US20150032164A1 - Methods for Performing Invasive Medical Procedures Using a Surgical Robot - Google Patents

Abstract

Embodiments are directed to a medical robot system including a robot coupled to an end-effectuator element with the robot configured to control movement and positioning of the end-effectuator in relation to the patient. One embodiment is a method for removing bone with a robot system comprising: taking a two-dimensional slice through a computed tomography scan volume of target anatomy; placing a perimeter on a pathway to the target anatomy; and controlling a drill assembly with the robot system to remove bone along the pathway in the intersection of the perimeter and the two-dimensional slice.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS
• This application is a continuation-in-part of U.S. application Ser. No. 13/924,505, entitled “Surgical Robot Platform,” filed on Jun. 21, 2013, which claims priority to U.S. Application No. 61/800,527 filed on Mar. 15, 2013, and claims priority to U.S. Provisional Patent Application No. 61/662,702 filed on Jun. 21, 2012, which are incorporated herein by reference in their entirety.
BACKGROUND
• Embodiments are directed to a medical robot system. More particularly, embodiments are directed to a medical robot system including a robot coupled to an end-effectuator element with the robot configured to control movement and positioning of the end-effectuator in relation to the patient.
• Various medical procedures require the precise localization of a three-dimensional position of a surgical instrument within the body in order to effect optimized treatment. For example, some surgical procedures to fuse vertebrae require that a surgeon drill multiple holes into the bone structure at specific locations. To achieve high levels of mechanical integrity in the fusing system, and to balance the forces created in the bone structure, it is necessary that the holes are drilled at the correct location. Vertebrae, like most bone structures, have complex shapes made up of non-planar curved surfaces making precise and perpendicular drilling difficult. Conventionally, a surgeon manually holds and positions a drill guide tube by using a guidance system to overlay the drill tube's position onto a three dimensional image of the bone structure. This manual process is both tedious and time consuming. The success of the surgery is largely dependent upon the dexterity of the surgeon who performs it.
• Robotic systems have been employed to help reduce tedious and time consuming processes. Many of the current robots used in surgical applications are specifically intended for magnifying/steadying surgical movements or providing a template for milling the bone surface. However, these robots are suboptimal for drilling holes and other related tasks.
• Consequently, there is a need for a robot system that minimizes human and robotic error while allowing fast and efficient surgical access. The ability to perform operations on a patient with a robot system and computer software will greatly diminish the adverse effects upon the patient. The application of the robot system and the techniques used with the robot system may enhance the overall surgical operation and the results of the operation.
SUMMARY
• Embodiments are directed to a method for removing bone with a robot system. The method may comprise extracting a two-dimensional slice from a three-dimensional computed tomography scan of a vertebra. The method may further comprise defining a perimeter on a pathway through the vertebra. The method may further comprise controlling a drill assembly with the robot system to remove bone from the pathway in the intersection of the perimeter and the two-dimensional slice.
• Additional embodiments are directed to a method for inserting a tubular element into a patient with a robot system. The method may comprise loading computed tomography scans on to the robot system. The method may further comprise programming a route for the tubular element to travel through the patient to a section of the vertebra on a display, wherein the display may manipulate the robot system. The method may further comprise controlling the tubular element with the robot system to guide the tubular element along the programmed route through the patient.
• Additional embodiments are directed to a method for aligning vertebrae for a surgical procedure using a robot system. The method may comprise inserting a tubular element into a patient and next to a disc space between adjacent vertebral bodies. The method may comprise attaching the tubular element to an end-effectuator of the robot system. The method may further comprise controlling a vertebral alignment tool with the robot system to insert the vertebral alignment tool through the tubular element such that vertebral alignment tool is inserted between the adjacent vertebral bodies to distract the adjacent vertebral bodies.
• The foregoing has outlined rather broadly the features and technical advantages of the present invention in order that the detailed description of the invention that follows may be better understood. Additional features and advantages of the invention will be described hereinafter that form the subject of the claims of the invention. It should be appreciated by those skilled in the art that the conception and the specific embodiments disclosed may be readily utilized as a basis for modifying or designing other embodiments for carrying out the same purposes of the present invention. It should also be realized by those skilled in the art that such equivalent embodiments do not depart from the spirit and scope of the invention as set forth in the appended claims.
BRIEF DESCRIPTION OF THE DRAWINGS
• For a detailed description of the preferred embodiments of the invention, reference will now be made to the accompanying drawings in which:
• FIG. 1 illustrates a partial perspective view of a room in which a medical procedure is taking place by using a surgical robot;
• FIG. 2 illustrates a perspective view of a surgical robot according to an embodiment of the invention;
• FIG. 3 illustrates a perspective view of a robot system including a camera arm in accordance with one embodiment of the invention;
• FIG. 4 illustrates a front-side perspective view of a robot system including a camera arm in a stored position in accordance with one embodiment of the invention;
• FIG. 5 illustrates a rear-side perspective view of a robot system including a camera arm in a stored position in accordance with one embodiment of the invention;
• FIG. 6 illustrates a side cross-sectional view of a bony structure and critical structure with a milling bit inside a cannula positioned adjacent to the bony structure in accordance with one embodiment of the invention;
• FIG. 7aillustrates a side cross-sectional view of a bony structure and a milling bit with a programmed perimeter in accordance with one embodiment of the invention;
• FIG. 7billustrates a top end cross-sectional view of the same bony structure asFIG. 7awith a programmed perimeter in accordance with one embodiment of the invention;
• FIG. 8aillustrates a side cross-sectional view of a bony structure with a 2D slice through the bony structure indicated in accordance with one embodiment of the invention;
• FIG. 8billustrates a top end cross-sectional view of the 2D slice through the bony structure confined to the programmed perimeter in accordance with one embodiment of the invention;
• FIG. 9 illustrates a side cross-sectional view of a bony structure with the milling bit extending out of a cannula removing bone in accordance with one embodiment of the invention;
• FIG. 10 illustrates a side cross-sectional view of a bony structure with the milling bit extending out of a cannula and removing bone from around a critical structure in accordance with one embodiment of the invention;
• FIG. 11 illustrates a computerized display used to program the route of tubular element by a robot system in accordance with one embodiment of the invention;
• FIG. 12 illustrates a center tool held by an end-effectuator and positioned next to an intervertebral disc space in accordance with one embodiment of the invention;
• FIG. 13aillustrates the spacer being removed from the end-effectuator in accordance with one embodiment of the invention;
• FIG. 13billustrates a first dilator being positioned over a center tool in accordance with one embodiment of the invention;
• FIG. 13cillustrates a second dilator being positioned over a previously positioned dilator in accordance with one embodiment of the invention;
• FIG. 13dillustrates a third dilator being positioned over a previously positioned dilator in accordance with one embodiment of the invention;
• FIG. 13eillustrates the removal of a center tool and other dilators, with the largest dilator remaining in the patient in accordance with one embodiment of the invention;
• FIG. 14 illustrates a vertebral alignment tool with a working channel in accordance with one embodiment of the invention;
• FIG. 15 illustrate a vertebral alignment tool positioned outside two vertebral bodies in accordance with one embodiment of the invention;
• FIG. 16 illustrates a vertebral alignment tool inserted into an intervertebral disc space, thereby aligning two vertebral bodies in accordance with one embodiment of the invention;
• FIG. 17 illustrates a view looking down a tubular element with a vertebral alignment tool positioned inside the tubular element in accordance with one embodiment of the invention;
• FIG. 18 illustrate an axial anatomical view of a vertebra with a tubular element and inserted interbody device in accordance with one embodiment of the invention;
• FIG. 19 illustrates an axial view of a vertebra with a tubular element and inserted interbody device with the distance and angle needed to correctly position the interbody device in accordance with one embodiment of the invention;
• FIG. 20 illustrates a perspective view of a surgical robot according to an embodiment of the invention; and
• FIG. 21 illustrates a perspective view of a surgical robot separated in two structures according to an embodiment of the invention.
DETAILED DESCRIPTION
• In an embodiment, as illustrated inFIGS. 1-5, a surgical robot system1 is disclosed in aroom10 where a medical procedure is occurring. In some embodiments, surgical robot system1 may comprise asurgical robot15, a display means29, and ahousing27 to enclose arobot arm23, and an end-effectuator30 coupled torobot arm23 controlled by at least one motor (not illustrated). In some embodiments a display means29 may be attached tosurgical robot15, whereas in other embodiments, a display means29 may be detached fromsurgical robot15, either withinsurgical room10 or in a remote location. In some embodiments, end-effectuator30 may comprise a surgical instrument35. In other embodiments, end-effectuator30 may be coupled to surgical instrument35. As used herein, the term “end-effectuator” is used interchangeably with the term “effectuator element.” In some embodiments, end-effectuator30 may comprise any known structure for effecting the movement of surgical instrument35 in a desired manner.
• In some embodiments, prior to performance of an invasive procedure, a three-dimensional (“3D”) image scan may be taken of a desired surgical area ofpatient18 and sent to a computer platform in communication withsurgical robot15. In some embodiments, a physician may then program a desired point of insertion and trajectory for surgical instrument35 to reach a desired anatomical target within or upon the body ofpatient18. In some embodiments, the desired point of insertion and trajectory may be planned on the 3D image scan, which in some embodiments, may be displayed on display means29. In some embodiments, a physician may plan the trajectory and desired insertion point (if any) on a computed tomography scan (hereinafter referred to as “CT scan”) ofpatient18. In some embodiments, the CT scan may be an isocentric C-arm type scan, an O-arm type scan, or intraoperative CT scan as is known in the art. However, in some embodiments, any known 3D image scan may be used in accordance with the embodiments of robot system1 described herein.
• In some embodiments, surgical robot system1 may comprise a local positioning system (“LPS”) subassembly to track the position of surgical instrument35. In some embodiments, robot system1 includes at least onemounted camera56. For example,FIG. 3 illustrates a perspective view of a robot system1 including acamera arm55 in accordance with one embodiment of the invention. In some embodiments, to overcome issues with line of sight, it is possible to mountcameras56 for trackingpatient18 androbot15 on anarm50 extending from the robot. As shown inFIG. 3, in some embodiments,arm50 is coupled to acamera arm55 via a joint60, andarm50 is coupled to robot system1 viajoint65. In some embodiments,camera arm55 may be positioned above a patient (for example, abovepatient18 lying on a bed or stretcher as illustrated inFIG. 3). In this position, in some embodiments, it might be less likely for the surgeon to block thecamera56 when robot system1 is in use (for example, during a surgery and/or patient examination). Further, in some embodiments, thejoints60,65 may be used to sense the current position of the cameras56 (i.e. the position of the camera arm55). Moreover, in some embodiments, the exact position of end-effectuator30 in the camera's56 coordinate system may be calculated based on monitored counts on each robot axis, and in some embodiments,cameras56 would therefore only have to collect data from tracked markers (not illustrated) onpatient18 to exactly calculate end-effectuator position relative to the anatomy.
• Some embodiments include anarm50 andcamera arm55 that may fold into a compact configuration for transportation of robot system1. For example,FIG. 4 illustrates a front-side perspective view of a robot system including acamera arm55 in a stored position, andFIG. 5 illustrates a rear-side perspective view of a robot system including acamera arm55 in a stored position in accordance with one embodiment of the invention.
• In some embodiments, surgical robot system1 may comprise acontrol device100. In some embodiments, the processor ofcontrol device100 may be configured to perform time of flight calculations of radiofrequency signals emitted at the surgical instrument35 or end-effectuator30 and received by wall-mountedreceivers5. Further, in some embodiments, robot system1 may be configured to provide a geometrical description of the location of at least one bony structure such as a vertebra with respect to an operative end of surgical instrument35 or end-effectuator30 that is utilized to perform or assist in performing an invasive procedure. In some further embodiments, the position of vertebrae, as well as the dimensional profile of surgical instrument35 oreffectuator element30 may be displayed on a monitor (for example on display means29). In one embodiment, end-effectuator30 may be a tubular element80 (for example acannula121,dilator200,probe190, or guide tube) that is positioned at a desired location with respect to, for example, patient's18 spine to facilitate the performance of a spinal surgery. In some embodiments,tubular element80 may be aligned with a z axis defined by a corresponding robot motor (not illustrated) or, for example, may be disposed at a selected angle relative to the z-axis. In either case, the processor of control device100 (i.e. a computer) may be configured to account for the orientation oftubular element80 and the position of vertebrae. In some embodiments, the memory of control device100 (i.e. a computer) may store software for performing the calculations and/or analyses required to perform many of the surgical method steps set forth herein. The software or a computer program may be provided on a tangible computer readable storage media, which is non-transitory in nature.
• Another embodiment of the disclosed surgical robot system1 involves the utilization of arobot15 that is capable of moving end-effectuator30 along x-, y-, and z-axes. In this embodiment, an x-axis may be orthogonal to a y-axis and the z-axis, the y-axis may be orthogonal to the x-axis and the z-axis, and the z-axis may be orthogonal to x-axis and y-axis. In some embodiments,robot15 may be configured to effect movement of end-effectuator30 along one axis independently of the other axes. For example, in some embodiments,robot15 may cause end-effectuator30 to move a given distance along the x-axis without causing any significant movement of end-effectuator30 along the y-axis or the z-axis.
• In some further embodiments, end-effectuator30 may be configured for selective rotation about one or more of the x-axis, y-axis, and z-axis (such that one or more of the Cardanic Euler Angles (e.g., roll, pitch, and/or yaw) associated with end-effectuator30 may be selectively controlled). In some embodiments, during operation, end-effectuator30 and/or surgical instrument35 may be aligned with a selected orientation axis that may be selectively varied and monitored by an agent (i.e. control device100) that may operate surgical robot system1. In some embodiments, selective control of the axial rotation and orientation of end-effectuator30 may permit performance of medical procedures with significantly improved accuracy compared to conventional robots that utilize, for example, a six degree offreedom robot arm23 comprising only rotational axes.
• In some embodiments, as illustrated inFIG. 1,robot arm23 may be positioned above the body ofpatient18, with end-effectuator30 selectively angled relative to the z-axis toward body ofpatient18. In this aspect, in some embodiments, robotic surgical system1 may comprise systems for stabilizingrobotic arm23, end-effectuator30, and/or surgical instrument35 at their respective positions in the event of power failure. In some embodiments,robotic arm23, end-effectuator30, and/or surgical instrument35 may comprise a conventional worm-drive mechanism (not illustrated) coupled torobotic arm23, configured to effect movement ofrobotic arm23 along the z-axis. In some embodiments, the system for stabilizingrobotic arm23, end-effectuator30, and/or surgical instrument35 may comprise a counterbalance coupled torobotic arm23. In another embodiment, the means for maintainingrobotic arm23, end-effectuator30, and/or surgical instrument35 may comprise a conventional brake mechanism (not illustrated) that is coupled to at least a portion ofrobotic arm23, such as, for example, end-effectuator30, and that is configured for activation in response to a loss of power or “power off” condition ofsurgical robot15.
• In some embodiments,control device100 is also in communication withsurgical robot15. In some embodiments, a conventional processor (not illustrated) ofcontrol device100 may be configured to effect movement ofsurgical robot15 according to a preplanned trajectory selected prior to the procedure. For example, in some embodiments, controllingdevice100 may use robotic guidance software (not illustrated) and robotic guidance data storage (not illustrated) to effect movement ofsurgical robot15.
• In some embodiments, the position of surgical instrument35 may be dynamically updated so thatsurgical robot15 is aware of the location of surgical instrument35 at all times during the procedure. Consequently, in some embodiments,surgical robot15 may move surgical instrument35 to the desired position quickly, with minimal damage topatient18, and without any further assistance from a surgeon (unless the surgeon so desires). In some further embodiments,surgical robot15 may be configured to correct the path of surgical instrument35 if surgical instrument35 strays from the selected, preplanned trajectory.
• In some embodiments,surgical robot15 may be configured to permit stoppage, modification, and/or manual control of the movement of end-effectuator30 and/or surgical instrument35. Thus, in use, in some embodiments, an agent (e.g., surgeon, a physician or other user) that may operate robot system1 has the option to stop, modify, or manually control the autonomous movement of end-effectuator30 and/or surgical instrument35. Further, in some embodiments, tolerance controls may be preprogrammed intosurgical robot15 and/or control device100 (such that the movement of the end-effectuator30 and/or surgical instrument35 is adjusted in response to specified conditions being met). For example, in some embodiments, ifsurgical robot15 cannot detect the position of surgical instrument35 because of a malfunction in the LPS system, thensurgical robot15 may be configured to stop movement of end-effectuator30 and/or surgical instrument35. In some embodiments, ifsurgical robot15 detects a resistance, such as a force resistance or a torque resistance above a tolerance level, thensurgical robot15 may be configured to stop movement of end-effectuator30 and/or surgical instrument35.
• In some embodiments,control device100, as further described herein, may be located withinsurgical robot15, or, alternatively, in another location withinsurgical room10 or in a remote location. In some embodiments,control device100 may be positioned in operative communication withcameras56, for tracking, andsurgical robot15.
• In some further embodiments,surgical robot15 may also be used with existing conventional guidance systems. Thus, alternative conventional guidance systems beyond those specifically disclosed herein are within the scope and spirit of the invention. For instance, a conventional optical tracking system (not illustrated) for tracking the location of the surgical device, or a commercially available infrared optical tracking system (not illustrated), such as Optotrak® (Optotrak® is a registered trademark of Northern Digital Inc. Northern Digital, Waterloo, Ontario, Mayada), may be used to track patient's18 movement and robot's base25 location and/or intermediate axis location, and used with surgical robot system1. In some embodiments in which surgical robot system1 comprises a conventional infrared or visible light optical tracking system (not illustrated), surgical robot system1 may comprise conventional optical markers attached to selected locations on end-effectuator30 and/or surgical instrument35 that are configured to emit or reflect light. In some embodiments, the light emitted from and/or reflected by the markers may be read bycameras56 and/or optical sensors and the location of the object may be calculated through triangulation methods (such as stereo-photogrammetry).
• Illustrated inFIG. 2, it is seen that, in some embodiments,surgical robot15 may comprise a base25 connected towheels31. The size and mobility of these embodiments may enable the surgical robot to be readily moved from patient to patient and room to room as desired. As shown, in some embodiments,surgical robot15 may further comprise acase40 that is slidably attached tobase25 such thatcase40 may slide up and down along the z-axis substantially perpendicular to the surface on whichbase25 sits. In some embodiments,surgical robot15 may include a display means29, and ahousing27 which containsrobot arm23.
• As described earlier, end-effectuator30 may comprise a surgical instrument35, whereas in other embodiments, end-effectuator30 may be coupled to surgical instrument35. In some embodiments,arm23 may be connected to end-effectuator30, with surgical instrument35 being removably attached to end-effectuator30.
• In some embodiments, robot system1 may be used in common spinal surgery procedures such as Transforaminal Lumbar Interbody Fixation (“TLIF”), Posterior Lumbar Interbody Fixation (“PLIF”), Lateral Lumbar Interbody Fixation (“LLIF”), laminectomy or foraminotomy procedures. Robot system1 may be used in any of the above mentioned approaches where bone removal may be needed. Specifically, robot system1 may be able to target selected areas of bone for milling. Robot system1 may further be registered topatient18. In some embodiments, the means for registering may comprise radio-opaque fiducial markers and optical tracking markers rigidly attached to a patient-mounted fixture. Locations of fixture's fiducial markers on the 3D image may be related to tracked locations of the fixture's optical tracking markers toco-register camera56 and medical image coordinate systems. In still further embodiments,cameras56 may be used for tracking the location of the end-effectuator30 or surgical instrument35 in relation to the patient.Cameras56 that may be used are to be similar to those used by the StealthStation® S7®, StealthStation i7™, or StealthStation iNav®, which track light-emitting or reflective markers using stereophotogrammetry. (StealthStation® S7®, StealthStation i7™, or StealthStation iNav® are registered trademarks of Medtronic, Inc.)Cameras56 may be located oncamera arm55, seeFIG. 2, or stationed aroundpatient18. Once registered topatient18, robot system1 may very accurately gauge its end-effectuator's30 location relative to any layer of bone viewable on a CT.
• Embodiments of spine surgery techniques may include creating an access channel between two vertebral bodies or through bone.FIG. 6 illustrates acannula assembly120 that may be used to create an access channel through the tissue ofpatient18 to target anatomy in accordance with one embodiment of robot system1. In the illustrated embodiment, thecannula assembly120 comprises acannula121 configured to allow passage of various instruments and materials through the pathway to target anatomy. The cannula may have an inside diameter just large enough to pass a drill bit or needle, or an inside diameter large enough to pass implants such as interbody grafts used in TLIF, PLIF, or LLIF.Cannula121 may have aproximal end122 and adistal end123.Cannula assembly120 further may include a drill assembly which may be removed fromcannula121. As illustrated inFIG. 6,drill shaft151 may be positioned incannula121 with millingbit160 positioned atdistal end123. Drill assembly (not pictured) may further comprise a motor, a body, and parts known to one of ordinary skill in the art. In an embodiment,cannula assembly120 may further comprise a handle (not illustrated) disposed on theproximal end122 ofcannula121. In an embodiment,cannula assembly120 may be a trocar-tipped cannula. By way of example,cannula assembly120 may be a diamond, scoop, bevel, or trocar tipped cannula.
• To create an access channel, the surgeon, for example, may make an incision in the back ofpatient18.Distal end123 ofcannula121 may be inserted into the incision. The surgeon may then apply longitudinal force tocannula assembly120 while rotating the handle to advancecannula121 through the soft tissue ofpatient18 and causedistal end123 to abut or penetrate into a bony structure. In an embodiment,cannula121 may be inserted into the vertebral body through a pedicle (not illustrated). Oncecannula121 has been inserted to the necessary depth, the handle may be removed, leavingcannula121. In this manner,cannula121 may provide an access channel into the target site.
• In a similar method, to form an access channel, the surgeon may make an incision in the back ofpatient18.Proximal end122 ofcannula121 may be attached to robot system1 by way of end-effectuator30. As described above, CT scans ofpatient18 may be loaded to controldevice100. Once loaded,control device100 may register robot system1, end-effectuator30, CT scans ofpatient18, and the current position ofpatient18 oncontrol device100. Once registration oncontrol device100 is complete, the surgeon may program robot system1 to aligncannula121 to a desiredtrajectory line400 throughpatient18 to a target site. As illustrated inFIG. 11, the surgeon may designate atrajectory line400 oncontrol device100, using display means29, to reach the interbody space between two vertebral bodies. The robot system1 may then control thecannula121 to place thecannula121 intopatient18 along the programmed trajectory. The surgeon may then insert a probe (not illustrated) throughcannula121 to monitor nerve activity. If adjustments to the trajectory are needed the surgeon may altertrajectory line400 oncontrol device100 to an alternate position by means ofcontrol device100, through an interface on display means29. Robot system1 may then immediately shifttrajectory line400 alongnew trajectory line400.Control device100 may be enabled to automatically shifttrajectory line400 away from neural activity, as provided by the probe, which may have reached a critical threshold. This automatic shift may allowtubular element80 to reach the intervertebral disc space with a greater ability of avoiding nerves and causing nerve damage.
• Whilecannula assembly120 may be suited for creating an access channel to vertebral bodies or intervertebral disc spaces in all regions of the vertebral column,cannula assembly120 may be particularly suited for access in the middle and lower areas of the thoracic region. If access is desired from the middle of the thoracic region and above, a device having a tapered cannula (not illustrated) may be used. While the tapered cannula may be particularly suited for accessing the middle of the thoracic region and above, it should be understood that the tapered cannula may also be used to create an access channel to vertebral bodies in all regions of the vertebral column.
• Aftercannula121 has been inserted and correctly positioned inside the body ofpatient18, a drill assembly500 may be inserted intocannula121. The drill assembly500 may comprisedrill shaft151, millingbit160, and may further comprise a motor, a body, and parts known to one of ordinary skill in the art. Drill assembly500 may attach to end-effectuator30 by any suitable means. Furthermore, drill assembly500 may be attached to end-effectuator30 before insertion ofcannula121 or after insertion ofcannula121 intopatient18. As illustrated inFIGS. 7aand7b, a surgeon may usecontrol device100 to define aperimeter110 around an area within which the surgeon may desire to remove some bone with drill assembly500.Perimeter110 may be of any suitable shape or design the surgeon chooses. Without limitation, a suitable perimeter shape may be round, square, rectangular, any surgeon hand drawn enclosure, or any combination thereof. In one embodiment, perimeter may match the circular shape of the outer diameter of the cannula. As illustrated inFIG. 7a, a side view of the bony structure illustrates the outer edges ofperimeter110. An end-on view, as illustrated inFIG. 7b, illustrates the area ofperimeter110 in which milling bit160 may operate. Uploadingperimeter110 intocontrol device100 may instruct end-effectuator30 to prevent millingbit160 from moving outsideperimeter110.
• Afterperimeter110 is loaded,control device100 may then proceed to remove bone. By way of example, thecontrol device100 of the robot system1 may control the drill assembly500 for bone removal. In some embodiments, thecontrol device100 may turn on the drill assembly500. Turning “on” the drill assembly may rotate millingbit160 at about 500 to about 30,000 RPM, for example. Before removing bone,control device100 may assess the demarcation between bone and soft tissue on a 2D reformatted slice (reslice) of uploaded CT volume of the anatomy insidepatient18. As illustrated inFIGS. 8aand8b,reslice plane170 may be perpendicular to the approach pathway but could alternately be perpendicular to the axis of thedrill shaft151, the axis of thecannula121, or any suitable axis. Surgeon may instructcontrol device100 to iteratively movereslice plane170 distally down the axis of approach and distal to millingbit160 before millingbit160 advances.Control device100 may display an image ofreslice plane170 as it advances. As illustrated inFIG. 8, the surgeon may halt advancement and display of thereslice plane170 at a position where the first bone is to be encountered.Control device100 may be used to monitor exact location ofdrill bit160 relative to the anatomy while surgeon advancescannula121 to a known position relative toreslice plane170 anddrill bit160. In one embodiment, this known position may be proximal to the reslice plane by the head depth of thedrill bit160. As illustrated inFIG. 8b, an end-on view illustrates the cross section ofreslice plane170 andperimeter110. The area in white is bone that may be removed by millingbit160 and the area in black is soft tissue. In one embodiment, grayscale thresholding may be used to automatically assess and delineate white from black regions, providing data to controldevice100 to automatically set boundaries for allowing or preventing drilling in different regions in this plane and bounded byperimeter110. In another embodiment, the surgeon uses a software interface to manually mark bone and soft tissue areas onreslice plane170. In one embodiment,control device100 may enable drill shaft's151 position to be moved laterally while maintaining angular orientation.Control device100 may also only allow the drill bit to advance distally past the cannula tip if it is in the region in white but not in the region in black. In another embodiment,control device100 may enable rotation ofdrill shaft151 and may have it coupled with translation so that millingbit160 position stays inreslice plane170.Control device100, withperimeter110, may prevent drilling in any region that is not bone and allow removal of bone that is present within the cross section ofperimeter110 andreslice plane170. Themilling bit160 may be advanced to remove bone distal to thecannula121. In one embodiment, to limit bone removal to a region that has been viewed on resliced CT, themilling bit160 is advanced only until it reaches thereslice plane170. As illustrated inFIG. 9, because the milling bit diameter is larger than the drill shaft diameter, millingbit160 may be advanced to remove bone lateral tocannula121 by the distance from the outer edge of thedrill shaft151 to the outer edge of themilling bit160. This feature may allow for millingbit160 to remove enough bone forcannula121 to advance through or past the bony structure after bone is removed from in front of the cannula's leading edge. After removal of bone between cannula tip andreslice plane170, which may be assessed by recording the area removed manually or oncontrol device100 by monitoring the registered position of end-effectuator and path of the bit, the surgeon may manually advance thecannula121 into vacatedspace185. Anew reslice plane170 on the CT scan ofpatient18 may then be assessed from the existing CT scan volume bycontrol device100. In other embodiments, robot system1 may assessmultiple reslice planes170 of the CT scan ofpatient18 at the same time. The use ofmultiple reslice planes170 may “look ahead” of millingbit160. Viewing sequential slices in the path ahead of the current cannula location may alert the surgeon to acritical structure180 that would harmpatient18 if removed by millingbit160. As illustrated onFIG. 9, themilling bit160, which is connected to end-effectuator30, may be advanced into or past bony structures in advance of thecannula121. Themilling bit160 may remove bone allowing thecannula121 to be advanced into or past the bony structure. Without the bone structures to block it, thecannula121 would be pushed past soft tissues, which were not drilled, pushing these tissues aside as commonly occurs with cannula insertion.
• As illustrated inFIG. 10, areslice plane170 may eventually revealcritical structure180.Control device100 may alert the surgeon tocritical structure180. Acritical structure180 may be, but is not limited to a nerve, blood vessel, tumor, fracture, muscle, tendon, or any combination thereof into which one of ordinary skill in the art would not want to drill. The surgeon may then create asecond perimeter115.Second perimeter115 may be plotted aroundcritical structure180.Second perimeter115 may be of any suitable shape or design the surgeon chooses. Without limitation, a suitable shape may be round, square, rectangular, any surgeon hand drawn enclosure, or any combination thereof.Second perimeter115 may be loaded intocontrol device100.Control device100 may then prevent millingbit160 orcannula121 from entering the area defined bysecond perimeter115. This second perimeter may allow for millingbit160 to continue removing bone from aroundcritical structure180 without harmingcritical structure180. As illustrated inFIG. 10,critical structure180 may preventcannula121 from advancing farther into the patient. In this respect, the critical structure is treated differently than soft tissues appearing as black on the reslice plane—with the soft tissues, the surgeon continues to advance the cannula forward and pushes them aside whereas with a critical structure, cannula advancement must stop. Millingbit160 may continue to remove bone farther into the bony structure by staying within the bounds ofperimeter110, outside ofsecond perimeter115.
• In some embodiments, robot system1 may be used during LLIF operations. Current technology requires an LLIF access portal to be established. Portal placement is normally accomplished by a surgeon who inserts a probe from a lateral approach and guides the probe toward the disc space, adjusting the path as needed to steer the probe away from nerves in the psoas muscle and exiting the spine. As illustrated inFIG. 12, robot system1 may be used to move or guide manual movement of acenter tool190 throughpatient18 during a LLIF procedure. Further illustrated inFIG. 12 are end-effectuator30,spacer210,dilator200, andtrajectory line400. End-effectuator30 is attached to robot system1 and may be used to guidecenter tool190 or holdcenter tool190 anddilators200 in place. End-effectuator30 may graspcenter tool190 ordilators200 by way ofspacer210 or any other means known to one skilled in the art.Spacer210 may be removed and replaced as necessary to properly attachcenter tool190 ordilators200 to end-effectuator30. As described above,patient18 and CT scan volume ofpatient18 may be registered together throughcontrol device100. The surgeon may then plottrajectory line400 oncontrol device100 through display means29, which may display key anatomical views generated from the CT scans. Robot system1 may aligntrajectory line400 based upon the surgeon's inputs. The surgeon may insert a probe (not illustrated) throughcenter tool190 to monitor nerve activity ascenter tool190 is maneuvered throughpatient18 by robot system1. If an adjustment totrajectory line400 ofcenter tool190 is required, the surgeon may re-plottrajectory line400 to an alternate position oncontrol device100, through display means29. Robot system1 may immediately correcttrajectory line400 ofcenter tool190, based upon re-plotting oftrajectory line400. Furthermore,control device100 may be programmed to automatically shifttrajectory line400 ofcenter tool190 away from areas where neural activity has reached a critical threshold as measured by the probe inserted incenter tool190. After placement ofcenter tool190 against an intervertebral disc space,dilators200 may be used to expand the working space available to a surgeon.
• As illustrated inFIGS. 13a,13b,13c,13d, and13e, aftercenter tool190 has reached the intended intervertebral disc space, one ormore dilators200a,200b,or200cmay be maneuvered down the length ofcenter tool190 to the intervertebral disc space.Center tool190 anddilators200 may be held in position byspacer210.Spacer210 may aligncenter tool190 anddilators200 to end-effectuator30. As illustrated inFIG. 13a,spacer210 may be removed to allow for the insertion ofdilators200a,200b,and200c.As illustrated inFIG. 13a,center tool190 may be positioned against the intervertebral disc space inpatient18 by end-effectuator30. Aftercenter tool190 has been positioned,spacer210 may be removed for the insertion of dilators to increase the work space available to a surgeon. Illustrated inFIG. 13b,dilator200a,which may have inside diameter slightly larger than outside diameter ofcenter tool190, may be placed aroundcenter tool190 and moved downcenter tool190 until adjacent to the intervertebral disc space inpatient18.FIG. 13cillustrates the same process inFIG. 13bwithdilator200bbeing slightly larger and moved alongdilator200a.FIG. 13dillustrates the same process inFIG. 13cwithdilator200cbeing slightly larger and moved alongdilator200b.These steps may be repeated multiple times as desired by the surgeon (additional steps may not be pictured). As illustrated inFIG. 13e, afterdilators200a,200b,and200chave been placed,center tool190 anddilators200aand200bmay be removed. This removal may leavedilator200cattached to end-effectuator30, creating a working space for a surgeon to operate in.
• FIG. 14 illustrates avertebral alignment tool250, which may be used after insertion oftubular element80, in certain embodiments.Vertebral alignment tool250 may be used to prepare the intervertebral disc space ofpatient18 for further surgical operations. As illustrated inFIG. 14,vertebral alignment tool250 may comprise abody251, apenetrating end252, and a workingchannel253.Body251 may be of any suitable width to fit withintubular element80.Body251 may be any suitable length to traverse the length oftubular element80 and have a sufficient amount ofbody251 exposed outsidetubular element80 for robot system1, through end-effectuator30, or a surgeon to manipulatevertebral alignment tool250 insidetubular element80 for placement betweenvertebral body600 andvertebral body601, indisc space602.Body251 may be of any shape (i.e. square, rectangular, round, polyhedral, etc.) that may distract (i.e. separatevertebral body600 and vertebral body601)vertebral body600 andvertebral body601.Penetrating end252 may be attached tobody251 at one end ofbody251.Penetrating end252 may comprise two individual projections which may have tapered ends that come to a point. Both projections may be of any desirable length or width so as to prevent interference with workingchannel253. Workingchannel253 may traverse the interior length ofbody251. Workingchannel253 may be of any shape (i.e. square, rectangular, round, polyhedral, etc.) desired by a surgeon. Furthermore, workingchannel253 may allow for surgical tools to pass throughbody251 andpenetrating end252 to enter the disc space for surgical operations.
• FIGS. 15 and 16 illustratebody251, which may be the width of tubular element80 (i.e. cannula, dilator, or guide tube) used during the operation. As illustrated inFIG. 15,angled end252 is positioned between two adjacentvertebral bodies600,601, which may not be prepared for surgical operations. As illustrated inFIG. 16,vertebral alignment tool250 may be moved intodisc space602 between adjacentvertebral bodies600,601, distracting adjacentvertebral bodies600,601 for surgical operations. The pointed tip of penetratingend252 penetrates through the soft tissue and annulus and into thedisc space602. Thevertebral bodies600,601 may slide along the tapering ofangled end252, coming to rest uponbody251. With the vertebralbody alignment tool250, the surgeon may employ tools down workingchannel253 ofvertebral alignment tool250 for surgical operations.
• Illustrated inFIG. 17 is a view looking through workingchannel253 ofvertebral alignment tool250 in accordance with some embodiments. The orientation of thevertebral bodies600,601 relative totubular element80 may be known, and therefore, it is possible to insertvertebral alignment tool250 into the disc space in proper alignment with thevertebral bodies600,601 to allow entry betweenvertebral bodies600,601. A locking dial portal (not illustrated), may be used on the proximal end of end-effectuator30, allowing robot system1 to holdvertebral alignment tool250 in place. The dial, (not illustrated), may move to a new radial position through end-effectuator30 bycontrol device100. Through registration of the robot system1 to CT image volume, as described earlier, and with additional spatial information from the position of the dial, exact orientation and position of thevertebral alignment tool250 relative to the anatomy is known.Control device100 may then insert or guidevertebral body tool250 between twovertebral bodies600,601 using end-effectuator30.Control device100 may track the movement of thevertebral bodies600,601 and control the depth and movement ofvertebral alignment tool250 until thevertebral bodies600,601 may be in a parallel configuration. A drill assembly500, with a depth stop (not illustrated), or other disc removal tool such as Kerrison or pituitary rongeurs may be safely inserted into the disc space603, through workingchannel253, between thevertebral bodies600,601 to remove disc material.
• After the surgeon has completed the operation,control device100 may removevertebral alignment tool250 using end-effectuator30.Control device100 may monitor the movement of the vertebral bodies and remove thevertebral alignment tool250 in a manner that may not harm the vertebral bodies. Similarly, the surgeon may remove the end-effectuator30 fromvertebral alignment tool250 and removevertebral alignment tool250 manually. This method may be employed to remove anycannula121,dilators200, or drill assembly safely from thepatient18, after surgery.
• Knowing the exact orientation of the disc space, by registration ofpatient18 to robot system1 (as discussed above), it may be possible to insert aninterbody device260 throughtubular element80, as illustrated inFIG. 18, during XLIF with much better knowledge and real-time feedback about the actual final positioning of the implant than is currently possible. As theinterbody device260 advances throughtubular element80 and into the disc space, a representation may be displayed oncontrol device100 through display means29 with an axial view of thevertebral body700, especially the disc space, and current location of theinterbody device260 overlaid, as illustrated inFIG. 18.
• Another method for keeping track of the orientation ofinterbody device260 is the dialable portal (not illustrated) as described above in the method of insertingvertebral alignment tool250 using end-effectuator30 of robot system1. Such a portal would enable the user to control the orientation of theinterbody device260 during insertion and with feedback to controldevice100 about the portal's angular orientation, either automatic through a sensor or manually entered by surgeon or technician, the orientation of the interbody device may be continuously monitored. An insertion tool (not illustrated) may have a sliding mechanism, which may be attached to end-effectuator30, to orient the tool as is dictated by the portal.
• InFIG. 18, theinterbody device260 is intentionally illustrated malpositioned to clarify the degrees of freedom for which adjustment may be needed to fully seatinterbody device260 in the desired resting position. A surgeon advancinginterbody device260 from the lateral approach, predominantly movinginterbody device260 from a left to right position, may manipulateinterbody device260 as required to fully seatinterbody device260 in the desired resting position. Additionally, a means for manipulating predominantly the anterior-posterior position ofinterbody device260 and a means of manipulating the rotational orientation ofinterbody device260 in the plane may be required. One method for achieving the desired insertion is for the surgeon to dial in the necessary anteroposterior offset and the necessary rotation offset in robot system1 integrated withtubular element80, then to focus on advancinginterbody device260 throughtubular element80 until the desired depth of insertion is achieved. It may be necessary to displaceinterbody device260 by the linear and rotational offset after advancinginterbody device260 and the insertion tool (not illustrated) far enough thatinterbody device260 is clear of the distal end oftubular element80 but before detachinginterbody device260 from the insertion tool. The desired final insertion depth may be controlled by an adjustable stop on the proximal end oftubular element80 or by the user stopping when the user visually identifiesinterbody device260 is far enough inserted oncontrol device100 through display means29. Similarly, the angulation and linear offset of theinterbody device260 may be imposed after robot system1 detects that at least some portion ofinterbody device260 is clear of the distal end oftubular element80 or after the user visually see theinterbody device260 is far enough inserted, oncontrol device100 through display means29, that the displacement may not causeinterbody device260 to collide withtubular element80. Detection of position and setting of robot system1 may be automatically or manually controlled. That is,control device100 may provide a surgeon with the anteroposterior distance “d” and the rotation angle “a”, as illustrated inFIG. 19, that are required to reach the target after the surgeon has completed planning of the desired final location ofinterbody device260 oncontrol device100 through display means29. Alternately,control device100 may automatically detect the required offsets and send a signal through robot system1 to end-effectuator30 to adjust to the appropriate offset positions.
• FIGS. 20 and 21 further illustrate embodiments of surgical robot system1 that may be used for any surgical procedure described above.FIG. 20 illustrates surgical robot system1 in a stowed position. In the stowed position, surgical robot system1 may be maneuvered into any surgical room, storage room, or down any hallway. Robot system1 may comprise of abase25, asurgical robot15, asupport structure28, ahousing27, a display means29, and arobot arm23. Robot system1 may further comprise a plurality ofarms50, a joint65, a joint60, and acamera arm55. Robot system1 may be maneuvered using a plurality ofwheels31 which may attach to robot system1 through awheel base26.Wheel base26 may support robot system1. As illustrated inFIG. 20, afirst structure200 and asecond structure205 may be attached to form robot system1.First structure200 may comprise of abase25, asurgical robot15, asupport structure28, ahousing27, a display means29, and arobot arm23. Thesecond structure205 may further comprise a plurality ofarms50, a joint60, a joint65, acamera56, andcamera arm55.
• FIG. 21 illustrates an embodiment of surgical robot system1 in a deployed state, whereinstructures200 and205 are separated from each other.First structure200 may comprise abase25, asurgical robot15, asupport structure28, ahousing27, a display means29, and arobot arm23.Support structure28 may support display means29,housing27, androbot arm23. An end effectuator30 (not pictured) may attach torobot arm23 by any suitable means.End effectuator30 may attach by any suitable means to any surgical tools described above (i.e. a cannula or drill assembly).Robot arm23,end effectuator30, and any attached surgical tools may operate according to any above described disclosure.Support structure28 may rotate 360 degrees along the y-axis in relation tosurgical robot15.Robot arm23 may further rotate or maneuver along the y-axis and x-axis, in relation tohousing27.Surgical robot15 may move laterally along the y-axis in relation tobase25.
• Asecond structure205, illustrated inFIG. 21, may comprise acamera56, acamera arm55, a joint60, a joint65, a plurality ofarms50, awheel base26, and a plurality ofwheels31.Structure205 may be positioned away fromstructure200 by a surgeon in preparation for surgery. The surgeon myposition structure205 in any manner in relation to structure200 to relay information fromcamera56 tosurgical robot15. Thesecond structure205 may positioncamera56 above a patient (not illustrated), orposition camera56 in any relation to the patient.Camera56 may send information fromsecond structure205 tofirst structure200. The information transmitted may be received bysurgical robot15 and transmitted to display means29 for display.
• Although the present invention and its advantages have been described in detail, it should be understood that various changes, substitutions and alterations may be made herein without departing from the spirit and scope of the invention as defined by the appended claims.

Claims (20)

What is claimed is:

1. A method for removing bone with a robot system comprising:

reformatting a two-dimensional slice perpendicular to the surgical entry pathway from a computed tomography scan volume of a patient anatomy;

defining a perimeter on a pathway through the anatomy; and

controlling a drill assembly with the robot system to remove bone from the pathway in the intersection of the perimeter and the two-dimensional slice.

2. The method ofclaim 1, further comprising controlling a tubular element with the robot system to place the tubular element adjacent to a target anatomy.

3. The method ofclaim 2, wherein the drill assembly is placed through the tubular element.

4. The method ofclaim 2, wherein the tubular element is advanced farther into the patient after the drill assembly removes bone from the pathway.

5. The method ofclaim 1, wherein sections of bone for drilling and soft tissue for avoiding are automatically demarcated using grayscale thresholding, and further wherein controlling the drill assembly to drill only in the area demarcated as bone.

6. The method ofclaim 1, wherein the two-dimensional slice is based on a CT scan and identifies a critical structure.

7. The method ofclaim 6, wherein a second perimeter is placed around the critical structure.

8. The method ofclaim 7, controlling the drill assembly to remove bone around the second perimeter but within the first perimeter.

9. A method for inserting a tubular element into a patient with a robot system comprising:

loading a computed tomography scan volume on to the robot system;

programming a route for the tubular element to travel through the patient to a target anatomical location on a display, wherein the display may manipulate the robot system; and

controlling the tubular element with the robot system to guide the tubular element along the programmed route through the patient.

10. The method ofclaim 9, wherein the programmed route may be altered by a surgeon while the robot system is moving the tubular element through the patient.

11. The method ofclaim 9, wherein a neural sensing probe is inserted into the tubular element before insertion into the patient.

12. The method ofclaim 11, wherein the route may be automatically changed by the robot system based upon the neural activity sensed by the neural probe.

13. The method ofclaim 9, wherein the display is separate from the robot system.

14. A method for aligning vertebrae for a surgical procedure using a robot system comprising:

inserting a tubular element into a patient and next to a disc space between adjacent vertebral bodies;

attaching the tubular element to an end-effectuator of the robot system; and

controlling a vertebral alignment tool with the robot system to insert the vertebral alignment tool through the tubular element such that the vertebral alignment tool is inserted between the adjacent vertebral bodies to distract the adjacent vertebral bodies.

15. The method ofclaim 14, further comprising rotating the end-effectuator of the robot system to align the vertebral alignment tool with disc space between the adjacent vertebral bodies.

16. The method ofclaim 15, wherein a locking dial portal is used to align the vertebral alignment tool.

17. The method ofclaim 14, wherein the tubular element is inserted into the patient while attached to the end-effectuator, the tubular element being controlled by the robot system.

18. The method ofclaim 14, wherein the vertebral alignment tool has a working channel.

19. The method ofclaim 18, further comprising inserting one or more additional surgical tools through the working channel and into disc space between the adjacent vertebral bodies.

20. The method ofclaim 14, further comprising removing disc material from between the adjacent vertebral bodies through a working channel in the vertebral alignment tool.

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