The present disclosure relates to orthopedics, and more particularly, to apparatus, systems, and methods for spinal surgery through a lateral approach.
The lateral approach to the spine is appealing because it avoids the major neural and vascular structures on the anterior and posterior aspects of the spine. However, the lateral approach may encounter other sensitive structures, such as the psoas muscle, neural plexus, vascular plexus, or other peritoneal structures. The psoas muscle is of particular interest because it is highly innervated. Therefore, insult to the psoas muscle is quite painful. Surgical procedures or approaches which minimize trauma to the psoas muscle may reduce postoperative pain and improve outcomes.
Various embodiments will now be discussed with reference to the appended drawings. It is appreciated that these drawings depict only typical embodiments and are therefore not to be considered limiting of the scope of the invention as set forth in the claims.
The present disclosure relates to systems and methods for direct lateral approach spine surgery. Those of skill in the art will recognize that the following description is merely illustrative of principles which may be applied in various ways to provide many different alternative embodiments. This description is made for the purpose of illustrating the general principles and is not meant to limit the inventive concepts in the appended claims.
One principle in the present disclosure is to reduce trauma to the psoas muscle. For example, the present disclosure teaches that the discectomy portion of a spinal procedure may be performed through a very small working portal. In another example, the present disclosure teaches that all instruments may be cannulated or otherwise adapted to be guided into the disc space by a guide-wire that is anchored to the disc annulus and/or vertebral body. These guided instruments would not require visualization of the procedural site, allowing for the minimal dissection size. In yet another example, at least some of the instruments may expand at the distal (working) tip to clear a path larger than that created outside the disc space by the access corridor. Once the discectomy is complete, the corridor through the psoas may be dilated to a larger size to accommodate implant placement.
A segmented fusion cage is disclosed. With a segmented implant, the entire procedure may be performed through a smaller working cannula. It may not be necessary to dilate the access corridor to a larger size after discectomy for fusion cage placement. The disclosed segmental fusion cage may be in two parts, so that half of the implant may be placed, followed by the other half.
Various apparatus, systems and methods will now be described with reference to the drawings.
A method of positioning a patient 2 for lateral spine surgery may place the patient 2 in a prone position, as illustrated in
Another method of positioning a patient 2 for lateral spine surgery may place the patient 2 in a lateral decubitus position, as illustrated in
Regardless of the patient position, the table 4 may provide one or more rails 16 to which apparatus may be secured. Specialized adapters may be useful with certain tables, depending on rail design.
After the patient 2 is prepared and draped, fluoroscopy may be used to locate the relevant spinal anatomy. The use of biplanar fluoroscopy may facilitate this step. Anatomy may be marked on the skin for later reference.
A method of locating the appropriate disc space may rely upon a targeting post 30. This method is illustrated in
The targeting post 30 may be positioned and oriented so that the tip 34 of the obturator 36 is seated at the midpoint of the superior endplate 18 of the inferior vertebra 38. Lateral fluoroscopy may be used to verify the position of the obturator tip 34. The targeting post depth stop mechanism 32 may be engaged. The obturator 36 may be oriented collinear with the superior endplate 18 of the inferior vertebra 38. Lateral fluoroscopy may be used to verify the orientation of the obturator 36. The micrometer 40 may be aligned with the spinous processes 42 and its position verified by anterior-posterior fluoroscopy. The targeting post 30 may be affixed to the clamp on the articulating surgical support arm.
The initial dilator 48 may be inserted into the offset arm 50 of the targeting apparatus 52 using the cam clamp 54. The initial dilator 48 shown in
An incision may be made through the skin into the initial fascial plane. The skin incision may be extended through the muscle fibers of the external and internal obliques and transversus abdominis. The initial incision may be large enough to permit finger dissection. Once through the abdominal muscles, blunt finger dissection may be used to access the retroperitoneal space. These anatomical structures are not shown but are well documented elsewhere, for example, in anatomy texts. Blunt finger dissection may extend down the transverse process to the psoas muscle 60. Optionally, a slender blunt instrument, such as a Kittner probe (not shown), may be used to gently dissect through the psoas muscle 60 between the middle and anterior third. One or more peritoneal retractors (not shown) may be used, as necessary. A neural monitoring system (not shown) may be clipped to the retractors.
An electrode (not shown) may be attached to the proximal end 62 of the initial dilator 48. Some or all of the dilators disclosed herein may include insulation to decrease current shunting whenever there is an exposed distal electrode at the tip of the dilator that acts as the stimulation source. The initial dilator 48 may be inserted all the way through the psoas muscle 60 up to the disc space 26, while observing the neural monitoring system, as shown in
A guide pin or k-wire (not shown) may be placed down the first dilator 48 and may be inserted into the disc space 26 to secure the dilator 48. The guide pin or k-wire may be inserted at least half way across the disc space 26. The position of the guide pin or k-wire may be verified with biplanar fluoroscopy.
Another method of locating the appropriate disc space may use the services of an interventional radiologist. This method is not illustrated in the present disclosure. Prior to the surgical procedure, the interventional radiologist may place catheters within each operative disc space 26. Catheters may be placed under conscious sedation. For example, an introducer needle may be placed on or in the outer annulus, with the optional use of biplanar fluoroscopy. A guide wire may be introduced through the needle and into the disc space 26. A catheter may be placed over the guide wire and through the introducer needle into the nucleus, after which the guide wire and needle may be removed. The balloon anchor of the catheter may be slightly inflated to anchor the catheter within the disc space. For example, the balloon may be inflated with contrast medium. The proximal end of the catheter may be capped and secured to the patient 2 with sterile tape. The patient 2 may then be transferred to the operating room for lateral access spine surgery.
When the lateral access spine surgery begins, a new guide wire may be introduced through the catheter directly into the disc space 26. The catheter may then be removed. The guide wire may be used to establish a safe operative corridor to the lateral spine.
Yet another method of locating the appropriate disc space may rely upon manual finger palpation. This method is illustrated in
A method of placing a retractor 76 and dilating surrounding tissues may dock the retractor 76 to the spine. This method is illustrated in
Another method of placing a retractor and dilating surrounding tissues may dock at least a portion of the apparatus to a rail 16 of the table 4. This method is illustrated in
A method for placing an anchor 88 on a contralateral side 27 of the disc 26 may deploy an anchor 88 that resembles a grappling hook. This method is shown in
Another method for placing an anchor 100 on a contralateral side 27 of the disc 26 may deploy an anchor 100 that resembles a button. This method is illustrated in
Regardless of the anchor used, the guide wire 98 or 110 is thus constrained to the contralateral annulus so that cannulated instruments or additional implants may be passed over the guide wire 98, 110 with confidence that the instruments or implants will follow a safe trajectory.
A method for performing at least a partial discectomy and/or endplate preparation may employ cannulated instruments which operate over the guide wire 98 or 110 to remove disc material and/or prepare the endplates.
After the disc space 26 and/or endplates are prepared, the contralateral anchor 88 or 100 and guide wire 98 or 110 may be removed as described above.
A method for selecting and inserting a spinal implant 122 is illustrated in
Another method for selecting and inserting a spinal implant 130 is shown in
The present invention may be embodied in other specific forms without departing from its spirit or essential characteristics. It is appreciated that various features of the above-described examples can be mixed and matched to form a variety of other alternatives. It is also appreciated that this system is not limited to spinal surgery; it may be used for surgical approaches to other body structures or in other directions. As such, the described embodiments are to be considered in all respects only as illustrative and not restrictive. The scope of the invention is, therefore, indicated by the appended claims rather than by the foregoing description. All changes which come within the meaning and range of equivalency of the claims are to be embraced within their scope.
This application claims the benefit of the filing date of: U.S. Application No. 61/324,384 filed Apr. 15, 2010, entitled DIRECT LATERAL SPINE SYSTEM—INSTRUMENTS, IMPLANTS AND ASSOCIATED METHODS, which is pending. The above-identified document is incorporated herein by reference.
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