have arced longitudinal axes, allowing the patient to be positioned prone for the operation. This is the most natural position for spinal surgery, allowing for posterior decompression and surgical manipulation through the same surgical field without the need to reposition the patient or the need for an access surgeon. Additionally, the present invention's approach direction adjacent to the spine being transverse allows relatively unimpeded access to the surgical area where a large implant or instrumentation may be utilized.
• In some embodiments, the present invention relates to a device for performing an interbody fusion procedure on the spine of a patient. The device includes a working portal configured to be advanced toward a surgical site located at the spine of the patient. The working portal includes a distal end and a proximate end, a working portal housing having an open interior channel disposed between the distal end and the proximate end. The working portal can also include an exterior channel disposed on an outside surface of the working portal housing and between the distal end and the proximate end. The distal end is configured to be disposed at the surgical site and the proximate end is disposed away from the surgical site. The housing has a curved shape defined between the proximate end and the distal end. In some embodiments, the proximate end is disposed substantially perpendicularly with respect to the distal end. The working channel is configured to allow advancement of at least one surgical tool and/or at least one implant toward the surgical site. In other embodiments, the present invention relates to a guided lumbar interbody fusion (“GLIF”) device for performing a procedure on a vertebral disc of a spine of a patient. In other embodiments, the procedure can be used to perform neural decompression, total disc arthroplasty, and/or nucleus replacement, among other spinal surgical procedures.
• In some embodiments, the present invention relates to a method for performing an interbody fusion procedure on the spine of a patient. The method includes advancing a working portal toward a surgical site located at the spine of the patient. The working portal includes a distal end and a proximate end, a working portal housing having an open interior channel disposed between the distal end and the proximate end. The working portal can also include an exterior channel disposed on an outside surface of the working portal housing and between the distal end and the proximate end. The distal end is configured to be disposed at the surgical site and the proximate end is disposed away from the surgical site. The housing has a curved shape defined between the proximate end and the distal end, wherein the proximate end is disposed substantially perpendicularly with respect to the distal end. The method further includes advancing at least one surgical tool and/or at least one implant toward the surgical site via the working channel to perform the procedure. In some embodiments, the present invention relates to a method for performing a guided lumbar interbody fusion (“GLIF”) procedure on a vertebral disc of the spine of a patient.
• Further features and advantages of the invention, as well as structure and operation of various embodiments of the invention, are disclosed in detail below with references to the accompanying drawings.
BRIEF DESCRIPTION OF THE DRAWINGS
• The present invention is described with reference to the accompanying drawings. In the drawings, like reference numbers indicate identical or functionally similar elements. Additionally, the left-most digit(s) of a reference number identifies the drawing in which the reference number first appears.
• FIG. 1 illustrates an exemplary measuring device with cutout designations for locating a point of entry for delivering of instrumentation, according to some embodiments of the present invention.
• FIG. 2 illustrates an exemplary trocar guide, according to some embodiments of the present invention.
• FIG. 3 is a cross-sectional view of the trocar guide shown inFIG. 2 that illustrates a curved channel for accepting a trocar or a neuro-monitoring stylette, according to some embodiments of the present invention.
• FIG. 4 illustrates an exemplary cutting trocar, according to some embodiments of the present invention.
• FIG. 5 illustrates an exemplary barbed/docking trocar, according to some embodiments of the present invention.
• FIG. 6 illustrates an exemplary trocar handle, according to some embodiments of the present invention.
• FIG. 7 is an exploded view of the trocar handle shown inFIG. 6.
• FIG. 8 is a sectional view of the trocar handle shown inFIG. 6.
• FIG. 9 illustrates the trocar handle loaded with the trocar, according to some embodiments of the present invention.
• FIG. 10 is detailed sectional view of the trocar/trocar handle interaction, according to some embodiments of the present invention.
• FIG. 11 illustrates an exemplary tissue separator, according to some embodiments of the present invention.
• FIG. 12 illustrates exemplary working aspects of the tissue separator, according to some embodiments of the present invention.
• FIG. 13 illustrates the tear-drop working end geometry of the tissue separator shown inFIG. 11.
• FIG. 14 illustrates an exemplary trocar channel cutout on the underside of the tissue separator, according to some embodiments of the present invention.
• FIG. 15 illustrates exemplary anterior and dorsal tissue distracters, according to some embodiments of the present invention.
• FIG. 16 illustrates an exemplary assembly of a neuro monitoring ribbon installed on the dorsal tissue distracter shown inFIG. 15, according to some embodiments of the present invention.
• FIG. 17 illustrates an exemplary tissue distracter alignment block, according to some embodiments of the present invention.
• FIG. 18 illustrates an exemplary cutout for receiving tissue distracters and exemplary internal components of a spring ball detents that lock the tissue distracters, according to some embodiments of the present invention.
• FIG. 19 is an exploded view of the tissue distracter alignment block, according to some embodiments of the present invention.
• FIG. 20 illustrates an exemplary way of fitting the tissue distracters inside the alignment block, according to some embodiments of the present invention.
• FIG. 21 illustrates an exemplary small dilator, according to some embodiments of the present invention.
• FIG. 22 an exemplary large dilator, according to some embodiments of the present invention.
• FIG. 23 an exemplary curved portal, according to some embodiments of the present invention.
• FIG. 24 is another view of the curved portal shown inFIG. 23.
• FIG. 25 is a rear view of the curved portal shown inFIG. 23.
• FIG. 26 illustrates an exemplary anterior awl, according to some embodiments of the present invention.
• FIG. 27 illustrates an exemplary way of measurement from the midline of patient in order to locate incision, according to some embodiments of the present invention.
• FIG. 28 illustrates an exemplary usage of the trocar guide to reach a “50-yard line” of a vertebral disc, according to some embodiments of the present invention,
• FIG. 29 illustrates the trocar with handle traveling through channel in the trocar guide, according to some embodiments of the present invention.
• FIG. 30 illustrates the docked trocar with handle removed through trocar guide, according to some embodiments of the present invention.
• FIG. 31 illustrates the docked trocar with trocar guide removed, according to some embodiments of the present invention.
• FIG. 32 illustrates the tissue separator traveling the length of the trocar to an operating site, where the tear drop end will sweep approximately12 mm above and below trocar, according to some embodiments of the present invention.
• FIG. 33 illustrates tissue distracters with alignment block traveling the length of the trocar to the operating site, according to some embodiments of the present invention.
• FIG. 34 illustrates tissue distracters being fully inserted, according to some embodiments of the present invention.
• FIG. 35 illustrates the small dilator spreading the tissue distracters, according to some embodiments of the present invention.
• FIG. 36 illustrates the large dilator spreading the tissue distracters over the small dilator, according to some embodiments of the present invention.
• FIG. 37 illustrates the portal sliding over the dilators, according to some embodiments of the present invention.
• FIG. 38 illustrates the anterior awl securing the portal, according to some embodiments of the present invention.
• FIG. 39 illustrates the anterior awl being fully seated, according to some embodiments of the present invention.
• FIG. 40 illustrates an exemplary stabilization arm being mounted to the portal, according to some embodiments of the present invention.
• FIG. 41 illustrates an exemplary portal assembly with dilators and trocar being removed, according to some embodiments of the present invention.
• FIG. 42 illustrates an exemplary final portal assembly and a protrusion of the anterior awl, according to some embodiments of the present invention.
• FIG. 43 illustrates a patient in a prone position for performance of the disclosed procedure, according to some embodiments of the present invention.
• FIGS. 44a-c illustrate an exemplary working portal with an endoscope, displaying the endoscope's field of view, according to some embodiments of the present invention.
DETAILED DESCRIPTION OF THE INVENTION
• As required, detailed embodiments of the present invention are disclosed herein; however, it is to be understood that the disclosed embodiments are merely exemplary of the invention, which may be embodied in various forms. Therefore, specific structural and functional details disclosed herein are not to be interpreted as limiting, but merely as a basis for the claims and as a representative basis for teaching one skilled in the art to variously employ the present invention in virtually any appropriately detailed structure.
• The following description provides a general overview of the concepts discussed in the present application. Additional embodiments are discussed below with regard toFIGS. 1-44c.
• The procedure begins with placing the patient in a prone position and arranging the proper drapery to establish proper sterilization of the operation site. Next, the surgeon uses a measuring device to measure a specified distance from the midline. At this point, the surgeon will make a mark using some marking device as a reference point to create an incision. The specified distance can be calculated using a chart or sliding scale that determines the appropriate distance to make the incision. This distance is directly related to the distance of the center of the vertebral body to the flat surface of the patient's back; given this distance along with the known arc angle of the portal and known center of the midline, the incision distance can be properly calculated.
• An incision is created at the marked point and the surgeon performs blunt dissection with a finger to estimate retroperitoneal space (“RPS”) and tissue, such as the psoas muscle. Then, the trocar guide is advanced over the finger of the surgeon into the tissue splitting the fibers vertically until it abuts the spine on the centerline of the vertebral body (as shown inFIG. 28). Positioning of the trocar guide is confirmed with x-ray. The trocar guide has a curved body that has an inner cannulated channel and an offset handle. The instrument may have a small “tooth” on the inner wall to engage the spine and hold it in place. A neurophys stylette can be put in the trocar guide through this process to safely monitor potential nerve disruption. Once successful docking is achieved and the optional neurophys is acceptable, the neurophys stylette is removed.
• A cutting trocar of similar shape and size as the neurophys stylette with a sharp tip is then passed through the cannulated channel in the trocar guide to pierce the spine. To facilitate better control, the trocar handle can be applied to the cutting trocar. A mallet may also be used to advance the cutting trocar. The cutting trocar is then removed and replaced with the barbed trocar which is similarly sized and has a blunt tip and barbed features to anchor the trocar. The trocar handle can be similarly applied to facilitate handling of the barbed trocar. The barbed trocar can be “tapered” or “notched” so that the anatomy “grabs” the barbed features. The trocar handle is removed from the trocar and the trocar guide can be removed.
• The tissue separator is followed down the length of the barbed trocar to the lateral surface of the spine, such as the vertebral disc annulus. The device is actuated to “peel” tissue, such as muscle, off the spine and prepare the surgical site for further instrumentation, similar to periostial elevators. In some embodiments, a ringed handle is contracted and expanded to create a sweeping motion of a blade at the end of the tissue separator instrument. This blade can be of tear-dropped shape to better facilitate insertion and removal of the device with minimal anatomic disruption and can be bifurcated to enable “peeling” of the tissue above and below the trocar without removing the instrument to “peel” above then reinserting to “peel” below the trocar. There can also be features to help maintain the instrument along the trocar. The tissue separator is then removed.
• The tissue distracters are then assembled in the tissue distracter alignment block so that the ends of the tissue distracters are together. The tissue distracters are curved instruments of suitable material and geometry to move anatomy without harming or otherwise disrupting the patient's internals. The tips of the tissue distracters contain a lip of approximately 5 mm in order to “catch” the tissue along the spine and maintain positioning against the lateral wall of the spine. The tips of the tissue distracters can also be tapered to aid in insertion. The opposite ends of the tissue distracters have geometry to interact with the alignment block. This end also has outwardly curved geometry to facilitate the later part of the procedure. The dorsal tissue distracter can have neurophys in the form of a cable or ribbon to help monitor nerve disruption during installation and through the remainder of the operation. To aid in keeping this assembly together, an elastic polymer sheath can be slipped over assembly before insertion. The alignment block is removed.
• The small dilator is then pushed between outwardly curved geometry through the tissue distracters and over the barbed trocar until it abuts the lateral wall of the spine. This procedure in turn expands the distance between the tissue distracters. A second large dilator is then followed in a similar fashion to further distract tissue distracters. Though only two dilators are described in the above embodiment, more sequential smaller dilators can be used. The dilators are created in such fashion that they are consecutively smaller in length so that the end part from the preceding dilator protrudes from the subsequent dilator to aid in the later removal. Finger notches can be added for better grip while insertion and removal. Through this process the sheath aids in preventing tissue creep between tissue distracters.
• The curved portal is then passed over the largest dilator between the tissue distracters. Proper location is verified and adjusted using X-ray and endoscopic visualization. Once proper location is achieved, the anterior awl is passed through a channel in the curved portal to firmly “dock” the assembly to the annulus. Further, a stabilization arm can be applied to a boss feature off the curved portal. At this point, the barbed trocar and dilators can be removed. The portal is securely docked and ready to begin the technique.
• In some embodiments, to safely guide the portal to the surgical site, the curved portal has slots and/or rails that interact with preceding instrumentation that also includes corresponding slots and/or rails. Examples of the preceding instrumentation include, but are not limited to, trocars, tissue distracters, and/or dilators.
• Specialized curved instrumentation, inserted through the curved portal, is then used to complete the surgical procedures. In some embodiments, this instrumentation can have slots and/or rails which interact with the curved portal to safely guide instrumentation to the surgical site. In at least one embodiment, these procedures include removing the annulus, cleaning and preparing the disc space, inserting and securing the implant. In these embodiments, instrumentation can include an annulotomy knife, disc whisk, curettes, chisels, implant trials and curved inserting devices. In the embodiments where an implant is used in the procedure, proper location of the implant is then confirmed via x-ray. Finally, the curved portal and tissue distracters are removed to complete the procedure. Posterior fixation can be then begin, if needed.
• The following is a more detailed description of the exemplary interbody fusion procedure and instrumentation with regard toFIGS. 1-44c,according to some embodiments of the present invention. In some embodiments, the present invention relates to a guided lumbar interbody fusion procedure and instrumentation.
• FIG. 1 illustrates anexemplary measuring device100 for locating a point of entry for delivering of instrumentation, according to some embodiments of the present invention. In some embodiments, the measuringdevice100 can be a ruler. In some embodiments, the measuringdevice100 can be a straight x-ray ruler withcutout designations102 that include notches that can be seen in a fluoroscopy image.
• To perform the procedure, the patient is placed in a prone position, as illustrated inFIG. 43. Using the measuringdevice100, the surgeon measures a specified distance from the midline of the back of the patient, as shown inFIG. 27. Once the measurement is made, the surgeon makes a mark using a marking device as a reference point to create an incision. In some embodiments, the incision can be about 4 to about 50 millimeters (“mm”) wide. In some embodiments, the surgeon can use a chart, a sliding scale or any other methodology to determine location of the incision and the width of the incision. In some embodiments, based on this determination, the surgeon can also decide as to the angle of the portal through which the surgery will be performed.
• FIG. 2 illustrates anexemplary trocar guide200, according to some embodiments of the present invention.FIG. 3 is a cross-sectional view of thetrocar guide200 shown inFIG. 2 that illustrates acurved channel302 for accepting a trocar or a neuro-monitoring sty lette, according to some embodiments of the present invention. The trocar will be further discussed below with regard toFIG. 4.
• During the procedure, the surgeon uses thetrocar guide200 and a dissecting finger to navigate through soft tissue, such as the fascia and psoas muscles of the patient, as shown inFIG. 28. Thetrocar guide200 includes ahandle202 and ashaft212. Theshaft212 includes aproximal end204 and adistal end206. Theproximal end204 includes a flat surface that the surgeon can use to hammer in thetrocar guide200. Thedistal end206 further includes atip208 that can be configured to include a neuro-monitoring element. Thedistal end206 also includes arasping surface210 to help anchor against lateral wall of the spine. In some embodiments, the angle A that is formed between the plane of the handle and the plane that is perpendicular to the flat surface at theproximal end204 is approximately100 degrees. As can be understood by one skilled in the art, angle A can have any other value. In some embodiments, thehandle202 can be manufactured from silicone and can be further configured to comfortably guide the proximal end of the instrument to the centerline of the vertebral, body. As can be understood by one skilled in the art, other materials can be used for thehandle202.
• Thetrocar guide202 includes achannel302 that is configured to accommodate placement of the trocar or a stylette. Thechannel302 is disposed inside theshaft202 and is configured to track the curvature of the trocar guide'sshaft202. Suchcurved channel302 allows insertion of a curved trocar (as shown in FIGS,4-5).
• FIGS. 4-5 illustrate various exemplary trocars, according to some embodiments of the present invention.
• FIG. 4 illustrates an exemplary cutting trocar, according to some embodiments of the present invention. The cuttingtrocar400 includes adistal end402, aproximate end404 and ashaft410 disposed between thedistal end402 and theproximate end404. Theshaft410 is configured to be curved in a similar fashion as thetrocar guide200. Theproximate end404 includes a pointed tip. Thedistal end402 can be configured to include agrooved portion414 that allows thehandle600 to be secured to thetrocar400. The cutting trocar400 (shown inFIG. 4) is inserted down the trocar guide's channel302 (shown inFIG. 3) in order to make an incision or initial punch into the vertebral wall of the patient. Then, the cuttingtrocar400 is removed from thechannel302 and a barbed trocar500 (shown inFIG. 5) is inserted, as shown inFIG. 29.
• FIG. 5 illustrates an exemplary barbed/docking trocar, according to some embodiments of the present invention. Thebarbed trocar500 includes adistal end502, aproximate end504, ashaft510 disposed between thedistal end502 and theproximate end504. Theshaft510 is configured to be curved in a similar fashion as thetrocar guide200. Theproximate end504 includes a pointed tip andbarbs518 that can be configured to secure thebarbed trocar500 to the spine. Similar to thetrocar400, thedistal end502 of thetrocar500 can be configured to include agrooved portion514 that allows thehandle600 to be secured to thetrocar500. The barbed trocar is inserted down the trocar guide channel302 (shown inFIG. 3) in order to mount to the lateral wall of the spine to provide a guide to the surgical site. Once thebarbed trocar500 is secured to the vertebral wall, a handle600 (shown inFIGS. 6-8) is removed from thebarbed trocar500, thereby leaving thebarbed trocar500 secured to the spine, as shown inFIG. 30. Thetrocar guide200 is then removed from the incision, as shown inFIG. 31.
• FIGS. 6-8 illustrate anexemplary handle600, according to some embodiments of the present invention.FIG. 6 illustrates the assembledtrocar handle600.FIG. 7 is an exploded view of the trocar handle shown inFIG. 6.FIG. 8 is a sectional view of the trocar handle shown inFIG. 6.
• Referring toFIG. 7, thetrocar handle600 includes ahandle portion702,spring704,bottom portion706, atop portion708, ashaft710, and alocking pin712. Thehandle portion702 can be configured to be manufactured from silicon or any other suitable material(s). Thetop portion708 includes ahardened surface715. The surgeon can usesurface715 to hammer in thetrocars400 and500. In some embodiments, thesurface715 can be manufactured, from any metal or any other suitable material(s). In some embodiments, thespring704 can be configured to control locking of the components withinhandle portion702.
• Thehandle portion702 includes anopening721. Theshaft710 includes anopening723. Theopenings721, and723 are configured to be sized to accommodate insertion of thelocking pin712. Theshaft710 is configured to be inserted through thebottom portion706, thespring704, thehandle portion702, and thetop portion708. Once all the portions are assembled together, the lockingpin712 is inserted to secure thehandle600 together, as illustrated inFIGS. 6 and 8.
• Referring toFIGS. 7 and 10, theshaft710 of thehandle600 includes a hollow interior configured to accommodate placement of the trocar. Theshaft710 further includes alocking pin1010 that is configured to interact with thegrooves514 of thetrocar500 and lock thetrocar500 inside theshaft710. By squeezing thebottom portion706, thelocking pin1010 is shifted and thetrocar500 is released from theshaft710. As can be understood by one skilled in the art, other ways of securing thetrocar500 inside thehandle600 are possible,
• FIG. 9 illustrates the trocar handle loaded with thebarbed trocar500.FIG. 10 is detailed sectional view of thetrocar500 and trocar handle600 interaction, according to some embodiments of the present invention. As can be understood by one skilled in the art,trocar400 can also be loaded into thehandle600 in the same fashion as thetrocar500.
• FIGS. 11-14 illustrate anexemplary tissue separator1100, according to some embodiments of the present invention.FIG. 11 is a general view of thetissue separator1100.FIG. 12 illustrates exemplary working aspects of thetissue separator1100, according to some embodiments of the present invention.FIG. 13 illustrates the tear-drop working end geometry of thetissue separator1100.FIG. 14 illustrates an exemplarytrocar channel cutout1402 on the underside of thetissue separator1100. Thetissue separator1100 is guided down the barbed trocar500 (shown inFIG. 5) to the vertebral wall and is actuated to separate tissue from the vertebral wall, as illustrated inFIG. 32. The trocar channel cutout on the underside of the tissue separator can be used to aid in guiding the tissue separator down the barbed trocar. In some embodiments, the tissue can be separated above the trocar and then separated below the trocar.
• Thetissue separator1100 includes ashaft1102, handles1104,1106,distal portion1108 haveseparators1109aand1109b. Thehandles1104,1106 are hingedly coupled to theshaft1102 at thepivotal connection1120. Thehandles1104,1106 are configured to control movement of theseparators1109a,1109b. Theshaft1102 is configured to have a similar curved geometry as thetrocar guide200, as shown inFIG. 2. The separators1109(a, b) are configured to remove or peel tissue at the location of the docked barbed trocar500 (shown inFIG. 5). Such removal is possible through up and down pivotal movement B as illustrated inFIG. 12. In some embodiments, the movement B is possible through rotational motion of thehandles1104,1106 in a scissor like fashion. In some embodiments, one of thehandles1104,1106 (e.g.,1106) can be fixedly secured to theshaft1102, whereas the other handle (e.g.,1104) can be configured to rotate. Those skilled in the art will recognize that other actuation methods for this device can be used.
• In some embodiments, the distance betweenseparators1109aand1109bcan be configured to accommodate the diameter of thetrocar500. Thetissue separator1100 can be configured to be slid down thetrocar500 using channel1402 (illustrated inFIG. 14). Thechannel1402 is configured to be disposed on the back side of thetissue separator1100 and allows the surgeon to guide thetissue separator1100 to remove tissue(s) surrounding thetrocar500. The removal is accomplished through pivotal movement of the separators1109(a, b). In exemplary embodiments of spinal surgery procedures, thetissue separator1100 can be used to separate psoas muscle tissue. As can be understood by one skilled in the art, theseparator1100 can be used for any other tissue separation and/or removal.
• FIG. 15 illustrates an exemplaryanterior tissue distracter1502 anddorsal tissue distracter1504, according to some embodiments of the present invention.FIG. 16 illustrates an exemplary assembly of aneuro monitoring ribbon1602 installed on thedorsal tissue distracter1504, according to some embodiments of the present invention. The distracters can be also referred to as distraction ramps. In some embodiments, the distracters can be delivered as a single unit along the inserted barbed trocar500 (shown inFIG. 5), where thetrocar500 is placed between the distracters, to the vertebral wall. In some embodiments, the distraction ramps1502,1504 are delivered together as a single unit in a balloon, which keeps the ramps joined and prevents encroachment of soft tissue between the ramps.
• Referring toFIG. 15, theramp1504 will be discussed. The structure of theramp1502 is similar to theramp1504. Theramp1504 includes aproximal end1511 and adistal end1513. Theramp1504 further includes a rail/slot (shown as rail/slot1506 on ramp1502). The rail/slot1506 is configured to be disposed on the interior side of theramps1502 and1504 and further configured to accommodate guiding of instruments (such as trocars or dilators) down to the procedure working area at the surgical site. The rail/slot on each ramp is disposed between the proximal and distal ends and is further configured to create openings1530 at the proximal end1511 (formed by two rail/slot portions1530aand1530b) and1531 (formed by twoportions1531aand1531b) at thedistal end1508 of the ramps, when the ramps' interior sides are joined together. As stated above, such openings are configured to accommodate placement of instruments between the ramps.
• 100921 At thedistal end1508, theramp1504 further includes a lip1513 (theramp1502 includes a lip1510) that is configured to help navigate through the soft tissue and “grab” the tissue. As the ramps are guided down thebarbed trocar500, the lip1513 (and/or lip1510) on the ramp are configured to push away the tissue allowing the ramps to approach the wall of the vertebral disc. In some embodiments, the ramps include amonitoring element1602 disposed on the ramp1504 (also referred to as a dorsal ramp), as illustrated inFIG. 16. In some embodiments, themonitoring element1602 can be configured to be any conventional neural monitoring element that allows detection of approaching neural tissue via application of current. In some embodiments, theelement1602 can be configured to be coupled to an electrical supply (not shown) that delivers current to the tissue viaelement1602 and upon detection of a response, theelement1602 can determine whether neural tissue is proximate to theelement1602 and/or the ramp1504 (and/or1502). Further, the neuron-monitoring element1602 can be used to preserve the integrity of neural structures and provide an early detection to prevent or minimize damage to those structures during surgical procedures. As can be understood by one skilled in the art, bothramps1502 and1504 can be configured to includeelement1602.
• In some embodiments, the distraction ramps1502 and1504 can have variable lengths and adistracter alignment block1700, illustrated inFIG. 17, can be used to align theramps1502 and1504 for proper insertion and approach to the surgical site (as shown inFIG. 33).FIGS. 18-20 are various views of thedistracter alignment block1700.FIG. 18 is a cross-sectional view of theblock1700 showing tissue distracters and internal components ofblock1700 that include a spring ball detents that lock the tissue distracters, according to some embodiments of the present invention.FIG. 19 is an exploded view of the tissuedistracter alignment block1700.FIG. 20 illustrates an exemplary way of fitting the tissue distracters inside thealignment block1700.
• Referring toFIG. 17,block1700 includes ahousing1702 having anopen channel1704 disposed inside thehousing1702. Theopen channel1704 is further configured to be disposed between the top and the bottom of thehousing1702. Thechannel1704 includesgrooves1706 and1708 disposed on each side of theopen channel1704, as shown inFIG. 17. Thegrooves1706 and1708 are configured to accommodate placement of the proximal ends of the distraction ramps1502 and1504, respectively. Referring toFIGS. 15 and 17, the proximal ends of theramps1502,1504 include protruding portions that are configured to be curved away from their interior portions and are sized to fit inside theopen channel1704 and thegrooves1706 and1708, respectively. In some embodiments, theramps1502,1504 can be configured to be inserted into thechannel1704 simultaneously or one after the other. Since, thechannel1704 is open on one side of thehousing1702 and closed on the other side of thehousing1702, theramps1502,1504 are prevented from sliding out after being inserted into thegrooves1706,1708. To further prevent theramps1502,1504 from sliding out the open side of thechannel1704, lockingmechanisms1720,1722, respectively. The lockingmechanisms1720,1722 are configured to be disposed within the openings/holes1724,1726, respectively, which are further accessible through the top of thehousing1702 of theblock1700, as illustrated inFIG. 17.
• Referring toFIGS. 18 and 19, the lockingmechanisms1720,1722 are illustrated in further detail. Each one of the lockingmechanisms1720,1722 includes a ball1802(a, b,), a spring1804(a, b), and a locking pin1806(a, b). The balls1802 are configured to be inserted first into theopenings1724,1726, followed by the spring1804, and then pins1806. In some embodiments, thepin1806a is configured to be shorter than thepin1806b since thegroove1708 is disposed lower than thegroove1706 along theopen channel1704. The pins1806 can further include a locking device that prevents the pins from accidentally falling out of theopenings1724,1726. Upon insertion of the balls1802, springs1804, and pins1806 into theopenings1724,1726, respectively, and insertion of theramps1502,1504 into thegrooves1706,1708, respectively, the balls1802 upon being pushed by the pins1806 via springs1804, push on the protrusions of theramps1502,1504, which secures theramps1502,1504 inside thegrooves1706,1708. This locking arrangement prevents accidental slippage of theramps1502,1504 and allows proper insertion and advancement of the ramps toward the vertebral wall of the disc.FIG. 20 illustrates theramps1502,1504 being secured inside thealignment block1700. In some embodiments, thechannel1704, disposed on the interior portion of thehousing1702, is configured to be wider near the top of thehousing1702 and narrower near the bottom of thehousing1702, as illustrated inFIG. 20. This allows to further secure theramps1502,1504 inside thehousing1702. Once the ramps are advanced toward the surgical site, the alignment block can be removed to allow tissue distraction, which can be accomplished usingdistraction ramps1502,1504, and insertion of dilators (discussed below with regard toFIGS. 21-22), as shown inFIG. 34.
• FIGS. 21-22 illustrate exemplary dilators that are configured to be guided down the barbed trocar500 (shown inFIG. 5) and betweendistraction ramps1502,1504 using rail/slot1506.FIG. 21 illustrates an exemplarysmall dilator2100, according to some embodiments of the present invention.FIG. 22 an exemplarylarge dilator2200, according to some embodiments of the present invention. In some embodiments, thesmall dilator2100 is initially guided down over the barbed trocar500 (shown inFIG. 5) and between the distraction ramps1502,1504. Then, thelarge dilator2200 is guided down over thesmall dilator2100 and also between the distraction ramps1502,1504.
• Bothdilators2100 and2200 are further configured to be curved in a similar fashion as the trocar500 (shown inFIG. 5). The curvature radius of thetrocar500,dilators2100,2200, and other instruments discussed in the present application are configured to substantially match in order to prevent wobbling of these instruments when they are being advanced toward the surgical site. In some embodiments, thedilator2200 can be shorter than thedilator2100, which can further accommodate placement and removal of the dilators. The dilators can be manufactured from any biocompatible material such as, but not limited to stainless steel, titanium, aluminum, and/or polyetheretherketone (“PEEK”). In some embodiments, the material can be also non-conductive radiolucent material, and can be hammered with a mallet to advance it to the surgical site,
• Referring toFIG. 21,small dilator2100 includes ahousing2102 having anopen channel2104. Thechannel2104 is sized to accommodate insertion of thetrocar500. Thechannel2104 is disposed throughout the interior of thehousing2102 and begins with anopening2106 at the top (or near the proximal end) of thedilator2100 and ends with anopening2108 at the bottom (or near the distal end) of thedilator2100. Thedilator2100 is configured to be placed over the trocar500 (shown inFIG. 5) with theopening2108 and then slid down thetrocar500 until thedilator2100 reaches the surgical site, as shown inFIG. 35. Thehousing2102 of thedilator2100 further includes a plurality of graspingribs2120 disposed near the proximal end of the dilator. The graspingribs2120 are further configured to allow holding thedilator2100 when the dilator is being slid down thetrocar500. As illustrated inFIG. 21, thechannel2104 has a round cross-section in order to accommodate placement of thetrocar500. Further, thedilator2100 has a square cross-section. As can be understood by one skilled in the art, the cross-sections of thechannel2104 and thedilator2100 can vary as desired.
• Referring toFIG. 22,large dilator2200 includes ahousing2202 having an open rail/slot2204. The rail/slot2204 is sized to accommodate insertion of thesmall dilator2100. The rail/slot2204 is disposed throughout the exterior of thehousing2202 and begins with anopening2206 at the top (or near the proximal end) of thedilator2200 and ends with anopening2208 at the bottom (or near the distal end) of thedilator2200. Thedilator2200 is configured to be placed over the dilator2100 (shown inFIG. 21) with theopening2208 and then slid down thedilator2100 until thedilator2200 reaches the surgical site, as shown inFIG. 36. Thehousing2202 of thedilator2200 further includes a plurality of grasping ribs2220 disposed near the proximal end of the dilator. The grasping ribs2220 are further configured to allow holding thedilator2200 when the dilator is being slid clown thesmall dilator2100. As illustrated inFIG. 22, the rail/slot2204 has a square rail/slot cross-section in order to accommodate placement of thesmall dilator2100. Further, thedilator2200 has a square cross-section. As can be understood by one skilled in the art, the cross-sections of the rail/slot2204 and thedilator2200 can vary as desired.
• FIGS. 23-25 illustrate an exemplary curved portal2300, according to some embodiments of the present invention.FIG. 23 illustrates thecurved portal2300.FIG. 24 is another view of thecurved portal2300.FIG. 25 is a rear view of thecurved portal2300.
• As illustrated inFIGS. 23-25, the portal2300 includes ahousing2302 disposed between theproximate end2306 and adistal end2308. Thehousing2302 also includes aninterior channel2304 that is disposed between an opening at theproximate end2306 and an opening at thedistal end2308. Thechannel2304 is sized to accommodate insertion over the large dilator2200 (shown inFIG. 22) and subsequent instrumentation.Channel2304 may contain additional rail/slots to aid in guiding instrumentation. Thehousing2302 also includes an outside rail/slot2312 disposed on the rear portion of the workingportal2300, as illustrated inFIGS. 23-25. The rail/slot2312 is configured to extend through thewhole housing2302 and terminate at thedistal end2308 at anopening2310. Theopening2310 is further configured to accommodate protrusion of an awl2600 (shown inFIG. 26) upon its insertion through the rail/slot2312. The outside rail/slot2312 and2340 are configured to accommodate insertion of the workingportal2300 betweentissue distracters1502 and1504. The outside rail/slot2312 is also disposed between theproximate end2306 and thedistal end2308. Thedistal end2308 has a curved open end structure that can be configured to accommodate mounting to the lateral wall of the spine.
• In some embodiments, the width and/or height of the workingportal2300 can be in the range of 5 mm to 30 mm; alternately, between 10 mm and 25 mm; alternately, between 15 mm and 25 mm; alternately, between 18 mm and 23 mm. In some embodiments, the width of the workingportal2300 can be 20.3 mm. In some embodiments, the height of the portal2300 can be 24 mm. In some embodiments, the width and/or height of thechannel2304 can be in the range of 5 mm to 30 mm; alternately, between 10 mm and 25 mm; alternately, between 15 mm and 25 mm; alternately, between 18 mm and 23 mm. In some embodiments, the width of thechannel2304 can be 17 mm. In some embodiments, the height of thechannel2304 can be 19 min. The curvature radius of the workingportal2300 can be in above 3 mm. In some embodiments, the curvature radius of the workingportal2300 can be very large, thereby the workingportal2300 having only a slightly curved shape. In some embodiments, the curvature radius of the workingportal2300 is 12 cm,
• In some embodiments, the workingportal2300 can also accommodate placement of anendoscope4400 that allows viewing of the surgical area, as illustrated inFIG. 44a-c.Direct visualization is via a flexible or fixed radius endoscope. Intra-operative electrophysiological monitoring and fluoroscopy are utilized. Theendoscope4400 can be disposed along one of the walls of the workingportal2300, as shown inFIG. 44a, and can be mounted on theholding arm4402 that secures the workingportal2300. As illustrated inFIGS. 44b-c,the endoscope viewing area can be on the order of about 50.8 mm by 15.875 mm by 28.575 mm.FIG. 44cillustrates the field of view of the endoscope.
• Referring back toFIGS. 23-25, the workingportal2300 can be configured to have a substantially square or rectangular cross-section. As can be understood by one skilled in the art, the cross-section of the workingportal2300 can have any other shape, e.g., elliptical, round, polygonal, or any other desired shape. Because of the curvature of the workingportal2300, it can accommodate insertion of an implant at a direction that is substantially perpendicular to the surface of the body of the patient. Once the implant is inserted at the proximate end of the workingportal2300, it is advanced toward the surgical site down the interior channel of the workingportal2300. Upon approaching the surgical site, the direction of movement of the implant changes from substantially perpendicular or angular with regard to the body of the patient to substantially lateral or transverse. This allows the surgeon easily manipulate insertion and placement of the implant without having to create a large incision in the patient. The workingportal2300 can be configured to accommodate insertion of an implant having the following dimensions: height in the range of 8 mm to 18 mm, an anterior-posterior depth of in the range of 8 mm to 30 mm (alternately, between 10 mm to 25 mm; alternately, between 15 mm to 25 mm; alternately, between 18 mm to 23 mm; in some embodiments, the depth can be approximately 22 mm), and a lateral width in the range of 20 mm to 70 mm (alternately, between 30 mm to 65 mm; alternately, between 40 mm to 50 mm; alternately, between 45 mm to 55 mm).
• In some embodiments, the workingportal2300 can be manufactured from any biocompatible material such as, but not limited to stainless steel, titanium, aluminum, and/or PEEK. As can be understood by one skilled in the art, the portal2300 can be manufactured from any other suitable material(s).
• Once the portal2300 is satisfactorily located and its location is verified via x-ray (or any other means), ananterior awl2600 can be inserted within outer slot/rail2312 to secure theworking portal2300 to the spine.FIG. 37 illustrates the portal2300 prior to insertion ofanterior awl2600. As shown inFIG. 37, along with the portal2300, thetrocar500, thedilators2100 and2200, and theramps1502 and1504 are also inserted. Theawl2600 contains a handle configured to protrude away from thedistal end2308 of the portal2300 (as shown inFIGS. 38-39).
• Referring toFIG. 26, theawl2600 includes acurved shaft2602 disposed between ahandle2606 at the proximate end of theawl2600 and abarbed tip2604 at the distal end of theawl2600. Thebarbed tip2604 is configured to make an incision in the vertebral wall. Theshaft2602 is configured to be curved in a similar fashion as other instruments (e.g., the trocars, dilators, etc.) in order to allow adequate advancement of theawl2600 towards the surgical site. In some embodiments, theawl2600 is manufactured from any biocompatible material such as, but not limited to stainless steel, titanium, aluminum, and/or PEEK. In some embodiments, the material can be also a radio-opaque material. As can be understood by one skilled in the art, theawl2600 can be manufactured from any other suitable materials.
• The working portal construct can be further stabilized using a stabilization arm2314 (e.g., StrongArm, manufactured by Mediflex). Thearm2314 is coupled to a stationary equipment in the operating room, such as the operating table. As can be understood by one skilled in the art, any other holding arms can be used. Once the portal is docked using the anterior awl and stabilization arm, thedilators2100,2200 and thetrocar500 are removed, thereby leaving the workingportal2300 and thebarbed awl2600 allowing the surgeon to perform desired procedures (e.g., delivery of an implant), as shown inFIGS. 41-42.
• In some embodiments, where the present invention's device and instrumentation are used for implant delivery, the implants may include, but are not limited to: bone screws, plates, interbody devices, artificial discs, or any other implants. Further, the present invention's device and methodology can be used in any number of surgical procedures, including nucleus replacement, total disc replacement, interbody fusion, discectomy, neural decompression, implant delivery (whether for fixation purposes and/or stabilization), or any other procedure.
• Example embodiments of the methods and components of the present invention have been described herein. As noted elsewhere, these example embodiments have been described for illustrative purposes only, and are not limiting. Other embodiments are possible and are covered by the invention. Such embodiments will be apparent to persons skilled in the relevant art(s) based on the teachings contained herein. Thus, the breadth and scope of the present invention should not be limited by any of the above-described exemplary embodiments, but should be defined only in accordance with the following claims and their equivalents.

Claims (19)

1-51. (canceled)

52. A system for performing a procedure on a spine of a patient, comprising:

a curved tissue distractor including a first distractor ramp and a second distractor ramp;

a curved housing configured to slide between the first and second distractor ramps, said curved housing including

a distal end, a proximal end, and an interior channel disposed between the distal end and said proximate end;

an exterior channel disposed on an outside surface of said curved housing and between the distal end and the proximal end; and

wherein the curved housing is configured to slide between the first and second distractor ramps to provide access through the interior channel to the spine.

53. The system ofclaim 52, further comprising a removable alignment block that couples proximal ends of the first and second distractor ramps.

54. The system ofclaim 52, further comprising a housing with first and second grooves for receiving proximal ends of the first and second distractor ramps.

55. The system ofclaim 52, further comprising a rail on an interior side of the first distractor ramp configured to engage the exterior channel and guide said curved housing towards the spine.

56. The system ofclaim 52, further comprising a neuro-monitoring device on at least one of the first and second distractor ramps of said curved tissue distractor.

57. A distractor instrument for opening a surgical site comprising:

a curved first distractor ramp;

a curved second distractor ramp that mates with the first distractor ramp; and

an alignment block that aligns the first and second distractor ramps.

58. The distractor instrument ofclaim 57, wherein the first distractor ramp includes a first arcuate length longer than a second arcuate length of the second distractor ramp.

59. The distractor instrument ofclaim 57, further comprising a rail on an interior surface of the first distractor ramp for guiding one or more surgical instruments to the surgical site.

60. The distractor instrument ofclaim 57, wherein the alignment block couples with proximal ends of the first and second distractor ramps.

61. The distractor instrument ofclaim 57, further comprising a monitoring element on at least one of the first and second distractor ramps.

62. The distractor instrument ofclaim 57, further comprising a deployment balloon surrounding the first and second distractor ramps for delivery to the surgical site.

63. The distractor instrument ofclaim 57, wherein the alignment block includes grooves that receive proximal ends of the first and second distractor ramps.

64. The distractor instrument ofclaim 57, wherein the alignment block includes a locking mechanism to retain the first and second distractor ramps within the alignment block.

65. A method of accessing a surgical site, comprising:

inserting a curved first distractor ramp;

inserting a curved second distractor ramp that mates with the first distractor ramp; and

coupling an alignment block to proximal ends of the first and second distractor ramps.

66. The method ofclaim 65, further comprising monitoring neural activity through a monitoring element on at least one of the first and second distractor ramps.

67. The method ofclaim 65, further comprising providing a deployment balloon around the first and second distractor ramps.

68. The method ofclaim 65, further comprising aligning the first and second distractor ramps with the alignment block.

69. The method ofclaim 65, further comprising sliding a curved housing with an interior channel between the first and second distractor ramps.

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