Patent Application
20110172709
This invention relates generally to the treatment of spinal conditions, and more particularly, to the treatment of spinal stenosis using devices for implantation between adjacent spinous processes.
The clinical syndrome of neurogenic intermittent claudication due to lumbar spinal stenosis is a frequent source of pain in the lower back and extremities, leading to impaired walking, and causing other forms of disability in the elderly. Although the incidence and prevalence of symptomatic lumbar spinal stenosis have not been established, this condition is the most frequent indication of spinal surgery in patients older than 65 years of age.
Lumbar spinal stenosis is a condition of the spine characterized by a narrowing of the lumbar spinal canal. With spinal stenosis, the spinal canal narrows and pinches the spinal cord and nerves, causing pain in the back and legs. It is estimated that approximately 5 in 10,000 people develop lumbar spinal stenosis each year. For patients who seek the aid of a physician for back pain, approximately 12%-15% are diagnosed as having lumbar spinal stenosis.
Common treatments for lumbar spinal stenosis include physical therapy (including changes in posture), medication, and occasionally surgery. Changes in posture and physical therapy may be effective in flexing the spine to decompress and enlarge the space available to the spinal cord and nerves—thus relieving pressure on pinched nerves. Medications such as NSAIDS and other anti-inflammatory medications are often used to alleviate pain, although they are not typically effective at addressing spinal compression, which is the cause of the pain.
Surgical treatments are more aggressive than medication or physical therapy, and in appropriate cases surgery may be the best way to achieve lessening of the symptoms of lumbar spinal stenosis. The principal goal of surgery is to decompress the central spinal canal and the neural foramina, creating more space and eliminating pressure on the spinal nerve roots. The most common surgery for treatment of lumbar spinal stenosis is direct decompression via a laminectomy and partial facetectomy. In this procedure, the patient is given a general anesthesia as an incision is made in the patient to access the spine. The lamina of one or more vertebrae is removed to create more space for the nerves. The intervertebral disc may also be removed, and the adjacent vertebrae may be fused to strengthen the unstable segments. The success rate of decompressive laminectomy has been reported to be in excess of 65%. A significant reduction of the symptoms of lumbar spinal stenosis is also achieved in many of these cases.
Alternatively, the vertebrae can be distracted and an interspinous process device implanted between adjacent spinous processes of the vertebrae to maintain the desired separation between the vertebral segments. Such interspinous process devices typically work for their intended purposes, but some could be improved. Typically the spacer portion of the implant is formed from a hard material. Unfortunately, point loading of the spinous process can occur due to the high concentration of stresses at the point where the hard material of the spacer contacts the spinous process. This may result in excessive subsidence of the spacer into the spinous process. In addition, if the spinous process is osteoporotic, there is a risk that the spinous process could fracture when the spine is in extension. Moreover, some interspinous process devices unduly restrict the patient's freedom of movement.
Thus, a need exists for improvements in interspinous process devices so as to minimize or eliminate point loading of the spinous process and to allow more freedom of movement for the patient.
An interspinous process device described herein includes a pair of superior plates, a pair of inferior plates, a plurality of spikes located along the interior faces of the superior plates and inferior plates, and a joint that connects the superior plates and the inferior plates and that allows relative movement between the superior plates and inferior plates. In addition, such an interspinous process device may include a spacer disposed between the superior plates and inferior plates. The spacer may be located such that it is adjacent to the mechanism for connecting the superior plates and the inferior plates.
One embodiment of the joint that connects the superior plates and inferior plates is a channel formed in the inferior portion of at least one, but preferably each, of the superior plates that is sized to allow a superior portion of one of the inferior plates to extend into one of the channels. Alternatively, a channel may be formed in the superior portion of at least one, but preferably each, of the inferior plates that is sized to allow an inferior portion of one of the superior plates to extend into one of the channels. The channels preferably extend longitudinally through the inferior portions of the superior plates to allow a linear motion between the superior and inferior plates. Alternatively, the channels may extend in a curvilinear fashion to allow a curvilinear motion between the superior and inferior plates.
Other joints that connect the superior plates and inferior plates are contemplated as well. For example, the inferior portion of the superior plates and the superior portion of the inferior plates may be connected to a universally directional capsule that allows relative movement between the superior plates and the inferior plates in three planes. The capsule can have various characteristics that allow for preferred motion in particular directions. Another mechanism for connecting the superior plates and the inferior plates includes a spring joint. For example, the inferior portion of the superior plates and the superior portion of the inferior plates may be connected to either a compression spring or a torsion spring. The choice of a compression spring or a torsion spring is based on the relative movement desired for the interspinous process device. Yet another mechanism for connecting the superior plates and the inferior plates includes a ball joint. In this embodiment, the inferior portions of the superior plates include a socket and the superior portions of the inferior plates include a ball that fits within the socket of the superior plates. This ball and socket configuration allows relative motion of the superior plates and the inferior plates. Of course, the inferior portions of the superior plates could include the ball and the superior portions of the inferior plates could include the socket.
The interspinous process device described herein is implanted such that one superior plate is located along one side of a superior spinous process and the second superior plate is located along the opposite side of the superior spinous process. The spikes are located on the interior portions of the superior portions of each of the superior plates such that they can be embedded in the superior spinous process to affix the superior plates to the superior spinous process at the desired location. Similarly, one inferior plate is located along one side of an adjacent inferior spinous process and the second inferior plate is located along the opposite side of the adjacent inferior spinous process. Additional spikes are located on the interior portions of the inferior portions of each inferior plate such that they can be embedded in the adjacent inferior spinous process to affix the inferior plates to the inferior spinous process at the desired location.
In this orientation, and with the adjacent vertebrae distracted, the inferior portions of the superior plates and the superior portions of the inferior plates are disposed adjacent to each other to allow desired motion of the adjacent vertebrae but prevent unwanted extension and compression. In one embodiment of the interspinous process device of this invention, the superior portions of the inferior plates are located in channels formed in the inferior portions of the superior plates to allow relative linear motion between the superior and inferior plates. Thus, when the spine is in flexion, the interspinous process device of this invention extends and allows the adjacent spinous processes to move apart as the two adjacent vertebrae pivot. And, when the spine is in extension, the interspinous process device of this invention collapses and allows the adjacent spinous processes to move toward each other as the two adjacent vertebrae pivot in the opposite direction. The height of the channels limits the total distance that the interspinous process device collapses to ensure there is sufficient decompression to eliminate the patient's pain. In addition, a spacer may be included with the interspinous process device to limit the amount of extension by the spine and minimize any stress on the spinous processes caused by the spikes, which are embedded in the spinous processes. Where a universally directional capsule, spring joint or ball and socket joint is used to join the superior and inferior plates, the overall height of the superior plate, inferior plate and capsule, spring joint or ball and socket joint, define the overall minimum spacing between adjacent vertebrae. In the embodiment where a universally directional capsule or spring joint is used, there is some flexion because the capsule and spring joint are somewhat flexible. However extension is limited by the extent of the compressibility of the capsule and spring joint.
As used in this specification and the appended claims, the singular forms “a,” “an” and “the” include plural referents unless the context clearly dictates otherwise. Thus, for example, the term “a member” is intended to mean a single member or a combination of members, and “a material” is intended to mean one or more materials, or a combination thereof. Furthermore, the words “proximal” and “distal” refer to directions closer to and away from, respectively, an operator (e.g., surgeon, physician, nurse, technician, etc.) who would insert the medical device into the patient, with the tip-end (i.e., distal end) of the device inserted inside a patient's body first. Thus, for example, the device end first inserted inside the patient's body would be the distal end of the device, while the device end last to enter the patient's body would be the proximal end of the device.
As used in this specification and the appended claims, the term “body” when used in connection with the location where the device of this invention is to be placed to treat lumbar spinal stenosis, or to teach or practice implantation methods for the device, means a mammalian body. For example, a body can be a patient's body, or a cadaver, or a portion of a patient's body or a portion of a cadaver.
As used in this specification and the appended claims, the term “parallel” describes a relationship, given normal manufacturing or measurement or similar tolerances, between two geometric constructions (e.g., two lines, two planes, a line and a plane, two curved surfaces, a line and a curved surface or the like) in which the two geometric constructions are substantially non-intersecting as they extend substantially to infinity. For example, as used herein, a line is said to be parallel to a curved surface when the line and the curved surface do not intersect as they extend to infinity. Similarly, when a planar surface (i.e., a two-dimensional surface) is said to be parallel to a line, every point along the line is spaced apart from the nearest portion of the surface by a substantially equal distance. Two geometric constructions are described herein as being “parallel” or “substantially parallel” to each other when they are nominally parallel to each other, such as for example, when they are parallel to each other within a tolerance. Such tolerances can include, for example, manufacturing tolerances, measurement tolerances or the like.
As used in this specification and the appended claims, the terms “normal”, perpendicular” and “orthogonal” describe a relationship between two geometric constructions (e.g., two lines, two planes, a line and a plane, two curved surfaces, a line and a curved surface or the like) in which the two geometric constructions intersect at an angle of approximately 90 degrees within at least one plane. For example, as used herein, a line is said to be normal, perpendicular or orthogonal to a curved surface when the line and the curved surface intersect at an angle of approximately 90 degrees within a plane. Two geometric constructions are described herein as being “normal”, “perpendicular”, “orthogonal” or “substantially normal”, “substantially perpendicular”, “substantially orthogonal” to each other when they are nominally 90 degrees to each other, such as for example, when they are 90 degrees to each other within a tolerance. Such tolerances can include, for example, manufacturing tolerances, measurement tolerances or the like.
Interspinous process device 100 includes a pair of superior plates 20a and 20b, a pair of inferior plates 30a and 30b, a plurality of spikes 50 located along the interior faces of superior plates 20a, 20b and inferior plates 30a, 30b, and a joint that connects superior plates 20a, 20b and inferior plates 30a, 30b and that allows relative movement between superior plates 20a, 20b and inferior plates 30a, 30b. Superior plate 20a is connected to superior plate 20b by a connecting rod 70, which may be formed on one of the superior plates. The other end of connecting rod 70 fits in a recess or hole 75 formed in the other superior plate. Alternatively, the connecting rod could be a separate piece that fits into recesses formed in each of superior plates 20a and 20b or inferior plates 30a, 30b. In addition, interspinous process device 100 may include a spacer 60 disposed between superior plates 20a, 20b and/or inferior plates 30a, 30b adjacent to the joint that connects superior plates 20a, 20b and inferior plates 30a, 30b. Spacer 60 is preferably disposed about connecting rod 70. It is to be understood that this general configuration may be used with all of the various joint mechanisms that are described herein for joining the superior plates to the inferior plates.
The joint that connects superior plates 20a, 20b and inferior plates 30a, 30b can take many forms. In the embodiment shown in
Channels 40a and 40b are defined by end walls 41a, 41b and a plurality of side walls. When the spine is in extension, interspinous process device 100 collapses by allowing the superior portions of inferior plates 30a and 30b to move completely into channels 40a and 40b respectively. End walls 41a and 41b act as a stop for the superior ends of the superior portions of inferior plates 30a and 30b, which are thus prevented from moving any farther superiorly along channels 40a and 40b. When the superior ends of the superior portions of inferior plates 30a and 30b are in contact with end walls 41a and 41b respectively, interspinous process device 100 is in its fully collapsed position. When interspinous process device 100 is in this position, the adjacent vertebrae on which interspinous process device 100 is affixed are held apart a sufficient amount to prevent compression of the relevant spinal nerves and provide pain relief for the patient. Thus, with interspinous process device 100, no spacer needs to be used to maintain decompression. However, if desired, spacer 60 can be used to act as a secondary stop that limits spinal extension and thus defines a minimum distance between the adjacent vertebrae. This ensures appropriate decompression for effective pain relief. In addition, spacer 60 alleviates some stress imposed on the adjacent spinous processes by the spikes 50 that are embedded therein by taking up some of the load on interspinous process device 100 when the spine is in extension.
The height of channels 40a and 40b and the length of the superior ends of inferior plates 30a and 30b that are disposed in channels 40a and 40b respectively are selected such that inferior plates 30a and 30b can not be completely withdrawn from channels 40a and 40b when the spine is in flexion. In other words, when the spine is in flexion and interspinous process device 100 is in its fully extended position, at least some part of the superior portions of inferior plates 30a and 30b are still disposed in channels 40a and 40b respectively. This maintains the integrity of interspinous process device 100.
It is to be understood that although the foregoing discussion discloses that the channels are disposed in the inferior portions of the superior plates, the channels could alternatively be formed in the superior portions of the inferior plates with the inferior portions of the superior plates being sized so they can be disposed in such channels. In addition, even though these embodiments have a pair of channels, it is to be understood that interspinous process device 100 could include a single channel formed in one of the superior plates or one of the inferior plates.
Spikes 50 are designed to be embedded in the lateral surface of the spinous processes when superior plates 40a and 40b and inferior plates 30a and 30b are squeezed laterally toward each other during implantation. Spikes 50 may have a pointed or otherwise sharp tip to facilitate embedding spikes 50 in the bone of the spinous process. With spikes 50 embedded in the lateral surfaces of the spinous processes, interspinous process device 100 is affixed to the adjacent spinous processes in the desired location.
Interspinous process device 100 is implanted such that superior plates 20a and 20b are located along opposite sides of a superior spinous process with spikes 50, located on the interior surface of superior plates 20a and 20b, embedded in the superior spinous process. Similarly, inferior plates 30a and 30b are located along opposite sides of the adjacent inferior spinous process with spikes 50, located on the interior surface of inferior plates 30a and 30b, embedded in the inferior spinous process. The superior portions of inferior plates 30a and 30b are located in channels 40a and 40b of superior plates 20a and 20b respectively. The combination of spikes 50, which fix interspinous process device 100 in place, and end walls 41a and 41b limit the amount that interspinous process device 100 can collapse. Moreover, there is no hard spacer needed to provide decompression. This eliminates a hard surface on which the adjacent spinous processes rest that could concentrate stresses on osteoporotic bone of the spinous processes. The elimination of a spacer is a significant advantage over current interspinous process devices where the spacer portion of the implant is formed from a hard material. Where spacer 60 is included in the interspinous process device of this invention, it may be sized so its diameter is slightly smaller than the distracted space between adjacent spinous processes when interspinous process device 100 is implanted. This prevents point loading on the spinous processes but still allows the spacer to act as a secondary stop in case spikes 50 somehow become disengaged from the spinous processes.
Other joints that connect the superior plates and inferior plates are contemplated as well. For example, the inferior portion of superior plates 20a″, 20b″ and the superior portion of inferior plates 30a″, 30b″ may be connected to a universally directional capsule 200 that allows relative movement between superior plates 20a″, 20b″ and inferior plates 30a″, 30b″ in three planes. See
Capsules 200 allow superior plates 20a″, 20b″ and inferior plates 30a″, 30b″ to move relative to each other thus allowing (i) spinal flexibility in flexion and extension, (ii) lateral bending of the spine, and (ii) axial rotation of the spine. In addition, capsule 200 provides some shock absorption when the spine is in extension. In other words, instead of allowing the inferior ends of superior plates 20a″, 20b″ to abut the superior ends of inferior plates 30a″, 30b″ to abruptly stop extension of the spine, capsule 200 may provide controlled movement when the inferior ends of superior plates 20a″, 20b″ and the superior ends of inferior plates 30a″, 30b″ move toward each other. This would thus prevent an abrupt shock to the spine during extension. This controlled motion also minimizes some of the stresses placed on the spinous processes by the spikes 50 embedded therein to fix interspinous process device 100″ in place. Of course, the overall height of interspinous process device 100″ with capsule 200 in its fully compressed condition determines the extent of decompression provided. Where capsule 200 is relatively stiff and non-compressible, interspinous process device 100″ limits flexion and extension. Where capsule 200 is more compliant, greater flexion and extension is possible.
As shown in
Another joint that connects the superior plates and the inferior plates includes a spring. For example, the inferior portion of superior plates 20a′″, 20b′″, and the superior portion of inferior plates 30a′″, 30b′″ may be connected to either a compression spring 310 or a torsion spring 320. The choice of a compression spring or a torsion spring is based on the relative movement desired for the interspinous process device.
Yet another joint that connects the superior plates and the inferior plates includes a ball joint. See
The interspinous process device described herein can be constructed with various biocompatible materials such as, for example, titanium, titanium alloy, surgical steel, biocompatible metal alloys, stainless steel, Nitinol, plastic, polyetheretherketone (PEEK), carbon fiber, ultra-high molecular weight (UHMW) polyethylene, and other biocompatible polymeric materials. The material of the interspinous process device can have, for example, a compressive strength similar to or higher than that of bone. Alternatively, the interspinous process device may have a lower elastic modulus than bone.
While various embodiments of the interspinous process device have been described above, it should be understood that they have been presented by way of example only, and not limitation. Many modifications and variations will be apparent to the practitioner skilled in the art. The foregoing description of the interspinous process device is not intended to be exhaustive or to limit the scope of the invention. It is intended that the scope of the invention be defined by the following claims and their equivalents.
