Patent Grant
10111704
Various embodiments of the invention pertain generally to generating passageways through tissue and to treatment or monitoring of intraosseous nerves, and more particularly to creating curved paths in bone and to treatment of basivertebral nerves within vertebral bodies of the spine.
Back pain is a very common health problem worldwide and is a major cause for work-related disability benefits and compensation. Back pain may arise from strained muscles, ligaments, or tendons in the back and/or structural problems with bones or spinal discs. The back pain may be acute or chronic. Treatments for chronic back pain vary widely and include physical therapy and exercise, chiropractic treatments, rest, pharmacological therapy such as pain relievers or anti-inflammatory medications, and surgical intervention such as vertebral fusion, discectomy or disc repair. Existing treatments can be costly, addictive, temporary, ineffective, and/or can increase the pain or require long recovery times.
The technique of accessing the vertebral body through minimally invasive means has been developed through the surgical techniques used in vertebroplasty and kyphoplasty. Although accessing the vertebral segments of the spine through the pedicle and into the lateral/anterior section of the body of the vertebra is a primary method of placing a treatment device or neuromodulation device (e.g. a bone cement delivery device, a chemical agent delivery device, and/or an RF probe) into the vertebra, it can be difficult to place a probe in the posterior midline section of the vertebra. Furthermore, accessing the posterior midline section of the S1 segment of the spine can be difficult with a straight linear access route. In several embodiments, a probe or other treatment device (e.g., neuromodulation device) advantageously is capable of navigating to the posterior section of the S1 vertebral segment, as well as to the same target area within a lumbar vertebral segment. In addition, in accordance with several embodiments, vertebral segments in the cervical and thoracic regions of the spine may also be targeted.
In order to accurately and predictably place a treatment device (e.g., neuromodulation device such as an energy or fluid delivery catheter or probe) in the posterior section of a lumbar vertebral body, a sacral vertebral body or other level vertebral body, the device or probe may navigate to the target area through varying densities of bone in some embodiments. However, due to the varying densities of bone, it can be difficult to navigate a probe in bone and ensure its positioning will be in the posterior (e.g., posterior to the midline) or posterior midline section of the vertebral body. Accordingly, several embodiments of the invention are directed to a system and method for generating a path in bone that predictably follows a predetermined curved path. The neuromodulation devices described herein can be configured to perform any of the method steps recited herein.
Several embodiments of the invention are directed to systems and methods to deploy and navigate a flexible treatment instrument, such as a neuromodulation device (e.g., a radiofrequency (RF) bipolar probe, a microwave energy delivery device, a fluid or agent delivery device) within bone. Although the systems and methods described herein are primarily directed to navigating through the bone of a vertebral member of the spine, and particularly to treat the basivertebral nerve (BVN) of a vertebral member, the treatment may be applied to any tissue segment of the body.
Several embodiments of this invention advantageously provide the ability to navigate a curve or angle within varying densities of cancellous bone and create a straight channel at the end of the navigated curve or angle.
In accordance with several embodiments, a method of therapeutically treating a vertebral body having an outer cortical bone region and an inner cancellous bone region, and a BVN having a trunk extending from the outer cortical bone region of the vertebral body into the inner cancellous region of the vertebral body and a plurality of branches extending from the trunk to define a BVN junction or terminus, comprises the steps of: a) inserting one or more energy devices into the vertebral body, and b) exclusively depositing energy within the inner cancellous bone region of the vertebral body between, but exclusive of, the BVN junction and the outer cortical bone region, to denervate the BVN. In some embodiments, the method comprises depositing, or delivering, energy, fluid, or other substance at or proximate (e.g., posterior to) the BVN junction, or terminus. In some embodiments, a delivery probe for delivering a non-energy therapeutic is provided instead of, or in addition to, the energy device.
In some embodiments, a tube-within-tube system comprises a deployable curved tube (e.g. comprised of Nitinol or other flexible, elastic, or shape memory material) that deploys from a straight cannula. The tube can be pre-curved to create an angular range of approximately 0° to approximately 180° (e.g., from approximately 45° to approximately 110°, from approximately 15° to approximately 145°, from approximately 30° to approximately 120°, from approximately 60° to approximately 90°, from approximately 10° to approximately 45°, overlapping ranges thereof, or any angle within the recited ranges), when fully deployed from the straight cannula. The design of the curve can be such that a flexible element (e.g., probe carrying a treatment device) can navigate through the angular range of deployment of the curved tube. The curved tube can allow the flexible element to navigate through a curve within cancellous bone tissue without veering off towards an unintended direction.
Cancellous bone density varies from person to person. Therefore, creating a curved channel within varying density cancellous bone may not predictably or accurately support and contain a treatment device as it tries to navigate the curved channel. With some embodiments, the flexible element is deployed into the bone through the curved tube, which supports the flexible element as it traverses through the curve, thereby preventing the flexible element from channeling its own path. When the flexible element (e.g., energy or agent delivery probe) departs from the tube, it can do so in a linear direction towards the target zone or location. In accordance with several embodiments, this design allows the user to predictably and accurately deploy the flexible element (e.g., treatment device) towards the target zone or location regardless of the density of the cancellous bone.
One embodiment of the invention comprises a system for channeling a path into bone. The system may comprise a trocar having a central channel and opening at its distal tip, and a cannula sized to be received in said central channel and to be delivered to the distal opening. The cannula may comprise a deflectable or deformable tip with a preformed curve such that the tip straightens while being delivered through the trocar and regains its preformed curve upon exiting and extending past the distal opening of the trocar to generate a curved path in the bone corresponding to the preformed curve of the deflectable or deformable tip. At least the distal tip or distal section of the cannula may comprise a resiliently deformable material (such as Nitinol or other shape memory material). The cannula may comprise a central passageway or lumen having an internal diameter configured to allow a treatment device to be delivered through the central passageway to a location beyond the curved path in the bone.
In one embodiment, the system further includes a straight stylet configured to be installed in the trocar, wherein the straight stylet comprises a sharp distal tip that is configured to extend beyond the distal opening of the trocar to pierce the bone as the trocar is being delivered to a treatment location within the bone (e.g., within the inner cancellous bone region of a vertebral body).
The system may further include one or more straightening stylets configured to be introduced in the cannula, wherein the straightening stylet comprises a rigid construction configured to straighten the distal tip of the curved cannula when positioned in the trocar. In some embodiments, the straightening stylet further comprises a sharp distal end to pierce the bone, and the straightening stylet and curved cannula are installed or inserted in the trocar in place of the straight stylet as the trocar is delivered into the bone.
In some embodiments, the system further comprises a curved stylet having an outer radius sized to fit within the central passageway of the curved cannula. The curved stylet is configured to be installed or inserted in the curved cannula while the curved cannula is extended past the distal opening of the trocar, the curved stylet configured to block the distal opening of the curved cannula while being delivered into the bone. In some embodiments, the curved stylet advantageously has a curved distal end corresponding to the curve of the curved cannula.
In one embodiment, the curved stylet has a sharp distal tip configured to extend past the curved cannula to pierce the bone as the cannula is delivered past the distal opening of the trocar. The curved stylet also may advantageously comprise an angled distal tip configured to further support and maintain the curved stylet radius as it is delivered past the distal opening of the trocar and into bone. The curved stylet and the curved cannula may have mating proximal ends (e.g., visual indicia or corresponding physical mating elements) that align the curve of the curved stylet with the curve of the curved cannula.
In one embodiment, the system further includes a straight channeling stylet configured to be installed in the curved cannula after removing the curved stylet, wherein the straight channeling stylet is flexibly deformable to navigate the curved cannula yet retain a straight form upon exiting the curved cannula. The straight channeling stylet may have a length longer than the curved cannula such that it creates a linear path beyond the distal end of the curved cannula when fully extended. Curved and/or straightening stylets may be used for non-spinal embodiments.
In accordance with several embodiments, a method for channeling a path into bone to a treatment location in the body of a patient is provided. The method includes, in one embodiment, inserting a trocar having a central channel and an opening at its distal tip into a region of bone at or near the treatment location, and delivering a cannula through the central channel and to the distal opening. In one embodiment, the cannula comprises a deflectable or deformable tip with a preformed curve such that the tip straightens while being delivered through the trocar and regains its preformed curve upon exiting the trocar, and extending the cannula past the distal opening of the trocar to generate a curved path in the bone corresponding to the preformed curve of the deflectable tip. In some embodiments, a treatment device is delivered through a central passageway or lumen in the cannula to the treatment location beyond the curved path. The treatment device may facilitate or effect energy delivery, fluid delivery, delivery of an agent, etc.
In one embodiment, inserting a trocar into a region of bone comprises inserting a stylet into the trocar such that the stylet extends beyond the distal opening of the trocar, and inserting the stylet and trocar simultaneously into the region of bone such that the stylet pierces the bone as the trocar is being delivered to a treatment location.
In one embodiment, delivering a cannula through the central channel comprises inserting a straightening stylet into the central passageway of the cannula and inserting the straightening stylet and straightened cannula simultaneously into the trocar. In one embodiment, the straightening stylet comprises a rigid construction configured to straighten the curved distal tip of the cannula. In one embodiment, the straightening stylet further comprises a sharp distal end to pierce the bone. In one embodiment, the straightening stylet and cannula are installed simultaneously along with the trocar as the trocar is delivered into the bone.
In one embodiment, extending the cannula past the distal opening is performed by inserting a curved stylet into the central passageway of the curved cannula such that a distal tip of the curved stylet extends to at least the distal opening of the curved cannula and simultaneously extending the curved cannula and curved stylet from the distal end of the trocar such that the curved stylet blocks the distal opening of the curved cannula while being delivered into the bone.
In some embodiments, the curved stylet has a curved distal end corresponding to the curve of the curved cannula such that the curved stylet reinforces the curved shape of the curved cannula as the curved cannula is extended past the distal opening of the trocar. The curved stylet may have a sharp distal tip so that when the curved stylet extends past the distal opening of the curved cannula the curved stylet is configured to pierce the cancellous bone tissue as the curved cannula is delivered past the distal opening of the trocar.
In some embodiments, the curved stylet is then removed from the curved cannula, and a straight channeling stylet is inserted into the curved distal end of the cannula. The straight channeling stylet can be flexibly deformable to navigate the curved cannula, yet retain a straight form upon exiting the curved cannula. The straight channeling stylet can advantageously be longer than the curved cannula to create a linear channel beyond the distal tip of the curved cannula.
In some embodiments, the trocar is inserted through a cortical bone region and into a cancellous bone region of a vertebral body, and the curved cannula is extended though at least a portion of the cancellous bone region to a location at or near a target treatment location. A target treatment location may comprise a BVN within the vertebra, and treatment may be delivered to the target treatment location to modulate (e.g., denervate, ablate, stimulate, block, disrupt) at least a portion of the BVN (e.g., terminus or junction or a portion of the BVN between the terminus or junction and the posterior wall). In one embodiment, a portion of the BVN is modulated by delivering focused, therapeutic heating (e.g., a thermal dose) to an isolated region of the BVN. In another embodiment, a portion of the BVN is modulated by delivering an agent to the treatment region to isolate treatment to that region. In accordance with several embodiments of the invention, the treatment is advantageously focused on a location of the BVN that is upstream of one or more branches of the BVN.
In accordance with several embodiments, a kit for channeling a path into bone is provided. The kit comprises a trocar having a central channel and opening at its distal tip, and a cannula selected from a set of cannulas sized to be received in the central channel and delivered to the distal opening. The cannula has a deflectable or deformable distal tip with a preformed curve such that the tip straightens while being delivered through the trocar and regains its preformed curve upon exiting and extending past the distal opening of the trocar to generate a curved path in the bone corresponding to the preformed curve of the deflectable tip. The cannula comprises a central passageway or lumen having an internal diameter configured to allow a treatment device to be delivered through the central passageway or lumen to a location beyond the curved path within bone, wherein the set of cannulas comprises one or more cannulas that have varying preformed curvatures at the distal tip.
In some embodiments, the one or more cannulas have a varying preformed radius at the distal tip. In addition, the one or more cannulas may each have distal tips that terminate at varying angles with respect to the central channel of the trocar. The length of the distal tips may also be varied. The angle of the distal tip with respect to the central channel of the trocar may vary from 0 degrees to 180 degrees (e.g., from 10 degrees to 60 degrees, from 15 degrees to 45 degrees, from 20 degrees to 80 degrees, from 30 degrees to 90 degrees, from 20 degrees to 120 degrees, from 15 degrees to 150 degrees, overlapping ranges thereof, or any angle between the recited ranges). The kit may further include a straight stylet configured to be installed in the trocar, the straight stylet comprising a sharp distal tip that is configured to extend beyond the distal opening of the trocar to pierce the bone as the trocar is being delivered to a treatment location within the bone. The kits may be adapted for non-spinal embodiments.
In some embodiments, the kit includes a set of curved stylets having an outer radius sized to fit within the central passageway of the curved cannula, wherein each curved stylet is configured to be installed in the curved cannula while the curved cannula is extended past the distal opening of the trocar. The curved stylet may be configured to block the distal opening of the curved cannula while being delivered into the bone. In one embodiment, each curved stylet has a varying curved distal end corresponding to the curve of a matching curved cannula in the set of curved cannulas. The curved stylet may have a sharp distal tip configured to extend past the curved cannula to pierce the bone as the cannula is delivered past the distal opening of the trocar.
In some embodiments, the kit includes a set of straight channeling stylets wherein one of the set of stylets is configured to be installed in the cannula after removing the curved stylet. The straight channeling stylet can be flexibly deformable to navigate the curved cannula yet retain a straight form upon exiting the curve cannula. Each of the straight channeling stylets can have a varying length longer than the curved cannula such that the straight channeling stylet creates a predetermined-length linear path beyond the distal end of the curved cannula when fully extended.
In accordance with several embodiments, a system for channeling a path into bone comprising a trocar with a proximal end, a distal end and a central channel disposed along a central axis of the trocar and extending from the proximal end toward the distal end is provided. The trocar, in one embodiment, comprises a radial opening at or near the distal end of the trocar, the radial opening being in communication with the central channel. The system further comprises, in one embodiment, a curveable or steerable cannula sized to be received in said central channel and delivered from the proximal end toward said radial opening. In several embodiments, the curveable cannula comprises a curveable and/or steerable distal end configured to be extended laterally outward from the radial opening in a curved path extending away from the trocar, and a central passageway having a diameter configured allow a treatment device (e.g., probe, catheter) to be delivered through the central passageway to a location beyond the curved path.
In several embodiments, the curveable cannula comprises a proximal end having a proximal body. In one embodiment, the proximal end of the trocar comprises a housing. The housing may comprise a proximal recess configured to allow reciprocation (e.g., alternating back-and-forth motion or other oscillatory motion) of the proximal body of the curveable cannula. The proximal recess of the housing may be in communication with the central channel of the trocar. In several embodiments, a proximal body of the curveable cannula is configured to be releasably restrained with respect to translation within the trocar housing. In several embodiments, the system comprises a probe sized to fit within the central channel of the cannula. The probe may comprise a proximal end configured to be releasably restrained with respect to translation within the proximal body of the curveable cannula. In one embodiment, the probe comprises mating threads that mate with corresponding mating threads of a distal recess of the drive nut so as to allow controlled translation of the probe with respect to the drive nut.
In several embodiments, a spine therapy system is provided. In one embodiment, the system comprises a trocar having a proximal end, a distal end and a central channel. The central channel can be disposed along a central axis of the trocar and extend from the proximal end toward the distal end. In one embodiment, the trocar comprises a radial opening at or near the distal end of the trocar, the radial opening being in communication with the central channel. In one embodiment, the trocar is configured to be deployed through a cortical bone region and into a cancellous bone region of a vertebral body. In one embodiment, a curveable cannula is configured (e.g., sized) to be received in said central channel and delivered from the proximal end toward the radial opening. The curveable cannula may comprise a central passageway and a curveable and/or steerable distal end configured to be extended laterally outward from the radial opening in a curved path extending away from the trocar. The curved path may be generated through at least a portion of the cancellous bone region of the vertebral body. In one embodiment, a treatment device or probe is configured to be delivered through the central passageway to a location beyond the curved path. The trocar, curveable cannula, and/or treatment device can have a sharp distal end or tip configured to penetrate bone tissue. In some embodiments, the distal ends of the trocar, curveable cannula, and/or treatment device are rounded or blunt. In some embodiments, the distal ends of the trocar or curved or curveable cannula have a full radius on the inside and/or outside diameter to prevent other devices from catching when being pulled back into the distal end after being delivered out of the distal end.
In accordance with several embodiments, a method for channeling a path into bone to a treatment location in the body of a patient is provided. The bone may be within or proximal a vertebral body, or may be non-spinal (e.g., knee or other joints). In one embodiment, the method comprises inserting a trocar into a region of bone near the treatment location. In one embodiment, the trocar comprises a proximal end, a distal end, and a central channel disposed between the two ends. In one embodiment, the method comprises delivering a curveable cannula through the central channel and to a radial opening at or near the distal end of the curveable cannula. In one embodiment, the method comprises deploying the curveable cannula laterally outward from the radial opening in a curved path extending away from the trocar. In one embodiment, the method comprises steering the curveable cannula (e.g., via a pull cord coupled to the distal tip of the curveable cannula or via other steering mechanisms) to bias the curveable cannula in the curved path. Energy and/or another diagnostic or therapeutic agent is then optionally delivered to the treatment location.
In accordance with several embodiments, a method of treating back pain is provided. In some embodiments, the method comprises identifying a vertebral body for treatment (e.g., a target for treatment of chronic back pain). In some embodiments, the method comprises identifying a treatment zone, area or site within the inner cancellous bone region of the vertebral body. In some embodiments, the treatment zone, area or site is within a posterior section of the vertebral body (e.g., posterior to an anterior-posterior midline, within the area between 20% and 50% of the distance from the posterior wall of the vertebral body). In some embodiments, the treatment zone comprises a location corresponding to the mid-height of the vertebra from an anterior-posterior view. In some embodiments, a border of the treatment zone is at least 1 cm (e.g., between 1-2 cm, 2-3 cm, 3-4 cm, or more) from the posterior wall of the vertebral body. In some embodiments, the treatment zone is determined by measuring the distance from the posterior wall to the basivertebral foramen as a percentage of the total distance from the posterior wall to the anterior wall of the vertebral body.
In some embodiments, identifying a treatment zone is performed pre-operatively using imaging methods such as magnetic resonance imaging (MRI) or computed tomography (CT) imaging modalities. In some embodiments, the treatment zone, site, or location corresponds to a location that is about mid-height between the superior and inferior endplate surfaces of the vertebral body (which may be identified by imaging methods from an anterior-posterior view). In some embodiments, the treatment zone, site or location is identified by measuring the distance from the posterior wall of the vertebral body to the basivertebral foramen from images (e.g., (e.g., anteroposterior and/or lateral MRI or CT images) of the vertebral body as a percentage of the total distance from the posterior wall to the anterior wall of the vertebral body. In some embodiments, inserting the neuromodulation device within the treatment zone is performed under visualization (e.g., using fluoroscopy). In some embodiments, positioning a distal end portion of the neuromodulation device within the treatment zone comprises positioning the distal end portion (and any active elements such as electrodes located at the distal end portion) at a location corresponding to the measured distance percentage described above. In some embodiments, the percentage is a standardized distance percentage that is not individually measured for the individual subject or vertebral body being treated. In some embodiments, the treatment zone, site, or location corresponds to a location at or proximate (e.g., posterior to) a terminus of the basivertebral foramen.
In some embodiments, the method comprises inserting a curved cannula through the outer cortical bone region of the vertebral body and into the inner cancellous bone region of the vertebral body. The curved cannula can comprise a flexible catheter, tube, or other conduit having a pre-curved or steerable distal end. The curved cannula may comprise Nitinol, PEEK, or other thermoplastic, shape memory or resiliently deformable material. In some embodiments, the method comprises inserting a neuromodulation device within the curved cannula. The neuromodulation device can comprise an energy delivery device, a fluid delivery device, or an agent delivery device. The fluid may or may not comprise an agent, such as a chemical agent. In one embodiment, the chemical agent comprises a lytic agent.
In various embodiments, the energy delivery device is configured to deliver radiofrequency energy, microwave energy, light energy, thermal energy, ultrasonic energy, and/or other forms of electromagnetic energy, and/or combinations of two or more thereof. In accordance with several embodiments, the energy is configured to heat tissue within bone (e.g., a vertebral body) sufficient to modulate (e.g., denervate, ablate) intraosseous nerves (e.g., basivertebral nerves or other nerves located partially or fully within bone). In other embodiments, the energy is configured to treat tissue outside the spine, for example in non-spinal joints or in non-orthopedic applications (e.g., cardiac, pulmonary, renal, or treatment of other organs and/or their surrounding nerves). The temperature of the energy may be in the range of between 40° C. and 100° C., between 50° C. and 95° C., between 60° C. and 80° C., between 75° C. and 95° C., between 80° C. and 90° C., overlapping ranges thereof, or any temperature between the recited ranges. In some embodiments, the temperature and length of treatment can be varied as long as the thermal dose is sufficient to modulate (e.g., at least temporarily denervate, ablate, block, disrupt) the nerve. In some embodiments, the length of treatment (e.g., delivery of energy) ranges from about 5 to about 30 minutes (e.g., about 5 to 15 minutes, about 10 to 20 minutes, about 15 to 25 minutes, about 20 to 30 minutes, overlapping ranges thereof, 15 minutes, or about any other length of time between the recited ranges). In some embodiments, the neuromodulation device comprises a sensor to measure nerve conduction of the nerve at the treatment zone.
The energy delivery device may comprise one or more probes (e.g., a radiofrequency probe). In some embodiments, the probe comprises one or more electrodes configured to generate a current to heat tissue within bone. In one embodiment, the probe comprises a bipolar probe having two electrodes. The two electrodes may comprise an active electrode and a return electrode. In one embodiment, the active electrode comprises a tip electrode positioned at the distal tip of the radiofrequency probe and the return electrode comprises a ring electrode spaced proximally from the active electrode with insulation material between the two electrodes. In one embodiment, the return electrode comprises a tip electrode positioned at the distal tip of the probe (e.g., a radiofrequency probe) and the active electrode comprises a ring electrode spaced proximally from the return electrode. The two electrodes may be spaced about 1 mm, 2 mm, 3 mm, 4 mm, 5 mm, 6 mm, 7 mm, 8 mm, 9 mm or 1 cm apart. In various embodiments, the electrodes comprise cylindrical electrodes, tip electrodes, plate electrodes, curved electrodes, circular electrodes, or other shapes. In some embodiments, the electrodes comprise an electrode array. In various embodiments, the frequency of the energy can be between about 100 kHz and 1 MHz, between 400 kHz and 600 kHz, between 300 kHz and 500 kHz, between 350 kHz and 600 kHz, between 450 kHz and 600 kHz, overlapping ranges thereof, or any frequency within the recited ranges.
In one embodiment, the energy delivery device comprises an ultrasound probe having one or more ultrasound transducers. The ultrasound probe may be configured to deliver high-intensity focused ultrasonic energy, low-intensity ultrasonic energy or other forms of ultrasonic energy sufficient to modulate the nerve. The ultrasound energy may be used for cavitation or non-cavitation. In one embodiment, the energy delivery device comprises a laser or light energy delivery device configured to deliver light energy sufficient to modulate the nerve. In one embodiment, the energy delivery device is configured to deliver radiation sufficient to modulate the nerve. In one embodiment, the energy delivery device comprises a microwave energy delivery device comprising one or more microwave antennas configured to deliver microwave energy sufficient to effect modulation of the nerve.
In one embodiment, a fluid delivery device is used to effect a temperature change in a location in the disc. For example, the fluid delivery device may be used to deliver a cryoablative fluid. In another embodiment, the fluid delivery device may be used to deliver a cooling fluid to cool a region in conjunction with a therapy that generates heat. In some embodiments, a distal portion of the curved cannula is shaped so as to guide a distal end of the neuromodulation device towards the midline of the vertebral body (or other treatment area outside the spine). In some embodiments, a proximal end of the fluid delivery device is coupled to a fluid source or reservoir (e.g., syringe, fluid pump). In some embodiments, the fluid delivery device comprises a catheter, tube, sleeve, needle, cannula, wicking device, or other conduit configured to deliver fluid. The fluid may comprise neurolytic agents, chemotherapy agents, radioactive substances, medications, drugs, pharmaceuticals, alcohols, acids, solvents, cooling agents, nerve blocking agents, and/or other chemical agents.
In some embodiments, the method comprises advancing the distal end of the neuromodulation device out of a distal opening of said cannula and into the inner cancellous bone region of the vertebral body or treatment area. The distal opening may be an axial opening or a radial opening. In some embodiments, the method comprises positioning the distal end of said neuromodulation device within, at or proximate the treatment zone, area site, or location of the vertebral body or treatment area.
In some embodiments, the method comprises effecting modulation of at least a portion of a nerve (e.g., basivertebral nerve or intraosseous nerve) using the neuromodulation device. The modulation (e.g., neuromodulation) can comprise partial or complete and/or temporary or permanent blocking, disruption, denervation or ablation of the nerve. In various embodiments, the modulation comprises radiofrequency ablation, microwave energy ablation, chemical ablation, cryoablation, ultrasonic ablation, laser ablation, thermal ablation, thermal heating, cooling, mechanical severing, neuromodulation, and/or stimulation of the nerve. In one embodiment, stimulation of the nerve is performed to block the travel of signals indicative of pain. Stimulation may comprise mechanical, electrical, or electromechanical stimulation. The stimulation may be continuous or pulsed.
In accordance with several embodiments, a method of treating pain (e.g., back pain) is provided. In some embodiments, the method comprises identifying a treatment zone, such as a vertebral body for treatment (e.g., an identified source of pain or location likely to treat pain). In some embodiments, the treatment zone comprises a basivertebral residence zone within which a portion of the basivertebral nerve (e.g., main trunk, junction, terminus of basivertebral foramen, etc.) is likely to reside. In some embodiments, the treatment zone is identified without knowing the precise location of the basivertebral nerve. In some embodiments, the method comprises identifying a treatment zone, site, region or location within the inner cancellous bone region within a posterior section of the vertebral body. The posterior section may comprise a section posterior to an anterior-posterior midline or a region within a distance between about 10% and about 50%, between about 20% and about 50%, between about 10% and about 40% of the distance from the posterior wall. In some embodiments, the method comprises inserting a distal end portion of the neuromodulation device (e.g., energy and/or fluid delivery probe), and any active elements disposed thereon, within or proximate the treatment zone. In some embodiments, the method comprises thermally inducing modulation of a function of a basivertebral nerve within the vertebral body with the energy delivery probe.
In some embodiments, the method comprises generating a curved path within the inner cancellous bone region towards a midline of the vertebral body with a cannula having a pre-curved distal end portion to facilitate access to the posterior section of the vertebral body. In some embodiments, insertion of the neuromodulation device through a curved cannula allows for access straight through (e.g., concentrically through) the pedicle in a transpedicular approach instead of an off-center access, which may be difficult for some levels of vertebrae due to anatomic constraints. In some embodiments, the method comprises inserting the neuromodulation device within the curved path created by the cannula. In some embodiments, the cannula is shaped so as to guide a distal end portion of the neuromodulation device towards the midline of the vertebral body. In some embodiments, the method comprises inserting a stylet within the cannula that is adapted to penetrate bone tissue of the vertebral body beyond the curved path created by the cannula.
In accordance with several embodiments, a method of therapeutically heating a vertebral body to treat back pain is provided. In some embodiments, the method comprises identifying a residence zone of a basivertebral nerve within the inner cancellous bone region of the vertebral body. In some embodiments, the method comprises inserting two electrodes into the vertebral body. In some embodiments, the method comprises positioning the two electrodes within or proximate the residence zone. In some embodiments, the method comprises generating a heating zone between the two electrodes to heat the basivertebral nerve. For example, a first electrode may be activated to generate a current between the first electrode and a second electrode. The current may generate heat within the bone tissue. The heating zone may comprise an inner resistive heating zone and an outer conductive heating zone. In some embodiments, the heating zone is configured to have a radius or diameter between about 0.5 cm and 2 cm (e.g., 0.5 cm, 0.6 cm, 0.7 cm, 0.8 cm, 0.9 cm, 1 cm, 1.1 cm, 1.2 cm, 1.3 cm, 1.4 cm, 1.5 cm, 1.6 cm, 1.7 cm, 1.8 cm, 1.9 cm, 2 cm). In accordance with several embodiments, forming heating zones (and in some cases, lesions) of a specific size and shape can be improved by adjusting parameters such as diameter and active length of electrodes, initial and steady-state power input, length of treatment, and device control temperature.
In some embodiments, inserting two electrodes into the vertebral body comprises inserting a first energy delivery probe having a first electrode within the inner cancellous bone region and positioning a second energy delivery probe having a second electrode within the inner cancellous bone region. In some embodiments, inserting two electrodes into the vertebral body comprises inserting a single energy delivery probe having two electrodes within the inner cancellous bone region.
In some embodiments, positioning the two electrodes within or proximate the residence zone comprises positioning the electrodes at a location such that a single heating treatment modulates (e.g., denervates, ablates) the entire basivertebral nerve system without requiring separate downstream modulation (e.g., denervation, ablation) treatments. In some embodiments, positioning the two electrodes of within or proximate the residence zone comprises positioning the two electrodes to straddle the residence zone. In some embodiments, positioning the two electrodes within or proximate the residence zone comprises positioning a first electrode on a first side of the vertebral body and positioning a second electrode on a second side of the vertebral body.
In accordance with several embodiments of the invention, methods and systems allow for positioning of a treatment device in contact with or in close proximity to a basivertebral nerve without knowing the precise location of the basivertebral nerve. In attempting to place at least one electrode in close proximity to the BVN, the approaches disclosed in the teachings of the art are somewhat problematic. In particular, although the location of the BVN is somewhat well known, the BVN is radiolucent and so its precise location can not be easily identified by an X-ray. Since the BVN is also extremely thin, knowingly placing the electrode in close proximity to the BVN may be problematic in some cases. Moreover, in one embodiment, since certain RF electrodes appear to heat only a fairly limited volume of bone, misplacement of the electrode vis-à-vis the BVN may result in heating a volume of bone that does not contain the BVN. “Close proximity” with regard to the intraosseous or basivertebral nerve can mean located at a position such that the nerve is modulated upon activation of the neuromodulation device or delivery of fluid or other substances by the neuromodulation device.
For example, and now referring to
However, now referring to
Similarly, now referring to
Moreover, even if the precise location of the BVN were known, it has been found to be difficult to access the posterior portion of the BVN from a transpedicular approach with a substantially straight probe, especially for some levels of the vertebrae that have anatomical constraints.
Therefore, in accordance with several embodiments, the systems and methods described herein allow the practitioner to heat the basivertebral nerve without having to know the precise location of the basivertebral nerve, and without having to precisely place the electrode tip next to the portion of the basivertebral nerve to be treated, while still allowing the practitioner to access the vertebral body straight (e.g., concentrically) through the pedicle.
The terms “modulation” or “neuromodulation”, as used herein, shall be given their ordinary meaning and shall also include ablation, permanent denervation, temporary denervation, disruption, blocking, inhibition, therapeutic stimulation, diagnostic stimulation, inhibition, necrosis, desensitization, or other effect on tissue. Neuromodulation shall refer to modulation of a nerve (structurally and/or functionally) and/or neurotransmission. Modulation is not limited to nerves and may include effects on other tissue.
Several embodiments of the invention relate to the production of a large but well-controlled heating zone within bone tissue to therapeutically treat (e.g., modulate) an ION within the heating zone. Other embodiments provide modulation of non-spinal tissue (e.g., nerves).
Now referring to
Still referring to
Now referring to
Moreover, embodiments of the invention allow the practitioner to therapeutically treat the ION even when the ION is in fact located at the edges of the ION residence zone IRZ. Now referring to
Therefore, in one embodiment, the straddling of the ION residence zone satisfactorily locates the electrodes so that the total heating zone produced by the electrode activation includes the ION irrespective of the actual location of the ION within the ION residence zone IRZ, thereby ensuring that the electrodes heat the ION to therapeutically beneficial temperatures.
Therefore, some embodiments provide a method of therapeutically treating a bone having an intraosseous nerve ION defining first and second sides of the bone, comprising inserting an energy device having an active and a return electrode into the bone, and placing the active electrode on the first side of the bone and the return electrode on the second side of the bone to define a total heating zone therebetween. A sufficiently high frequency voltage may then be applied between the active and return electrodes to generate a current therebetween to resistively heat the total heating zone sufficient to denervate the ION.
Several embodiments provide a very controlled total heating zone which exists substantially only between the paired electrodes. In accordance with several embodiments, the consequent ability to both modulate the BVN with substantial certainty and to minimize the volume of bone tissue affected by the heating appears to be novel in light of the conventional bone-related technology.
Accordingly, some embodiments of the invention are advantageous because they allow the clinician to create a sufficiently large heating zone for therapeutically treating the ION (e.g., BVN) without requiring direct access to the ION. Some embodiments of the invention are particularly advantageous because such embodiments: (i) do not require knowing the precise location of the ION, (ii) do not require directly accessing the ION, and/or (iii) have a controlled heating profile that allows a clinician to avoid heating adjacent structures such as the healthy adjacent cancellous bone tissue, the spinal cord or opposing vertebral endplates.
In accordance with several embodiments, there is provided a method of therapeutically treating a vertebral body having a BVN defining first and second sides of the vertebral body In one embodiment, the method comprises determining a BVN residence zone within which the BVN likely resides, the BVN residence zone having a first side and a second side, inserting an energy device having an active and a return electrode into the vertebral body, placing the active electrode on the first side of the residence zone and the return electrode on the second side of the residence zone to define a total heating zone therebetween, and applying a sufficiently high frequency voltage between the active and return electrodes to generate a current therebetween to resistively heat the total heating zone to a temperature sufficient to denervate the BVN.
Further aspects of embodiments of the invention will be discussed in the following portions of the specification. With respect to the drawings, elements from one figure may be combined with elements from the other figures.
Several embodiments of the invention will be more fully understood by reference to the following drawings which are for illustrative purposes only:
Several embodiments of the invention are directed to systems and methods to deploy and navigate a treatment instrument, such as a neuromodulation device (e.g., a radiofrequency (RF) bipolar probe, a microwave energy delivery device, a fluid or agent delivery device) within bone. Although the systems and methods described herein are primarily directed to navigating through the bone of a vertebral member of the spine, and particularly to treat the basivertebral nerve (BVN) of a vertebral member, the treatment may be applied to any nerve and/or to any tissue segment of the body.
In accordance with several embodiments, the systems and methods of treating back pain or facilitating neuromodulation of intraosseous nerves described herein can be performed without surgical resection, without general anesthesia, and/or with virtually no blood loss. In some embodiments, the systems and methods of treating back pain or facilitating neuromodulation of intraosseous nerves described herein facilitate easy retreat if necessary. In accordance with several embodiments of the invention, successful treatment can be performed in challenging or difficult-to-access locations and access can be varied depending on bone structure. One or more of these advantages also apply to treatment of tissue outside of the spine (e.g., other orthopedic applications or other tissue).
Tube-in-Tube
The surgical devices and surgical systems described may be used to deliver numerous types of treatment devices to varying regions of the body. Although the devices and systems are particularly useful in navigating through bone, in one embodiment they may also be used to navigate through soft tissue, or through channels or lumens in the body, particularly where one lumen may branch from another lumen.
The following examples illustrate the system 10 applied to generating a curved bone path in the vertebral body, and more particularly for creating a bone path via a transpedicular approach to access targeted regions in the spine. In particular, the system 10 may be used to deliver a treatment device to treat or ablate intraosseous nerves, and in particular that basivertebral nerve (BVN). Although the system and methods provide significant benefit in accessing the BVN, in one embodiment, the system 10 may similarly be used to create a bone path in any part of the body (such as the humerus, femur, pelvis, fibula, tibia, ulna, radius, etc.)
In accordance with several embodiments, the basivertebral nerves are at, or in close proximity to, the exit point 142. In some embodiments, the exit point 142 is the location along the basivertebral nerve where the basivertebral nerve exits the vertebra. Thus, the target region of the BVN 122 is located within the cancellous portion 124 of the bone (i.e., to the interior of the outer cortical bone region 128), and proximal to the junction J of the BVN 122 having a plurality of branches 130. Treatment in this target region is advantageous because only a single portion of the BVN 122 need be effectively treated to modulate (e.g., denervate or otherwise affect the entire BVN system. Treatment, in accordance with one embodiment, can be effectuated by focusing in the region of the vertebral body located between 60% (point A) and 90% (point B) of the distance between the anterior and posterior ends of the vertebral body. In some embodiments, treatment is located at or proximate (e.g., posterior to) the junction J. In some embodiments, treatment of the BVN 122 in locations more downstream than the junction J requires the denervation of each branch 130. The target region may be identified or determined by pre-operative imaging, such as from MRI or CT images. In various embodiments, treatment can be effectuated by focusing in the region of the vertebral body located at a region that is more than 1 cm from the outer cortical wall of the vertebral body, within a region that is centered at or about 50% of the distance from the posterior outer wall of the vertebral body to the anterior outer wall, and/or within a region that is between 10% and 90% (e.g., between about 10% and about 60%, between about 5% and about 65%, between about 10% and about 55%, or overlapping ranges thereof) of the distance from the posterior outer wall of the vertebral body to the anterior outer wall.
In various embodiments, the junction J is located at a location of the terminus of the vertebral foramen, at the junction between a main trunk of the BVN 122 and the initial downstream branches, at a location corresponding to a junction between at least one of the initial downstream branches and its respective sub-branches, or other locations along the BVN 122.
In one approach for accessing the BVN, the patient's skin is penetrated with a surgical instrument which is then used to access the desired basivertebral nerves, i.e., percutaneously. In one embodiment, a transpedicular approach is used for penetrating the vertebral cortex to access the BVN 122. A passageway 140 is created between the transverse process 134 and spinous process 136 through the pedicle 138 into the cancellous bone region 124 of the vertebral body 126 to access a region at or near the base of the nerve 122. In one embodiment, a postereolateral approach (not shown) may also be used for accessing the nerve. The transpedicular approach, postereolateral approach, basivertebral foramen approach, and other approaches are described in more detail in U.S. Pat. No. 6,699,242, herein incorporated by reference in its entirety.
Referring now to
In some embodiments, after the proper depth is achieved, the straight stylet 80 is removed from the trocar 20, while the trocar 20 remains stationary within the vertebra 120. The straightening stylet 40 may be inserted into proximal aperture 52 (see
As shown in
Referring to
Once the stylet 60 is fully seated and aligned with the curved cannula 50, the tip of the curved stylet 60 may protrude from the tip of the curved cannula 50 by about 1/16 to 3/16 inches. This protrusion can help to drive the curve in the direction of its orientation during deployment.
Referring now to
Referring to
Referring now to
Referring now to
With the trocar 20 and curved cannula 50 still in place, a treatment device (e.g. treatment probe 100 shown in
In one embodiment, the active element 102 is delivered to the treatment site and activated to deliver therapeutic treatment energy. In various embodiments, the treatment device comprises a probe, catheter, antenna, wire, tube, needle, cannula, sleeve, or conduit. The treatment device may comprise an RF delivery probe having bipolar electrodes 106 and 108 that deliver a therapeutic level of heating (e.g., thermal dose) to modulate (e.g., stimulate or ablate) at least a portion of the nerve 122.
In some embodiments, the treatment device comprises a microwave energy delivery device comprising one or more antennas. In some embodiments, the treatment device comprises a chemical ablation or cryoablation device comprising a fluid conduit for delivery (e.g., injection) of fluids, chemicals or agents (e.g., neurolytic agents) capable of ablating, stimulating, denervating, blocking, disrupting, or otherwise modulating nerves. In some embodiments, the treatment device comprises an ultrasound delivery device having one or more transducers or a laser energy delivery device comprising one or more light delivery elements (e.g., lasers, such as fiber optic lasers or vertical cavity surface emitting lasers (VCSELs), or light emitting diodes (LEDs)).
According to several embodiments of the invention, many treatment modalities can be delivered to the treatment site for modulation of nerves or other tissue (e.g., neuromodulation, ablation, temporary or permanent denervation, stimulation, inhibition, blocking, disruption, or monitoring). For example, treatment may be affected by monopolar or tripolar RF, ultrasound, radiation, steam, microwave, laser, or other heating means. These modalities may be delivered to the treatment site through one or more of the embodiments of systems and/or methods disclosed herein, and treatment applied such that the nerve is heated to the desired level for the desired duration (e.g., a sufficient thermal dose is applied) to affect stimulation, denervation, ablation or the desired therapeutic effect.
For example, the ultrasonic energy can be controlled by dosing, pulsing or frequency selection to achieve the desired heating level for the desired duration. Similarly, microwave treatment may be applied using a microwave energy delivery catheter and/or one or more antennas. Microwaves may be produced with a frequency in the range of 300 GHz to 300 MHz, between 1 GHz and 5 GHz, between 2 GHz and 10 GHz, between 10 GHZ and 100 GHz, 100 GHz and 300 GHz, between 50 GHz and 200 GHz, between 200 GHz and 300 GHz, or overlapping ranges thereof. Pulses of between 1-5 seconds, between 2-3 seconds, between 0.5 seconds-2 seconds, between 4-5 seconds, between 5-10 seconds, between 10-30 seconds, or overlapping ranges between, in duration may be generated. In some embodiments, a single pulse, 1-3 pulses, 2-4 pulses, 3-8 pulses, 8-20 pulses, or overlapping ranges between, may be generated.
Radiation therapy may use radiation sources comprising any one of a number of different types, such as, but not limited to, particle beam (proton beam therapy), cobalt-60 based (photon or gamma-ray source such as that found in the GammaKnife), or linear accelerator based (e.g., linac source). The dose of radiation delivered to the patient will typically range between 10 Gy and 70 Gy. However, because the treatment region is contained within the large bony mass of the vertebral body, higher doses may be contemplated, as there is little risk to surrounding tissues that are more vulnerable. The dose may be varied based on the treatment volume, or other variables such as treatment time and dose concentration. A prescription of 35 instances of a 2 Gy dose might be replaced by 15 instances of a 3 Gy dose, a technique known as “hypofractionation.” Taken to its logical extreme, this might be replaced with a single 45 Gy dose if the dosage delivered to healthy tissue can be reduced significantly. An identification dose may in some embodiments be used prior to the treatment dose, for example, to elicit some response form the patient relating to the patient's pain. The identification dose is generally a much smaller dose than treatment dose TD, so as not to damage healthy tissue. An exemplary dose may range from 0.5 Gy to 5 Gy. However, this range may also change based on considerations such as anatomy, patient, etc.
Additionally or alternatively, the treatment device may comprise a fluid or agent delivery catheter that deposits an agent or fluid, e.g. bone cement, phenol, alcohol, neurotoxin, inhibitory or stimulatory drug, chemical, or medicament, for neuroablation or permanent or temporary denervation, or other therapeutic agent, to the treatment site or location T. Growth factors, stem cells, gene therapy or other biological therapeutic agents may also be delivered.
In some embodiments, cryogenic cooling may be delivered for localized treatment of the BVN or an intraosseous nerve using, for example, liquid nitrogen, liquid nitrous oxide, liquid air, or argon gas. Cryotherapy may be delivered in one or more freeze cycles. In several embodiments, two freeze-thaw cycles are used. In some embodiments, 3-5 freeze-thaw cycles are used. In some embodiments, a single freeze-thaw cycle is used In some embodiments, a desired temperature of the tissue is −40° C. to −50° C., −20° C. to −40° C., −35° C. to −45° C., −50° C. to −80° C., or overlapping ranges thereof. The desired temperature may be maintained for 5-20 minutes, 10-15 minutes, or greater than 10 minutes, depending on the temperature and thermal dose desired. Furthermore, treatment may be effected by any mechanical destruction and or removal means capable of severing or denervating the BVN. For example, a cutting blade, bur, electrocautery knife or mechanically actuated cutter typically used in the art of orthoscopic surgery may be used to effect denervation of the BVN.
In addition to or separate from treating (e.g., modulating) the BVN or an intraosseous nerve, a sensor may be delivered to the region to preoperatively or postoperatively measure nerve conduction at the treatment region. In this configuration, the sensor may be delivered on a distal tip of a flexible probe that may or may not have treatment elements as well.
In accordance with several embodiments, the goal of the treatment may be ablation, or necrosis of the target nerve or tissue, or some lesser degree of treatment to denervate the BVN. For example, the treatment energy or frequency may be just sufficient to stimulate the nerve to block the nerve from transmitting signals (e.g. signals indicating pain) without ablation or necrosis of the nerve. The modulation may be temporary or permanent.
In several embodiments, the therapeutic modalities described herein (including energy or agent delivery) modulates neurotransmission (e.g., neurotransmitter synthesis, release, degradation and/or receptor function, etc.). In some embodiments, signals of nociception are affected. Effects on neurokinin A, neuropeptide Y, substance P, serotonin and/or other signaling pathways are provided in some embodiments. Calcium and/or sodium channel effects are provided in one embodiment. In some embodiments, G-protein coupled receptors are affected.
Once the treatment is complete, the probe 100 may be withdrawn. The curved cannula 50 may then be withdrawn into the needle trocar 20. The needle trocar 20 with the curved cannula 50 may then be removed and the access site may be closed as prescribed by the physician or other medical professional.
In the above system 10, the design of the curves 56 and 66 of the curved cannula 50 and curved stylet 60 is such that a flexible element (e.g., distal portion of the treatment device) can navigate through the angular range of deployment of the curved cannula 50 (e.g., Nitinol or other material tube). The curved cannula 50 allows the flexible element to navigate through a curve within bone without veering off towards an unintended direction. Cancellous bone density varies from person to person. Therefore, creating a curved channel within varying density cancellous bone 124 will generally not predictably or accurately support and contain the treatment device as it tries to navigate the curved channel.
With the system 10, the treatment device 100 is deployed into the bone through the curved cannula 50 (e.g., Nitinol tube), which supports the flexible element (e.g., distal portion of the treatment device) as it traverses through the curve. When it departs from the tube, it will do so in a linear direction along path 146 towards the target zone. In accordance with several embodiments, this advantageously allows the user to predictably and accurately deploy the treatment device towards the target zone or location T regardless of the density of the cancellous bone.
In some embodiments, a radius of curvature that is smaller than that which can be achieved with a large diameter Nitinol tube may be advantageous. To achieve this, the curved portion of the curved cannula 50 may take one of several forms. In one embodiment, the curved cannula 50 is formed from a rigid polymer (e.g., formed PEEK) that can be heat set in a particular curve. If the polymer was unable to hold the desired curve, an additional stylet (e.g. curved stylet 60) of Nitinol, flexible stainless steel, shape memory material, metallic or metallic-based material, or other appropriate material, may also be used in conjunction with the polymer tube to achieve the desired curve. In some embodiments, the stylet comprises a braided tube, rod, or wire. In some embodiments, the stylet comprises a non-braided tube, rod, or wire, or combinations thereof. This proposed combination of material may encompass any number or variety of materials in multiple different diameters to achieve the desired curve. These combinations only need to ensure that the final outside element (e.g. trocar 20) be “disengageable” from the internal elements and have an inner diameter sufficient to allow the desired treatment device 100 to pass to the treatment region T. In accordance with several embodiments, the treatment region T is in a posterior section (e.g., posterior to a midline) of the vertebral body. The treatment region T may correspond to an expected location of a terminus of a basivertebral foramen.
In one embodiment, the curved cannula 50 may comprise a Nitinol, shape memory material, stainless steel or other metallic tube having a pattern of reliefs or cuts (not shown) in the wall of the tube (particularly on the outer radius of the bend). The pattern of cuts or reliefs could allow the tube to bend into a radius tighter than a solid tube could without compromising the integrity of the tubing wall. The curved portion of the curved cannula 50 may comprise a different material than the main body of the curved cannula or the same material.
In an embodiment of the method, the straightening stylet 40 is inserted into the curved cannula 50 and secured. In this embodiment, the straightening stylet 40 has a sharp tip 46 designed to penetrate bone. Once the straightening stylet 40 is secure and the curved cannula 50 is straight, they are inserted into the needle trocar 20 and secured. In tone embodiment, the curved cannula 50 and straightening stylet 40 are inserted into the shaft 28 of the trocar 20 only as far as to have sharp tip 46 of the straightening stylet 40 protrude from the distal end 22 of the trocar 20. Proper alignment is maintained by aligning a flat on the upper portion of the curved cannula 50 with a pin secured perpendicularly into the needle trocar 20 handle. Other alignment elements may also be used (e.g., visual indicia such as lines, text, shapes, orientations, or coloring).
Referring now to
After the proper depth is achieved, the straightening stylet 40 may be removed. The curved stylet 60 may then be straightened out by sliding the small tube 68 on its shaft towards the distal tip 64. In some embodiments, the curved distal tip 66 is straightened out and fully retracted inside the small tube 68, and then the curved stylet 60 is inserted into the curved cannula 50, which still resides inside the needle trocar 20. Once the curved stylet 60 is inserted into the curved cannula 50, the small tube 68 may be met by a stop 55 (see
To create a maximum force, it may be advantageous that the curves of the two parts (50 & 60) are aligned. To ensure alignment, the cap on the curved stylet 60 may have an alignment pin, which engages with a notch on the top of the curved cannula 50. Other alignment elements may also be used (e.g., visual indicia such as lines, text, shapes, orientations, or coloring).
When the stylet 60 is fully seated and aligned with the curved cannula 50, the tip of the curved stylet 60 may protrude from the tip of the curved cannula 50 by about 1/16 to 3/16 inches. This protrusion can help to drive the curved cannula 50 in the direction of its orientation during deployment. Once the curved stylet 60 and the curved cannula 50 are engaged, the lock nut at the top of the curved cannula 50 may be rotated counter clockwise to allow the cannula 50 and stylet 60 to be advanced with relation to the needle trocar 20 (as shown in
The curved stylet 60 may then be removed and replaced by the channeling stylet 90. In some embodiments, the channeling stylet 90 is advanced beyond the end of the curved cannula 50 (see
Once the treatment is complete, the treatment device 100 can be withdrawn. In some embodiments, the curved cannula 50 is then withdrawn into the needle trocar 20. The needle trocar 20 with the curved cannula 50 can then be removed and the access site can be closed as prescribed by the physician or other medical professional.
As shown in
In the example illustrated in
Any of the embodiments described herein may be provided as a kit of instruments to treat different regions of the body. For example, the location, orientation and angle of the treatment device with respect to the trocar 20 may be varied by providing a set of instruments at varying increments. This may be achieved by varying the curvature (56, 66) in the curved cannula 50 and curved stylet 60. The curvature may be varied by varying the radius of curvature r, the insertion depth (shaft length LS and tip length LT, and/or the final exit angle σ with respect to the trocar 20 central bore. Thus, the physician or other clinician may select a different kit for treating a lumber spine segment as opposed to a cervical spine segment, as the anatomy will dictate the path that needs to be channeled.
Thus, when treating different spine segments, a set out of the kit may be selected to match the vertebra (or other region being treated). For example, delivering the treatment device at or near the BVN junction or terminus for a lumbar vertebra may have a different angle than for a sacral or cervical vertebra, and may vary from patient to patient. The set may be selected from the kit intraoperatively, or from a pre-surgery diagnostic evaluation (e.g. radiographic imaging of the target region).
Tube in Windowed Tube
The elongate delivery tube 204 comprises a laterally positioned radial opening or window 212 disposed just proximal or at the distal tip 208. The window 212 provides radial access from the central channel 218 of tube 204 so that an instrument or probe (e.g. probe 250 distal end) may be delivered at an angle (e.g. non-axial) with respect to the tube axis or central channel 218.
The proximal end 206 of trocar housing 202 comprises a centrally-located, counter-bore or recess 216 that is in communication with trocar channel 218. Trocar recess 216 allows placement and reciprocation of curveable cannula 230 within the trocar recess 216 and trocar central channel 218. The curveable cannula 230 may be held in place at a specified location within the trocar recess 216 via a stop nut 240 that is threaded about proximal body 246 of the curveable cannula 230. The curveable cannula 230 also comprises a central recess 268 within proximal body 246 that is centrally aligned with cannula channel 245. Central recess 268 and cannula channel 245 are configured to receive and allow reciprocation of probe 250, which is threaded into drive nut 270. In several embodiments, the drive nut 270 comprises a hardened proximal surface suitable for applying an impact force to advance one or more of the trocar, curveable cannula, or probe through bone.
During insertion of the trocar 210, the stop nut 240 may be threaded distally along external threads 248 of the proximal body 246 of the curveable cannula 230 to restrict motion of the cannula 230 distally down trocar recess 216. This restrained motion may keep the distal end 232 of the cannula 230 from prematurely deploying while the trocar 210 is being delivered.
In accordance with several embodiments, the distal end of the curveable cannula is deformable so as to be delivered in a straight configuration through the trocar and deployed in a curved configuration outward from the radial opening at an angle with respect to the central axis. As shown in
The mating links 234 are held together with a cord 242 that runs from the proximal body 246 of the curveable cannula 230, and terminates at an aperture 236 in the distal link 232. In some embodiments, the distal end of cord 242 terminates at a ball 238 that is disposed in a counter-bore, countersink, or like retaining surface of the aperture 236 to retain the cord within the distal link 232.
Referring now to
The proximal body 246 of curveable cannula 230 may then be deployed downward within trocar recess 216, as shown in section view in
In some embodiments, a pull cord 242 is coupled to the distal tip of the curveable cannula 230, the pull cord extending to the proximal end of the trocar 210. In addition to the ramp 209, the curved path of the distal tip 233 is facilitated by tension provided by cord 242, which forces the mating links 232, 234 to arch upon the applied tension. The pull cord may be configured to apply a tensile force to the distal end of the curveable cannula to bias the curveable cannula into a curved configuration. In some embodiments, the cord 242 is coupled to male-threaded dial 212 (see
Alternatively, cord 242 may comprise a memory material such as a Nitinol wire that fastens the tube 244 and links 232, 234 in a preformed curved-shape. The cord 246 in this configuration stretches to allow the curveable cannula 230 to be delivered into and stowed in a linear form within channel 218, and retracts when not restrained in channel 218 to drive a curved path when exiting window 212.
As shown in
As shown in
Furthermore, the proximal end 254 of the probe 250 comprises a plurality of vertical grooves 264, at least one of which interfaces with key 266 of the curveable cannula 230. This interface only allows axial motion of the proximal body 264 with the curveable cannula 230, and restricts rotation of the proximal body 264 with the curveable cannula 230. Thus, rotation of the drive nut 270 may only result in proximal translation of the drive nut 270. As seen in
Referring now to
In one embodiment, a channeling stylet (such as stylet 90 shown in kit 10 of
Once the distal tip 274 of the probe 250 is positioned at the desired location, treatment of the target tissue may be performed. As shown in
Cap 290 may further be configured to include (e.g. a self contained unit) a power source (e.g. battery) and receptacles (not shown) to couple to the probe 250, thereby supplying the energy to deliver a therapeutic level of energy to the tissue. In this configuration, the cap 290 may have sufficient power to deliver one or more metered doses of energy specifically measured to modulate (e.g., denervate) at least a portion of the BVN of a vertebral body.
The cap 290 may be threaded (or otherwise releasable coupled) into drive nut 270 to be interchangeable depending on the application or step of the procedure. For example, a cap 290 having a reinforced/hardened surface 292 used for driving the system 201 into the bone may be replaced by another cap having couplings (not shown) for probe 250, an internal power supply (not shown), or couplings for an external power supply/controller (not shown) for delivering energy for treatment and/or diagnosis of a region of tissue. For embodiments wherein a fluid and/or agent is delivered to the target tissue, the cap 290 may be configured to facilitate delivery of the fluid through a probe having one or more fluid delivery channels. In some embodiments, the interchangeable cap 290 is configured to provide access to the probe 250 for providing a therapeutic energy.
A curveable cannula 322 is positioned in the trocar 302, the curveable cannula 322 having a distal end 324 coupled via linkage 326 to a pivotable arm 310. The proximal end (not shown) of the curveable cannula may comprise a portion or all of any of the previously described proximal ends for devices 10, 200, or 201 disclosed herein. The pivotable arm 310 has a first end pivotably coupled at joint 314 at a location at or near the distal tip 334 of the trocar 334. In a stowed configuration (illustrated in
As shown in
According to several embodiments, the above systems 201, 300 may be provided as a kit of instruments to treat different regions of the body. For example, the location, orientation and angle of the treatment device with respect to the trocar may be varied by providing a set of instruments at varying increments. This may be achieved by varying the curvature in the curveable cannula (230, 320). The curvature may be varied by varying the radius of curvature, the insertion depth (shaft length and tip length, and/or the final exit angle with respect to the trocar central bore. Thus, the physician may select a different kit for treating a lumber spine segment as opposed to a sacral or cervical spine segment, as the anatomy will dictate the path that needs to be channeled.
According to several embodiments, each of the instruments in the systems 10, 200, 201, and 300 detailed above may have any length, shape, or diameter desired or required to provide access to the treatment and/or diagnostic region (e.g. intraosseous nerve or basivertebral nerve trunk) thereby facilitating effective treatment/diagnostic of the target region. For example, the size of the intraosseous nerve to be treated, the size of the passageway in the bone (e.g. pedicle 138) for accessing the intraosseous nerve, and the location of the bone, and thus the intraosseous nerve, are factors that may assist in determining the desired size and shape of the individual instruments. In several embodiments, the treatment device (e.g., RF device) has a diameter between 1 mm and 5 mm (e.g., between 1 mm and 3 mm, between 2 mm and 4 mm, between 3 mm and 5 mm, 1 mm, 2 mm, 3 mm, 4 mm, 5 mm, or any diameter between the recited ranges).
The systems 10, 200, 201 and 300 described above may be used with a number of different treatment modalities for therapeutic treatment of the target region, which may be spinal or non-spinal. For example, in one embodiment, it is desirable to operate the treatment devices or probes in systems 100, 200, 201 and 300 in a manner that denervates (e.g., ablates) the tissue of the target region (e.g. BVN) to produce heat as described in U.S. Pat. No. 6,699,242, herein incorporated by reference in its entirety.
In another embodiment, the treatment device is configured to deliver therapeutic treatment that is targeted to block nerve conduction without ablating the nerve. For example, thermal treatment (e.g., a thermal energy dose) can be delivered to the nerve (e.g. via thermal therapy, agent or the like) that results in denervation of the BVN without necrosis of tissue. This non-ablative treatment may be achieved via delivery of a lesser amount of energy or agent to the tissue site (either in the form of less exposure time, concentration, intensity, thermal dose, etc.) than is required for ablation, but an amount sufficient to achieve some amount of temporary or permanent denervation.
In accordance with several embodiments, the treatment devices (e.g., probes) described herein may comprise non-therapy devices or elements, such as diagnostic devices (e.g. ultrasound, cameras, sensors, or the like) to diagnose a region of tissue independent of or in connection with treatment of the region of tissue.
In several embodiments, individual elements of any of the systems 10, 200, 201, and 300 detailed above may be used interchangeably where applicable. For example, the curved stylet 60 shown in systems 10 and 200 may be temporarily implemented in place of the probe of systems 201 and 300 to provide additional curving bias to the curveable cannula (230, 320) while the cannula is being driven into the bone. Furthermore, the channeling stylet 90 may be used to further generate a channel beyond the curved path provided by the curveable cannula (230, 320).
As used herein, the “resistive heating zone,” in addition to its ordinary meaning, is the zone of bone tissue that is resistively heated due to an energy loss incurred by current travelling directly through the bone tissue. Resistive heating, “joule” heating and “near-field” heating may be used interchangeably herein. The “conductive heating zone,” in addition to its ordinary meaning, is the zone of bone tissue that is heated due to the conduction of heat from an adjacent resistive heating zone. The total heating zone (THZ) in a bone tissue includes both the resistive heating zone and the conductive heating zone. The border between the conductive and resistive heating zones is defined by the locations where the strength of the electric field is 10% of the maximum strength of the electric field between the electrodes. As used herein, the heating zones encompass the volume of bone tissue heated to at least 42° C. by embodiments described herein. As used herein, the “first and second sides” of a vertebral body are the lateral-lateral sides intersected by the BVN. The modulation of the ION may be carried out by resistive heating, conductive heating, or by hybrid heating.
In some embodiments, the therapeutic heating of the ION is provided by both resistive and conductive heating. In some embodiments thereof, as in
In embodiments wherein the therapeutic heating of the ION is provided substantially by both resistive and conductive heating, it may be preferred that the length L1 of the ION treated by resistive heating comprise at least 25% or at least 50% of the total therapeutically treated length of ION. In other embodiments, the length may be in the range of 10-25% of the treated length of ION, in the range of 40-60% of the treated length of ION, in the range of 50-70% of ION, greater than 70% of the treated length of ION, or overlapping ranges thereof. In several embodiments, the peak temperature in the resistive heating zone IR is between 40° C. and 60° C. greater than the peak temperature in the conductive heating zone OC. In some embodiments, the peak temperature in the resistive heating zone IR is between about 20° C. and 40° C. greater than the peak temperature in the conductive heating zone, between about 10° C. and 20° C. greater than the peak temperature in the conductive heating zone OC, between about 5° C. and 10° C. greater than the peak temperature in the conductive heating zone OC, between 0° C. and 5° C. greater than the peak temperature in the conductive heating zone OC in the range of 2° C. and 5° C. greater than the temperature in the conductive heating zone OC, or overlapping ranges thereof. In some embodiments, the peak temperature in the resistive heating zone IR is no more than 15° C. greater than the peak temperature in the conductive heating zone OC, no more than 10° C. greater than the peak temperature in the conductive heating zone OC, or no more than 5° C. greater than the peak temperature in the conductive heating zone OC.
Now referring to
In some embodiments thereof, it may be desired that the separation distance (SD) between the ION and the resistive heating zone IR be no more than 1 cm. This is desired because the closer the ION is to the resistive heating zone, the higher the temperature experienced by the ION length L2. In some embodiments, the separation distance is no more than 0.5 cm or no more than 0.2 cm. In some embodiments, the SD is between 1 cm and 2 cm, between 0.75 and 1 cm, between 0.5 and 0.75 cm, between 0.3 cm and 0.6 cm, between 0.1 cm and 0.3 cm, between 0.02 cm to about 0.2 cm, or overlapping ranges thereof.
In some embodiments, as in
In several embodiments, methods are carried out via a dual probe system. In particular, embodiments of the dual probe system comprise an energy delivery device comprising a first probe having an active electrode and a second probe having a return electrode. Now referring to
In several embodiments, aligning the electrodes of such an apparatus to straddle the ION merely requires advancing the probes into the vertebral body and no complicated navigation is required. According to several embodiments, even if the location of the BVN were precisely known, conventional methods of accessing the BVN require either the BVN to be naturally located within the vertebral body so as to intersect the axis of the pedicle, or require a complicated probe configuration or navigation. In some embodiments, a dual probe approach simply requires substantially linear advance of a pair of substantially straight probes, and is much simpler and/or much more robust than the conventional methods of accessing nerves in bone. For example, the clinician may desirably access the vertebral body through the pedicles with substantially straight probes and have a high confidence that their activation can therapeutically treat the BVN.
In accordance with embodiments of the invention, there is provided a method of therapeutically treating a vertebral body having a BVN, comprising providing an energy device having an active electrode having a first face and a return electrode having a second face into the vertebral body, and placing the active electrode in the vertebral body to face a first direction. The return electrode can then be placed in the vertebral body to face a second direction, with the first and second faces defining an angle 2 of no more than 60 degrees. A sufficiently high frequency voltage difference can then be applied between the active and return electrodes to generate a current therebetween to produce a total heating zone to therapeutically heat (e.g., denervate or ablate) the BVN.
In accordance with embodiments of the invention, there is provided a method of therapeutically treating a vertebral body having a BVN comprising: providing an energy device having an active electrode and a return electrode, placing the active and return electrodes in the vertebral body to define an electrode axis, the axis forming an angle C of between 50 and 90 degrees with the BVN, and applying a sufficiently high frequency voltage difference between the active and return electrodes to generate a current therebetween to produce a total heating zone to therapeutically heat (e.g., denervate or ablate) the BVN.
Now referring to
Now referring to
In some embodiments, the cannula is shaped so as to guide the probe towards the midline of the vertebral body. This inward guidance will help move the electrodes closer to the BVN. In some embodiments, at least a portion of the cannula bore is curved. In some embodiments, at least half of the length of the cannula bore is curved. In other embodiments, substantially only the distal end portion of the cannula bore is curved.
Stylet 221 comprises a shaft 203 having a longitudinal axis F and a proximal 205 and distal end 207. Disposed at the distal end of the shaft is a tip 219 adapted for boring or drilling through cortical bone. In some embodiments, the outer diameter DO of the stylet shaft is preferably adapted to be received within the inner diameter DC of the cannula.
The combination of the cannula and the stylet is sometimes referred to herein as a “cannulated needle.” In some embodiments, access to the vertebral body is gained by first placing the stylet in the cannula to produce a cannulated needle, piercing the skin with the cannulated needle, and advancing the cannulated needle so that the stylet tip reaches a target tissue region within the cancellous portion of the vertebral body, and then withdrawing the stylet. At this point, the cannula is conveniently located at the target tissue region to receive a probe.
Probe 301 comprises a shaft 303 having a longitudinal axis G, a distal end portion 305 and a proximal end portion 307. Disposed near the distal end portion of the probe is a first electrode 309 having a first face 331 and a connection face 333. The probe 301 is designed so that the connection face 333 of the first electrode is placed in electrical connection with a first lead 403 of the power supply. In this particular embodiment, the shaft has a longitudinal bore 311 extending from the proximal end portion up to at least the first electrode 309. Disposed within the bore is a wire 321 electrically connected at its first end 323 to the first electrode 309 and having a second end 325 adapted to be electrically connected to a first lead of a power supply.
Several embodiments of systems comprise a cannula having a longitudinal bore, a stylet having an outer diameter adapted to be received within the longitudinal bore, and a distal tip adapted to penetrate cortical bone. The systems may comprise a probe or other treatment device. In one embodiment, the probe includes an outer diameter adapted to be received within the longitudinal bore, a first electrode, and a lead in electrical connection with the first electrode. A second, third, or fourth electrode is provided in some embodiments. In several embodiments, second, third, or fourth probes are provided.
In some embodiments, the outer surface of the probe or other treatment device is provided with depth markings or other indicia so that the clinician can understand the extent to which it has penetrated the vertebral body.
In some embodiments in which a cannulated stylet is first inserted, the stylet is removed and the cannula remains in place with its distal opening residing in the target tissue while the probe is inserted into the cannula. In one embodiment, the cannula provides a secure portal for the probe, thereby ensuring that the probe can enter the bone safely. This embodiment may be particularly advantageous when the probe is made of a flexible material, is curved, or is shaped with an irregular cross-section that could undesirably catch on the bone during probe advancement into the bone.
In the
Now referring to
In this configuration, the placement of the jacket provides a distal uninsulated shaft portion 1407 that could be used as an electrode. In several embodiments, the distal uninsulated portion of the shaft has a length of between 3 mm and 8 mm (e.g., about 5 mm). In some embodiments thereof, the insulation is selected from the group consisting of polyimide tape, PTFE tape, and heat shrink tubing. Preferred thickness of the insulation may range from about 0.00025 to 0.0005 inches.
In some embodiments using insulating jackets, the jacket has either a longitudinally extending slit or slot that exposes a longitudinal surface area of the underlying shaft, thereby producing either an essentially linear or an essentially planar electrode. In such embodiments, the distal end of the shaft is insulated. In other embodiments using insulating jackets, the insulated portion may comprise a proximal jacket and a distal jacket positioned to provide a space therebetween that exposes a surface area of the underlying shaft to produce the electrode. In some embodiments, the proximal and distal jackets substantially encircle the shaft to provide an annular electrode therebetween.
In some embodiments in which a cannulated stylet is used, both the stylet and the cannula are removed, and the probe is inserted into the hole created by the cannulated stylet. In one embodiment, the hole provides a large portal for the probe. This embodiment conserves the annulus of bone removed by the cannula, and so may be preferred when the probe has a relatively large diameter (e.g., more than 8 mm in diameter). In some embodiments, the cannula remains to ensure that the probe tracks the hole and does not form its own pathway through the cancellous bone.
In some embodiments in which a cannulated stylet is used, the cannula comprises at least one electrode. In one embodiment, the cannula acts as the probe as well. With this embodiment, the clinician can eliminate steps in the procedure that are related to introducing a body into the cannula. In some embodiments, the outer surface of the cannula is provided with depth markings so that the clinician can understand the extent to which the cannula has penetrated the vertebral body.
In some embodiments in which a cannulated stylet is first inserted, the stylet comprises at least one electrode. In this embodiment, the stylet acts as the probe as well. With this embodiment, the clinician can eliminate steps in the procedure that are related to removing the stylet and introducing a body into the cannula. In some embodiments, the outer surface of the stylet is provided with depth markings so that the clinician can understand the extent to which it has penetrated the vertebral body.
In conducting initial animal experiments with a dual probe embodiment, a bipedicle approach was used as shown in of 45 to about 55 degrees. Since both the probes and the electrodes disposed thereon were essentially cylindrical, the inner faces 605, 615 of the electrodes produced an angle 2
. Subsequent testing of the configuration of
In accordance with embodiments of the invention, the electrode design can be modified to reduce the angle 2 produced by the inner faces, so that the distance between the proximal end of the electrodes is more equal to the distance between the proximal end of the electrodes (e.g., the faces are more parallel). When the electrodes are provided in such a condition, their orientation reduces the significance of any path of least resistance, and so current flows more evenly across the face of each electrode, thereby providing even heating and greater control over the system.
In accordance with embodiments of the invention, there is provided an intraosseous nerve modulation system. In one embodiment, the modulation system comprises a first probe having an active electrode and a first lead, a second probe having a return electrode and a second lead, means for creating first and second bores within a bone for accommodating the first and second probes, and a power supply capable of generating a voltage difference between the active and return electrodes. In one embodiment, the power supply comprises third and fourth leads, wherein the first and third leads are in electrical connection, and the second and fourth leads are in electrical connection.
In some embodiments the electrodes are disposed so that the angle 2 produced by the inner faces is less than 60 degrees (e.g., no more than 30 degrees). In other embodiments, the angle is less than 1 degree. In some embodiments, the inner faces are substantially parallel.
Now referring to
In accordance with embodiments of the invention, there is provided an intraosseous nerve denervation system comprising a first probe having a first electrode and a first lead in electrical connection with the first electrode, wherein the first electrode has a proximal end having a proximal diameter and a distal end having a distal diameter, and the proximal end diameter is less than the distal end diameter, and, optionally a second probe. In one embodiment, the second probe comprises a first electrode and a first lead in electrical connection with the first electrode. In one embodiment, the first electrode has a proximal end having a proximal diameter and a distal end having a distal diameter, wherein the proximal end diameter is less than the distal end diameter. In one embodiment, the first and second electrodes are disposed so that the electrodes are parallel. Non-parallel positioning is provided in other embodiments.
In
In some embodiments, the frustoconical electrode is shaped so that the diameter of its distal end DD is between about 10% and 25% of the diameter of its proximal end DP. In some embodiments, the frustoconical nature of the electrode is provided by physically severing the sharp distal end of the electrode. In others, the frustoconical nature of the electrode is provided by insulating the sharp distal end of an electrode.
As noted above, when the probes are placed such that their corresponding electrodes are parallel to each other, the electric field produced by electrode activation is substantially uniform between the distal and proximal portions of the electrodes. However, as the probes are oriented at an angle from parallel, the electric field becomes strongest where the electrodes are closer together. In order to compensate for this nonuniform electric field, in some embodiments, the distal ends of the electrodes are tapered. In this tapered state, the regions of the electrodes that are closer together (e.g., the tip) also have a smaller surface area (thereby reducing the electric field in that region), while the regions of the electrodes that are farther apart (e.g., the trunk) have a larger surface area (thereby increasing the electric field in that region). Typically, the effect is largely determined by the cone size, electrode spacing and tissue type therebetween.
In some embodiments of the tapered electrode, and now referring to
Now referring to
Now referring to
Now referring to
In accordance with embodiments of the invention, there is provided an intraosseous nerve denervation system, comprising a cannula having a longitudinal bore defining a first axis, a stylet having an outer diameter adapted to be received within the longitudinal bore and a distal tip adapted to penetrate cortical bone, and a first probe. In one embodiment, the first probe comprises an outer diameter adapted to be received within the longitudinal bore, a first electrode, and a lead in electrical connection with the first electrode. Additional probes and/or electrodes are provided in other embodiments.
Now referring to
Therefore, there is provided an intraosseous nerve denervation system, comprising a cannula having a longitudinal bore defining a first axis, a stylet having an outer diameter adapted to be received within the longitudinal bore and a distal tip adapted to penetrate cortical bone, and probe or other treatment device. In one embodiment, the probe or other treatment device comprises an outer diameter adapted to be received within the longitudinal bore, at least one electrode, and a lead in electrical connection with the at least one electrode. Multiple probes and multiple electrodes may be provided in some embodiments.
Now referring to
In some embodiments, relatively even heating is provided by providing current density gradients. Now referring to
Current density gradients can also be produced by providing a plurality of electrodes on each probe. Now referring to
In accordance with several embodiments, a method of therapeutically treating a vertebral body having a BVN comprises providing a first energy device having distal and proximal active electrodes, providing a second energy device having distal and proximal return electrodes, placing the first and second energy devices in the vertebral body to define a first distance between the distal active electrode and the distal return electrode, and a second distance between the proximal active electrode and the proximal return electrode. In one embodiment, the first distance is less than the second distance. In one embodiment, the method further comprises applying a first high frequency voltage between the distal active and distal return electrodes, and applying a second high frequency voltage between the proximal active and proximal return electrodes, with the first high frequency voltage being less than the second high frequency voltage.
Because multiple voltage sources may add complexity to the device, in other embodiments, the differences in voltage may be provided by a single voltage source by using a poorly conductive electrode. In particular, in some embodiments thereof, the probe comprises an electrically conductive probe shaft and a plurality of spaced apart insulating jackets, wherein the spacing produces the electrodes of
In another dual probe approach, in some embodiments, and now referring to
Although the dual probe approach has many benefits in some embodiments, a single articulated probe having both active and return electrodes may be used in other embodiments. For example, a single probe may be placed such that a first electrode is on one side of midline (e.g., the left side) and a second electrode is on the other side of midline (e.g., the right side) of the vertebral body, or vice-versa. In some embodiments, the probe is curved such that one electrode is at or near the tip of the probe while the second electrode is near the beginning point of the curved region of the probe. The curved probe may be placed such that one electrode is opposite the other and both occupy similar positions relative to the anterior and posterior limits of the vertebral body. This can advantageously allow placement such that the two electrodes effectively straddle the BVN instead of using two separate probes. In some embodiments, the active electrode is at or near the tip of the probe, while in other embodiments, the return electrode is at or near the tip of the probe. In some embodiments, the first electrode comprises a tip electrode and the second electrode comprises a ring electrode.
Now referring to
Pivotable probe 951 comprises a shaft 953 having a longitudinal axis, a distal end portion 955, and a proximal end portion 957 pivotally attached to the fixed probe 901 by pivot 961. The pivot allows the pivoting probe 951 to pivot about the fixed probe 901. Disposed near the distal end portion of the pivotable probe 951 is second electrode 963. The probe is designed so that the second electrode 963 is placed in electrical connection with a second lead of the power supply.
In several embodiments, the pivotable probe has an undeployed mode and a deployed mode. In the undeployed mode, the pivotable probe is seated within the recess of the fixed probe so that the axis of its shaft is essentially in line with the axis of the fixed probe shaft. In this state, the pivotable probe essentially hides within the fixed probe. In the deployed mode, the pivotable probe extends at a significant angle from the fixed probe so that the axis of its shaft forms an angle of at least 10 degrees with the axis of the fixed probe shaft.
In some embodiments, a pusher rod is used to deploy the pivotable probe. Pusher rod 975 comprises a proximal handle (not shown) for gripping and a distal end portion 977 having a shape for accessing the bore of the fixed probe. Distal end portion has a tip 981 having a shape which, when advanced distally, can push the distal end portion of the pivotable probe laterally out of the recess.
In several embodiments, the pivotable device has both an active and a return electrode, and the device is introduced through a single pedicle. The location of these electrodes may vary depending upon the use of the pivotable device. For example, when the active electrode is located on the pivotable probe, the return electrode may be positioned in a location on the fixed probe distal of the pivot (as in
In general, it may be desirable to operate embodiments of the invention in a manner that produce a peak temperature in the target tissue of between about 80° C. and 95° C. When the peak temperature is below 80° C., the off-peak temperatures may quickly fall below about 45° C. When the peak temperature is above about 95° C., the bone tissue exposed to that peak temperature may experience necrosis and produce charring. This charring reduces the electrical conductivity of the charred tissue, thereby making it more difficult to pass RF current through the target tissue beyond the char and to resistively heat the target tissue beyond the char. In some embodiments, the peak temperature is between 86° C. and 94° C., between 80° C. and 90° C., 85° C., overlapping ranges thereof, or any temperature value between 80° C. and 95° C.
It may be desirable to heat the volume of target tissue to a minimum temperature of at least 42° C. When the tissue experiences a temperature above 42° C., nerves within the target tissue may be desirably damaged. However, it is believed that denervation is a function of the total quantum of energy delivered to the target tissue; i.e., both exposure temperature and exposure time determine the total dose of energy delivered. Accordingly, if the temperature of the target tissue reaches only about 42° C., then it is believed that the exposure time of the volume of target tissue to that temperature should be at least about 30 minutes and preferably at least 60 minutes in order to deliver the dose of energy believed necessary to denervate the nerves within the target tissue.
It may be desirable to heat the volume of target tissue to a minimum temperature of at least 50° C. If the temperature of the target tissue reaches about 50° C., then it is believed that the exposure time of the volume of target tissue to that temperature need only be in the range of about 2 minutes to 10 minutes (e.g., about 2-4, 4-6, 6-8, 8-10 minutes) or any duration therebetween to achieve denervation. Shorter time periods may also be used.
It may be even more desirable to heat the volume of target tissue to a minimum temperature of at least 60° C. If the temperature of the target tissue reaches about 60° C., then it is believed that the exposure time of the volume of target tissue to that temperature need only be in the range of about 0.01 minutes to 1.5 minutes to achieve denervation (e.g., 0.1 minutes to 0.25 minutes).
Typically, the period of time that an ION is exposed to therapeutic temperatures is in general related to the length of time in which the electrodes are activated. In some embodiments, the electrodes, when the peak temperature is between 80° C. and 95° C., may be activated between 10 and 20 minutes, between 10 and 15 minutes, 12 minutes, 15 minutes, less than 10 minutes, greater than 20 minutes, or any duration of time between 10 and 20 minutes, to achieve the minimum target tissue temperature such that the nerve tissue is modulated (e.g., denervated). However, since it has been observed that the total heating zone remains relatively hot even after power has been turned off (and the electric field eliminated), the exposure time can include a period of time in which current is not running through the electrodes.
In general, the farther apart the electrodes, the greater the likelihood that the ION will be contained within the total heating zone. Therefore, in some embodiments the electrodes are placed at least 5 mm apart or at least 10 mm apart. However, if the electrodes are spaced too far apart, the electric field takes on an undesirably extreme dumbbell shape. Therefore, in many embodiments, the electrodes are placed apart a distance of between 1 mm and 25 mm, between 5 mm and 15 mm, between 10 mm and 15 mm between 3 mm and 10 mm, between 8 mm and 13 mm, between 10 mm and 18 mm, between 12 mm and 20 mm between 20 and 25 mm, between 1 mm and 3 mm, or any integer or value between 1 mm and 25 mm.
In some embodiments, it is desirable to heat the target tissue so that at least about 1 cc of bone tissue experiences the minimum temperature. This volume corresponds to a sphere having a radius of about 0.6 cm. Alternatively stated, it is desirable to heat the target tissue so the minimum temperature is achieved by every portion of the bone within 0.6 cm of the point experiencing the peak temperature.
In accordance with several embodiments, it is desirable to heat the target tissue so that at least about 3 cc of bone experiences the minimum temperature. This volume corresponds to a sphere having a radius of about 1 cm (e.g., 0.7 cm, 0.8 cm. 0.9 cm, 1.0 cm, 1.1 cm, 1.2 cm, 1.3 cm, 1.4 cm).
Some embodiments provide a steady-state heated zone having a peak temperature of between 80° C. and 95° C. (e.g., between 86° C. and 94° C., between 80° C. and 90° C., or overlapping ranges thereof), and heat at least 1 cc of bone (e.g., at least 2 cc of bone, at least 3 cc of bone, at least 4 cc of bone, at least 5 cc of bone) to a temperature of at least 50° C. (e.g., 60° C.).
In accordance with several embodiments, a method of therapeutically treating a vertebral body having a BVN comprises providing an energy device having an active and a return electrode, inserting the active electrode into the vertebral body, inserting the return electrode into the vertebral body, and applying a sufficiently high frequency voltage difference between the active and return electrodes to generate a current therebetween to produce a total heating zone having a diameter of at least 0.5 cm and a steady state temperature of at least 50° C.
As noted above, a peak temperature below about 100° C. or below about 105° C. is desirable in order to prevent charring of the adjacent tissue, steam formation and tissue popping. In some embodiments, this is accomplished by providing the power supply with a feedback means that allows the peak temperature within the heating zone to be maintained at a desired target temperature, such as 90° C. In some embodiments, the peak temperature is in the range of 85° C. to 95° C. In other embodiments, the peak temperature is between about 70° C. and 90° C.
In some embodiments, between about 24 watts and 30 watts of power is first supplied to the device in order to rapidly heat the relatively cool bone, with maximum amperage being obtained within about 10-15 seconds. In other embodiments, between about 28 watts and 32 watts of power, between about 20 watts and 26 watts of power, between 30 watts and 40 watts of power, between 15 watts and 24 watts of power, overlapping ranges thereof, or any power level within the ranges, is first supplied to the device. In some embodiments, the maximum amperage may be obtained within 5-10 seconds, within about 15-25 seconds, within about 7-12 seconds, within about 13-18 seconds, overlapping ranges thereof, or any duration within the recited ranges. As the bone is further heated to the target temperature, the feedback means gradually reduces the power input to the device to between about 6-10 watts. In some embodiments, the power input is reduced to between 4-7 watts, about 8-12 watts, between 2-6 watts, between about 7-15 watts, or overlapping ranges thereto.
Cooling may be employed for any of the neuromodulation devices (e.g., energy delivery devices) described herein. In several embodiments, a cooling balloon or other cooling device or fluid (e.g., heat removal elements, heat sinks, cooling fluid circulating through one or more lumens of the neuromodulation device) is used for cooling the treatment zone or location or the area surrounding the treatment zone or location.
If the active electrode has no active cooling means, it may become subject to conductive heating by the heated tissue, and the resultant increased temperature in the electrode may adversely affect performance by charring the adjacent bone tissue. Accordingly, in some embodiments, a cool tip active electrode may be employed. The cooled electrode helps maintain the temperature of the electrode at a desired temperature. Cooled tip active electrodes are known in the art. Alternatively, the power supply may be designed to provide a pulsed energy input. It has been found that pulsing the current favorably allows heat to dissipate from the electrode tip, and so the active electrode stays relatively cooler.
In various embodiments, the neuromodulation device comprises an electrosurgical device having a shaft with a proximal end, a distal end, and at least one active electrode at or near the distal end. A connector may be provided at or near the proximal end of the shaft for electrically coupling the active electrode to a high frequency voltage source. In some embodiments, a return electrode coupled to the voltage source is spaced a sufficient distance from the active electrode to substantially avoid or minimize current shorting therebetween. The return electrode may be provided integral with the shaft of the device or it may be separate from the shaft.
In some embodiments, the electrosurgical probe or catheter comprises a shaft or a handpiece having a proximal end and a distal end which supports one or more electrode terminal(s). The shaft or handpiece may assume a wide variety of configurations, with the primary purpose being to mechanically support the active electrode and permit the treating physician to manipulate the electrode from a proximal end of the shaft. The shaft may be rigid or flexible, with flexible shafts optionally being combined with a generally rigid external tube for mechanical support. Flexible shafts may be combined with pull wires, shape memory actuators, and other known mechanisms for effecting selective deflection of the distal end of the shaft to facilitate positioning of the electrode array. The shaft will usually include a plurality of wires or other conductive elements running axially therethrough to permit connection of the electrode array to a connector at the proximal end of the shaft.
In several embodiments, the shaft is a rigid needle that is introduced through a percutaneous penetration in the patient. However, for endoscopic procedures within the spine, the shaft may have a suitable diameter and length to allow the surgeon to reach the target site (e.g., a disc) by delivering the shaft through the thoracic cavity, the abdomen or the like. Thus, the shaft may have a length in the range of about 5.0 to 30.0 cm (e.g., about 5-10, 10-15, 10-20, or 10-30 cm, or overlapping ranges thereof), and a diameter in the range of about 0.2 mm to about 10 mm (e.g., about 0.2-1, 1-2, 2-4, 2-6, 6-8, or 5-10 mm, or overlapping ranges thereof). In any of these embodiments, the shaft may also be introduced through rigid or flexible endoscopes.
The probe may include one or more active electrode(s) for applying electrical energy to tissues within the spine. The probe may include one or more return electrode(s), or the return electrode may be positioned on the patient's back, as a dispersive pad. In either embodiment, sufficient electrical energy is applied through the probe to the active electrode(s) to either necrose the blood supply or nerves within the vertebral body.
The electrosurgical instrument may also be a catheter that is delivered percutaneously and/or endoluminally into the patient by insertion through a conventional or specialized guide catheter, or the invention may include a catheter having an active electrode or electrode array integral with its distal end. The catheter shaft may be rigid or flexible, with flexible shafts optionally being combined with a generally rigid external tube for mechanical support. Flexible shafts may be combined with pull wires, shape memory actuators, and other known mechanisms for effecting selective deflection of the distal end of the shaft to facilitate positioning of the electrode or electrode array. The catheter shaft may include a plurality of wires or other conductive elements running axially therethrough to permit connection of the electrode or electrode array and the return electrode to a connector at the proximal end of the catheter shaft. The catheter shaft may include a guide wire for guiding the catheter to the target site, or the catheter may comprise a steerable guide catheter. The catheter may also include a substantially rigid distal end portion to increase the torque control of the distal end portion as the catheter is advanced further into the patient's body. Specific deployment means will be described in detail in connection with the figures hereinafter.
In some embodiments, the electrically conductive wires may run freely inside the catheter bore in an unconstrained made, or within multiple lumens within the catheter bore.
The tip region of the instrument may comprise many independent electrode terminals designed to deliver electrical energy in the vicinity of the tip. The selective application of electrical energy is achieved by connecting each individual electrode terminal and the return electrode to a power source having independently controlled or current limited channels. The return electrode(s) may comprise a single tubular member of conductive material proximal to the electrode array. Alternatively, the instrument may comprise an array of return electrodes at the distal tip of the instrument (together with the active electrodes) to maintain the electric current at the tip. The application of high frequency voltage between the return electrode(s) and the electrode array results in the generation of high electric field intensities at the distal tips of the electrode terminals with conduction of high frequency current from each individual electrode terminal to the return electrode. The current flow from each individual electrode terminal to the return electrode(s) is controlled by either active or passive means, or a combination thereof, to deliver electrical energy to the surrounding conductive fluid while minimizing or preventing energy delivery to surrounding (non-target) tissue, such as the spinal cord.
Temperature probes associated with the apparatus may be disposed on or within the electrode carrier; between the electrodes (may be preferred in bipolar embodiments); or within the electrodes (may be preferred for monopolar embodiments). In some embodiments wherein the electrodes are placed on either side of the ION, a temperature probe is disposed between the electrodes or in the electrodes. In alternate embodiments, the deployable portion of the temperature probe comprises a memory metal.
The electrode terminal(s) may be supported within or by an inorganic insulating support positioned near the distal end of the instrument shaft. The return electrode may be located on the instrument shaft, on another instrument or on the external surface of the patient (i.e., a dispersive pad). In some embodiments, the close proximity of the dual needle design to the intraosseous nerve makes a bipolar design more preferable because this minimizes the current flow through non-target tissue and surrounding nerves. Accordingly, the return electrode is preferably either integrated with the instrument body, or another instrument located in close proximity thereto. The proximal end of the instrument(s) may include the appropriate electrical connections for coupling the return electrode(s) and the electrode terminal(s) to a high frequency power supply, such as an electrosurgical generator.
In some embodiments, the active electrode(s) have an active portion or surface with surface geometries shaped to promote the electric field intensity and associated current density along the leading edges of the electrodes. Suitable surface geometries may be obtained by creating electrode shapes that include preferential sharp edges, or by creating asperities or other surface roughness on the active surface(s) of the electrodes. Electrode shapes can include the use of formed wire (e.g., by drawing round wire through a shaping die) to form electrodes with a variety of cross-sectional shapes, such as square, rectangular, L or V shaped, or the like. The electrodes may be tip electrodes, ring electrodes, plate electrodes, cylindrical electrodes, frustoconical electrodes, or any other shape electrodes. Electrode edges may also be created by removing a portion of the elongate metal electrode to reshape the cross-section. For example, material can be ground along the length of a round or hollow wire electrode to form D or C shaped wires, respectively, with edges facing in the cutting direction. Alternatively, material can be removed at closely spaced intervals along the electrode length to form transverse grooves, slots, threads or the like along the electrodes. In other embodiments, the device can be sectored so that a given circumference comprises an electrode region and an inactive region. In some embodiments, the inactive region is masked.
The return electrode is typically spaced proximally from the active electrode(s) a suitable. In most of the embodiments described herein, the distal edge of the exposed surface of the return electrode is spaced about 1 to 25 mm (or any distance therebetween) from the proximal edge of the exposed surface of the active electrode(s), in dual needle insertions. Of course, this distance may vary with different voltage ranges, the electrode geometry and depend on the proximity of tissue structures to active and return electrodes. In several embodiments, the return electrode has an exposed length in the range of about 1 to 20 mm, about 2 to 6 mm, about 3 to 5 mm, about 1 to 8 mm, about 4 to 12 mm, about 6 to 16 mm, about 10 to 20 mm, 4 mm, 5 mm, 10 mm, or any length between 1 and 20 mm. The application of a high frequency voltage between the return electrode(s) and the electrode terminal(s) for appropriate time intervals effects modifying the target tissue. In several embodiments, the electrodes have an outer diameter of between 1 and 2 mm (e.g., between 1 and 1.5 mm, between 1.2 and 1.8 mm, between 1.5 and 1.7 mm, between 1.6 and 2 mm, 1.65 mm, or any outer diameter between the recited ranges). In several embodiments, the electrodes have an inner diameter of between 0.5 and 1.5 mm (e.g., between 0.5 and 0.8 mm, between 0.75 and 0.9 mm, between 0.8 and 1 mm, between 1 mm and 1.5 mm, 0.85 mm, or any inner diameter between the recited ranges).
Embodiments may use a single active electrode terminal or an array of electrode terminals spaced around the distal surface of a catheter or probe. In the latter embodiment, the electrode array usually includes a plurality of independently current limited and/or power-controlled electrode terminals to apply electrical energy selectively to the target tissue while limiting the unwanted application of electrical energy to the surrounding tissue and environment resulting from power dissipation into surrounding electrically conductive fluids, such as blood, normal saline, and the like. The electrode terminals may be independently current-limited by isolating the terminals from each other and connecting each terminal to a separate power source that is isolated from the other electrode terminals. Alternatively, the electrode terminals may be connected to each other at either the proximal or distal ends of the catheter to form a single wire that couples to a power source.
In one configuration, each individual electrode terminal in the electrode array is electrically insulated from all other electrode terminals in the array within said instrument and is connected to a power source which is isolated from each of the other electrode terminals in the array or to circuitry which limits or interrupts current flow to the electrode terminal when low resistivity material (e.g., blood) causes a lower impedance path between the return electrode and the individual electrode terminal. The isolated power sources for each individual electrode terminal may be separate power supply circuits having internal impedance characteristics which limit power to the associated electrode terminal when a low impedance return path is encountered. By way of example, the isolated power source may be a user selectable constant current source. In one embodiment, lower impedance paths may automatically result in lower resistive heating levels since the heating is proportional to the square of the operating current times the impedance. Alternatively, a single power source may be connected to each of the electrode terminals through independently actuatable switches, or by independent current limiting elements, such as inductors, capacitors, resistors and/or combinations thereof. The current limiting elements may be provided in the instrument, connectors, cable, controller, or along the conductive path from the controller to the distal tip of the instrument. Alternatively, the resistance and/or capacitance may occur on the surface of the active electrode terminal(s) due to oxide layers which form selected electrode terminals (e.g., titanium or a resistive coating on the surface of me till, such as platinum).
In one embodiment of the invention, the active electrode comprises an electrode array having a plurality of electrically isolated electrode terminals disposed over a contact surface, which may be a planar or non-planar surface and which may be located at the distal tip or over a lateral surface of the shaft, or over both the tip and lateral surface(s). The electrode array may include at least two or more electrode terminals and may further comprise a temperature sensor. In one embodiment, each electrode terminal may be connected to the proximal connector by an electrically isolated conductor disposed within the shaft. The conductors permit independent electrical coupling of the electrode terminals to a high frequency power supply and control system with optional temperature monitor for operation of the probe. The control system may advantageously incorporate active and/or passive current limiting structures, which are designed to limit current flow when the associated electrode terminal is in contact with a low resistance return path back to the return electrode.
The use of such electrode arrays in electrosurgical procedures may be particularly advantageous as it has been found to limit the depth of tissue necrosis without substantially reducing power delivery. The voltage applied to each electrode terminal causes electrical energy to be imparted to any body structure which is contacted by, or comes into close proximity with, the electrode terminal, where a current flow through all low electrical impedance paths is preferably but not necessarily limited. Since some of the needles are hollow, a conductive fluid could be added through the needle and into the bone structure for the purposes of lowering the electrical impedance and fill the spaces in the cancellous bone to make them better conductors to the needle.
It should be clearly understood that the invention is not limited to electrically isolated electrode terminals, or even to a plurality of electrode terminals. For example, the array of active electrode terminals may be connected to a single lead that extends through the catheter shaft to a power source of high frequency current. Alternatively, the instrument may incorporate a single electrode that extends directly through the catheter shaft or is connected to a single lead that extends to the power source. The active electrode(s) may have ball shapes, twizzle shapes, spring shapes, twisted metal shapes, cone shapes, annular or solid tube shapes or the like. Alternatively, the electrode(s) may comprise a plurality of filaments, rigid or flexible brush electrode(s), side-effect brush electrode(s) on a lateral surface of the shaft, coiled electrode(s) or the like.
The voltage difference applied between the return electrode(s) and the electrode terminal(s) can be at high or radio frequency (e.g., between about 50 kHz and 20 MHz, between about 100 kHz and 2.5 MHz, between about 400 kHz and 1000 kHz, less than 600 kHz, between about 400 kHz and 600 kHz, overlapping ranges thereof, 500 kHz, or any frequency within the recited ranges. The RMS (root mean square) voltage applied may be in the range from about 5 volts to 1000 volts, in the range from about 10 volts to 200 volts, between about 20 to 100 volts, between about 40 to 60 volts, depending on the electrode terminal size, the operating frequency and the operation mode of the particular procedure. Lower peak-to-peak voltages may be used for tissue coagulation, thermal heating of tissue, or collagen contraction and may be in the range from 50 to 1500, from 100 to 1000, from 120 to 400 volts, from 100 to 250 volts, from 200 to 600 volts, from 150 to 350 volts peak-to-peak, overlapping ranges thereof, or any voltage within the recited ranges. As discussed above, the voltage may be delivered continuously with a sufficiently high frequency (e.g., on the order of 50 kHz to 20 MHz) (as compared with e.g., lasers claiming small depths of necrosis, which are generally pulsed about 10 to 20 Hz). In addition, the sine wave duty cycle (i.e., cumulative time in anyone-second interval that energy is applied) may be on the order of about 100%, as compared with pulsed lasers which typically have a duty cycle of about 0.0001%. In various embodiments, the current ranges from 50 to 300 mA (e.g., from 50 to 150 mA, from 100 to 200 mA, from 150 to 300 mA, overlapping ranges thereof, or any current level within the recited ranges).
A power source may deliver a high frequency current selectable to generate average power levels ranging from several milliwatts to tens of watts per electrode, depending on the volume of target tissue being heated, and/or the maximum allowed temperature selected for the instrument, tip. The power source allows the user to select the power level according to the specific requirements of a particular procedure.
The power source may be current limited or otherwise controlled so that undesired heating of the target tissue or surrounding (non-target) tissue does not occur. In one of the presently preferred embodiments, current limiting inductors are placed in series with each independent electrode terminal, where the inductance of the inductor is in the range of 10 uH to 50,000 uH, depending on the electrical properties of the target tissue, the desired tissue heating rate and the operating frequency. Alternatively, capacitor-inductor (LC) circuit structures may be employed, as described previously in U.S. Pat. No. 5,697,909. Additionally, current limiting resistors may be selected. In several embodiments, microprocessors are employed to monitor the measured current and control the output to limit the current.
The area of the tissue treatment surface can vary widely, and the tissue treatment surface can assume a variety of geometries, with particular areas and geometries being selected for specific applications. The geometries can be planar, concave, convex, hemispherical, conical, linear “in-line” array or virtually any other regular or irregular shape. Most commonly, the active electrode(s) or electrode terminal(s) can be formed at the distal tip of the electrosurgical instrument shaft, frequently being planar, disk-shaped, ring-shaped, or hemispherical surfaces for use in reshaping procedures or being linear arrays for use in cutting. Alternatively or additionally, the active electrode(s) may be formed on lateral surfaces of the electrosurgical instrument shaft (e.g., in the manner of a spatula), facilitating access to certain body structures in endoscopic procedures.
The devices may be suitably used for insertion into any hard tissue in the human body. In some embodiments, the hard tissue is bone. In other embodiments, the hard tissue is cartilage. In some embodiments when bone is selected as the tissue of choice, the bone is a vertebral body. In several embodiments, devices are adapted to puncture the hard cortical shell of the bone and penetrate at least a portion of the underlying cancellous bone. In some embodiments, the probe advances into the bone to a distance of at least ⅓ of the cross-section of the bone defined by the advance of the probe. Some method embodiments are practiced in vertebral bodies substantially free of tumors. In others, method embodiments are practiced in vertebral bodies having tumors.
In some embodiments using two separate probes, the device enters the hard tissue (e.g., bone such as the vertebral body) through two access points. In some embodiments, the pair of separate probes is adapted to denervate the BVN and enter through separate pedicles transpedicularly. In other embodiments, the pair of separate probes each enters the vertebral body extrapedicularly. In other embodiments, a first of the pair of separate probes enters the vertebral body extrapedicularly and the second enters the vertebral body transpedicularly. In embodiments using a single device, the device enters via a single pedicle. In such embodiments, both the active and return electrodes may be disposed on a single probe, which may be placed transpedicularly via either the left pedicle or the right pedicle, such that one electrode crosses the midline and the second electrode remains on the same side of the midline as the pedicle entered. Thus, energy transmitted between the two electrodes effectively targets the BVN, which is disposed between the two electrodes. In some embodiments, this may be accomplished by utilizing a curved probe, such that the distal electrode may be placed at or near the tip of the probe and the proximal electrode may be placed at or near the starting point of the curve. Therefore, upon deployment of the probe in the vertebral body, the two electrodes of the single probe end up on either side of the midline at approximately the same anterior-posterior position. In other embodiments, a single probe with a fixed segment and a pivotable segment, in which at least one active and one return electrode are located on the single probe. Either or both electrodes may be located on the fixed segment or the pivotable segment. A single probe, with two electrodes placed on the probe, may also be used via extrapedicular entrance to the vertebral body.
Now referring to
The following Examples illustrate some embodiments of the invention and are not intended in any way to limit the scope of the disclosure. Moreover, the methods and procedures described in the following examples, and in the above disclosure, need not be performed in the sequence presented.
This example describes an embodiment of a method of use of one of the dual probe embodiments.
First, after induction of an appropriate amount of a local anesthesia, the human patient is placed in a prone position on the table. The C-arm of an X-ray apparatus is positioned so that the X-rays are perpendicular to the axis of the spine. This positioning provides a lateral view of the vertebral body, thereby allowing the surgeon to view the access of the apparatus into the vertebral body.
Next, a cannulated stylet comprising an inner stylet and an outer cannula are inserted into the skin above each of the respective pedicles so that the distal tip of each stylet is in close proximity to the respective pedicle.
Next, the probe is advanced interiorly into the body so that the stylet tips bores through the skin, into and through the pedicle, and then into the vertebral body. The stylet is advanced until the tips reach the anterior-posterior midline of the vertebral body.
Next, the stylet is withdrawn and probe is inserted into the cannula and advanced until the first and second electrodes thereof each reach the midline of the vertebral body. The location of the two probes is shown from various perspectives in
Next, the power supply is activated to provide a voltage between the first and second electrodes. The amount of voltage across the electrodes is sufficient to produce an electric current between the first and second electrodes. This current provides resistive heating of the tissue disposed between the electrodes in an amount sufficient to raise the temperature of the local portion of the BVN to at least 45° C., thereby denervating the BVN.
This example describes the efficacy of heating a large zone of a vertebral body with an embodiment of a bipolar energy device. In accordance with one embodiment, the testing procedure was performed as follows:
A pair of probes was inserted into a vertebral body of an ovine animal model so that the tips of the electrodes were located substantially at the midline and separated by about 4 mm. Each electrode had a cylindrical shape, a length of about 20 mm, and an outer diameter of about 1.65 mm (16 gauge) to produce a surface area of about 100 mm2.
Next, and now referring to
Next; about 57 volts of energy was applied across the electrodes, and the temperature rise in the tissue was recorded at the thermocouple sites. These temperatures are provided in
The positive results provided by this example have great significance to the problem of therapeutically heating IONs, and the BVN in particular. In particular, the results of thermocouples T5-9 indicates that if an ION were located along the z-axis within 2 mm of the presumed center of the IRZ, then the ION could be sufficiently treated to at least 80° C. Similarly, the results of thermocouples T 0-4 indicate that as much as a 16 mm length of ION could be sufficiently treated to at least 80° C. Lastly, the results of thermocouples T 10-14 indicate that the ION could be off-center laterally in the IRZ by as much as 2 mm and at least about 10 mm of its length could be sufficiently treated to at least 80° C.
This embodiment describes an example of a method of use of an articulated probe. In accordance with one embodiment, the method is performed as follows:
The initial steps described above in Example I can be carried out so that the articulated probe is poised on the patient's skin and held in place by a ratchet type gun. See
Next, the distal end of the articulated probe is inserted into the skin above a pedicle so that the distal end of the fixed probe is in close proximity to the pedicle.
Now referring to
Now referring to
Now referring to
Next, the power supply is activated to provide a voltage between the first and second electrodes. The amount of voltage across the electrodes is sufficient to produce an electric current between the first and second electrodes. This current provides resistive heating of the tissue disposed between the electrodes in an amount sufficient to raise the temperature of the local portion of the BVN to at least 45° C., thereby denervating the BVN. In some embodiments, the temperature of the local portion of the BVN may be raised to between 40° C. and 100° C., between 40° C. and 60° C., between about 45° C. and 55° C., between 50° C. and 90° C., between 60° C. and 80° C., or in overlapping ranges thereof.
Next, the fixed probe is pushed forward to bring the pivotable probe back into the recess. Now referring to
Now referring to
A pilot human clinical study was performed to determine efficacy of a minimally invasive technique involving ablation of the basivertebral nerve in providing relief to patients with chronic lower back pain.
In the present study, a radiofrequency device was used to ablate the nerves within the vertebral bone that transmit pain signals. The study involved treatment of 16 human patients with chronic (greater than 6 months) isolated lower back pain who were unresponsive to at least 3 months of nonsurgical conservative care. The patients treated and observed in the study were an average of 47.6 years old and had undergone an average of 32.4 months of conservative treatment. The patients all had Oswestry Disability Index (ODI) scores greater than 30 and either pathologic changes or positive provocative discography at the targeted degenerated disc level.
In accordance with several embodiments, the intraosseous course of the basivertebral foramen for the targeted vertebral bodies was visualized and mapped using MRI imaging (e.g., anteroposterior and lateral still images). CT or other imaging techniques can also be used. In the study, treatment was performed using intraoperative fluoroscopy and a transpedicular approach; however, other visualization and approach techniques can be used. The treatment device used during the study was a bipolar radiofrequency probe with a curved obturator. In the study, the bipolar RF probe was inserted through a bone biopsy needle and guided to the target treatment location under fluoroscopy. The bipolar RF probe was then used to ablate the basivertebral nerve in a controlled manner. The RF energy delivered in the study had a frequency of 500 kHz, the temperature at the electrodes was 85° C., and the duration of treatment varied between 5 and 15 minutes. In accordance with several embodiments, the RF energy delivered may be between 400 and 600 kHz (e.g., 450 kHz, 500 kHz, 550 kHz), the temperature at the electrodes may be between 80° C. and 100° C. (e.g., 85° C., 90° C., 95° C.), and the duration of treatment may be between 4 and 20 minutes (e.g., 6 minutes, 8 minutes, 10 minutes, 12 minutes, 15 minutes).
In accordance with several embodiments, the treatment was limited to the L3, L4, L5 and S1 vertebrae. Two-level and three-level intraosseous ablation treatments were performed on various patients. The multiple levels treated during the study were at adjacent levels. Twelve patients were treated at the L4 and L5 levels, two patients were treated at L3 through L5 levels, and two patients were treated at the L5 and S1 levels.
Radiographs found no factures during the follow-up period, and no remodeling of bone was observed. Thirteen of the sixteen patients reported “profound and immediate relief” The treatment procedure resulted in improved ODI scores and Visual Analogue Pain Scale (VAS) values, which were sustained at one year. ODI scores were significantly improved at six weeks, three months, six months, and twelve months. The mean decrease in ODI scores at 1 year was 31 points. VAS values decreased from a preoperative average of 61.1 to an average of 45.6 at the 1-year follow-up. No device-related serious adverse events were reported. Accordingly, in one embodiment, basivertebral nerve ablation is a safe, simple procedure that is applicable during the early stages of treatment for patients with disabling back pain.
Conditional language, for example, among others, “can,” “could,” “might,” or “may,” unless specifically stated otherwise, or otherwise understood within the context as used, is generally intended to convey that certain embodiments include, while other embodiments do not include, certain features, elements and/or steps.
Although certain embodiments and examples have been described herein, aspects of the methods and devices shown and described in the present disclosure may be differently combined and/or modified to form still further embodiments. Additionally, the methods described herein may be practiced using any device suitable for performing the recited steps. Some embodiments have been described in connection with the accompanying drawings. However, it should be understood that the figures are not drawn to scale. Distances, angles, etc. are merely illustrative and do not necessarily bear an exact relationship to actual dimensions and layout of the devices illustrated. Components can be added, removed, and/or rearranged. Further, the disclosure (including the figures) herein of any particular feature, aspect, method, property, characteristic, quality, attribute, element, or the like in connection with various embodiments can be used in all other embodiments set forth herein.
For purposes of this disclosure, certain aspects, advantages, and novel features of the inventions are described herein. Embodiments embodied or carried out in a manner may achieve one advantage or group of advantages as taught herein without necessarily achieving other advantages. The headings used herein are merely provided to enhance readability and are not intended to limit the scope of the embodiments disclosed in a particular section to the features or elements disclosed in that section. The features or elements from one embodiment of the disclosure can be employed by other embodiments of the disclosure. For example, features described in one figure may be used in conjunction with embodiments illustrated in other figures.
Although the description above contains many details, these should not be construed as limiting the scope of the invention(s) but as merely providing illustrations of some of the embodiments of this invention. Therefore, the scope of the invention(s) described herein fully encompasses other contemplated embodiments, as well as their equivalents. The scope of the invention should be viewed in light of the appended claims. References herein to an element in the singular is not intended to mean “one and only one” unless explicitly so stated, but rather “one or more.”
This application is a continuation of U.S. application Ser. No. 14/673,172, filed Mar. 30, 2015, now U.S. Pat. No. 9,486,279, which is a continuation of U.S. application Ser. No. 13/923,798, filed Jun. 21, 2013, now U.S. Pat. No. 8,992,523, which is a continuation of U.S. application Ser. No. 13/615,300, filed Sep. 13, 2012, now abandoned, which is a continuation of U.S. application Ser. No. 13/612,541, filed on Sep. 12, 2012, now U.S. Pat. No. 8,361,067, which is a continuation-in-part of U.S. application Ser. No. 12/683,555, filed on Jan. 7, 2010, now U.S. Pat. No. 8,613,744, which is a continuation-in-part of U.S. application Ser. No. 12/566,895, filed on Sep. 25, 2009, now U.S. Pat. No. 8,419,730, which claims priority from U.S. Provisional Application No. 61/100,553 filed on Sep. 26, 2008, the content of each of which is incorporated herein by reference in its entirety. U.S. application Ser. No. 12/683,555 is also a continuation-in-part of U.S. application Ser. No. 11/123,766 filed on May 6, 2005, now U.S. Pat. No. 7,749,218, which is a divisional of U.S. application Ser. No. 10/260,879 filed on Sep. 30, 2002, now U.S. Pat. No. 6,907,884, the content of each of which is incorporated herein by reference in its entirety.
| Number | Name | Date | Kind |
|---|---|---|---|
| 3565062 | Kuris | Feb 1971 | A |
| 3822708 | Zilber | Jul 1974 | A |
| 3845771 | Vise | Nov 1974 | A |
| 3920021 | Hiltebrandt | Nov 1975 | A |
| 3938502 | Bom | Feb 1976 | A |
| 3997408 | MacKew | Aug 1976 | A |
| 4044774 | Corgin et al. | Aug 1977 | A |
| 4116198 | Roos | Sep 1978 | A |
| 4311154 | Sterzer et al. | Jan 1982 | A |
| 4312364 | Convert et al. | Jan 1982 | A |
| 4378806 | Henley-Cohn | Apr 1983 | A |
| 4448198 | Turner | May 1984 | A |
| 4449528 | Auth et al. | May 1984 | A |
| 4462408 | Silverstein et al. | Jul 1984 | A |
| 4528979 | Marchenko et al. | Jul 1985 | A |
| 4530360 | Durate | Jul 1985 | A |
| 4569351 | Tang | Feb 1986 | A |
| 4573448 | Kambin | Mar 1986 | A |
| 4586512 | Do-huu | May 1986 | A |
| 4601296 | Yerushalmi | Jul 1986 | A |
| 4612940 | Kasevich et al. | Sep 1986 | A |
| 4657017 | Sorochenko | Apr 1987 | A |
| 4662383 | Sogawa et al. | May 1987 | A |
| 4671293 | Shalov | Jun 1987 | A |
| 4676258 | Inokuchi et al. | Jun 1987 | A |
| 4679561 | Doss | Jul 1987 | A |
| 4681122 | Winters et al. | Jul 1987 | A |
| 4750499 | Hoffer | Jun 1988 | A |
| 4754757 | Feucht | Jul 1988 | A |
| 4757820 | Itoh | Jul 1988 | A |
| 4774967 | Zanakis et al. | Oct 1988 | A |
| 4800899 | Elliott | Jan 1989 | A |
| 4813429 | Eshel et al. | Mar 1989 | A |
| 4841977 | Griffith et al. | Jun 1989 | A |
| 4907589 | Cosman | Mar 1990 | A |
| 4924863 | Sterzer | May 1990 | A |
| 4936281 | Stasz | Jun 1990 | A |
| 4950267 | Ishihara et al. | Aug 1990 | A |
| 4951677 | Crowley et al. | Aug 1990 | A |
| 4955377 | Lennox et al. | Sep 1990 | A |
| 4959063 | Kojima | Sep 1990 | A |
| 4961435 | Kitagawa et al. | Oct 1990 | A |
| 4963142 | Loertscher | Oct 1990 | A |
| 4966144 | Rochkind et al. | Oct 1990 | A |
| 4967765 | Turner et al. | Nov 1990 | A |
| 4976711 | Parins et al. | Dec 1990 | A |
| 4977902 | Sekino et al. | Dec 1990 | A |
| 5000185 | Yock | Mar 1991 | A |
| 5002058 | Martinelli | Mar 1991 | A |
| 5002059 | Crowley et al. | Mar 1991 | A |
| 5007437 | Sterzer | Apr 1991 | A |
| 5025778 | Silverstein et al. | Jun 1991 | A |
| 5031618 | Mullett | Jul 1991 | A |
| 5061266 | Hakky | Oct 1991 | A |
| 5070879 | Herres | Dec 1991 | A |
| RE33791 | Carr | Jan 1992 | E |
| 5078736 | Behl | Jan 1992 | A |
| 5080660 | Buelna | Jan 1992 | A |
| 5084043 | Hertzmann et al. | Jan 1992 | A |
| 5090414 | Takano | Feb 1992 | A |
| 5098431 | Rydell | Mar 1992 | A |
| 5106376 | Mononen et al. | Apr 1992 | A |
| 5108404 | Scholten et al. | Apr 1992 | A |
| 5131397 | Crowley et al. | Jul 1992 | A |
| 5147355 | Friedman et al. | Sep 1992 | A |
| 5156157 | Valenta, Jr. et al. | Oct 1992 | A |
| 5158536 | Sekins et al. | Oct 1992 | A |
| 5161533 | Prass et al. | Nov 1992 | A |
| 5167231 | Matsui | Dec 1992 | A |
| 5186177 | O'Donnell et al. | Feb 1993 | A |
| 5190540 | Lee | Mar 1993 | A |
| 5190546 | Jervis | Mar 1993 | A |
| 5201729 | Hertzmann et al. | Apr 1993 | A |
| 5207672 | Martinelli et al. | May 1993 | A |
| 5209748 | Daikuzono | May 1993 | A |
| 5222953 | Dowlatshahi | Jun 1993 | A |
| 5226430 | Spear et al. | Jul 1993 | A |
| 5242439 | Larsen et al. | Sep 1993 | A |
| 5255679 | Imran | Oct 1993 | A |
| 5271408 | Breyer et al. | Dec 1993 | A |
| 5273026 | Wilk | Dec 1993 | A |
| 5281213 | Milder et al. | Jan 1994 | A |
| 5281215 | Milder et al. | Jan 1994 | A |
| 5282468 | Klepinski | Feb 1994 | A |
| 5292321 | Lee | Mar 1994 | A |
| 5295484 | Marcus et al. | Mar 1994 | A |
| 5300085 | Yock | Apr 1994 | A |
| 5304214 | DeFord et al. | Apr 1994 | A |
| 5305756 | Entrekin et al. | Apr 1994 | A |
| 5314463 | Camps et al. | May 1994 | A |
| 5320617 | Leach | Jun 1994 | A |
| 5324255 | Pasafaro et al. | Jun 1994 | A |
| 5325860 | Seward et al. | Jul 1994 | A |
| 5342292 | Nita et al. | Aug 1994 | A |
| 5342357 | Nardella | Aug 1994 | A |
| 5342409 | Mullett | Aug 1994 | A |
| 5344435 | Turner et al. | Sep 1994 | A |
| 5345940 | Seward et al. | Sep 1994 | A |
| 5348554 | Imran et al. | Sep 1994 | A |
| 5350377 | Winston et al. | Sep 1994 | A |
| 5351691 | Brommersma | Oct 1994 | A |
| 5366443 | Eggers et al. | Nov 1994 | A |
| 5366490 | Edwards et al. | Nov 1994 | A |
| 5368031 | Cline et al. | Nov 1994 | A |
| 5368035 | Hamm et al. | Nov 1994 | A |
| 5368557 | Nita et al. | Nov 1994 | A |
| 5368558 | Nita | Nov 1994 | A |
| 5370675 | Edwards et al. | Dec 1994 | A |
| 5370678 | Edwards et al. | Dec 1994 | A |
| 5372138 | Crowley et al. | Dec 1994 | A |
| 5374265 | Sand | Dec 1994 | A |
| 5383876 | Nardella | Jan 1995 | A |
| 5385148 | Lesh et al. | Jan 1995 | A |
| 5385544 | Edwards et al. | Jan 1995 | A |
| 5391197 | Burdette et al. | Feb 1995 | A |
| 5391199 | Ben-Haim | Feb 1995 | A |
| 5405376 | Mulier et al. | Apr 1995 | A |
| 5411527 | Alt | May 1995 | A |
| 5419767 | Eggers et al. | May 1995 | A |
| 5421338 | Crowley | Jun 1995 | A |
| 5423811 | Imran et al. | Jun 1995 | A |
| 5431649 | Mulier et al. | Jul 1995 | A |
| 5433739 | Sluijter | Jul 1995 | A |
| D361555 | Bettin et al. | Aug 1995 | S |
| 5437661 | Rieser | Aug 1995 | A |
| 5441499 | Fritzsch | Aug 1995 | A |
| 5443463 | Stern et al. | Aug 1995 | A |
| 5447509 | Millis et al. | Sep 1995 | A |
| 5449380 | Chin | Sep 1995 | A |
| 5454373 | Koger et al. | Oct 1995 | A |
| 5458596 | Lax et al. | Oct 1995 | A |
| 5458597 | Edwards et al. | Oct 1995 | A |
| 5471988 | Fujio et al. | Dec 1995 | A |
| 5472441 | Edwards et al. | Dec 1995 | A |
| 5474530 | Passafaro et al. | Dec 1995 | A |
| 5484432 | Sand | Jan 1996 | A |
| 5486170 | Winston et al. | Jan 1996 | A |
| 5501703 | Holsheimer et al. | Mar 1996 | A |
| 5505730 | Edwarrds | Apr 1996 | A |
| 5514130 | Baker | May 1996 | A |
| 5524624 | Tepper et al. | Jun 1996 | A |
| 5526815 | Granz et al. | Jun 1996 | A |
| 5529580 | Hagino et al. | Jun 1996 | A |
| 5540679 | Fram et al. | Jul 1996 | A |
| 5540681 | Strul et al. | Jul 1996 | A |
| 5540684 | Hassler, Jr. | Jul 1996 | A |
| 5545161 | Imran | Aug 1996 | A |
| 5560362 | Sliwa, Jr. et al. | Oct 1996 | A |
| 5565005 | Erickson et al. | Oct 1996 | A |
| 5569242 | Lax et al. | Oct 1996 | A |
| 5571088 | Lennox et al. | Nov 1996 | A |
| 5571147 | Sluijter et al. | Nov 1996 | A |
| 5575772 | Lennox | Nov 1996 | A |
| 5575788 | Baker et al. | Nov 1996 | A |
| 5588432 | Crowley | Dec 1996 | A |
| 5596988 | Markle et al. | Jan 1997 | A |
| 5601526 | Chapelon et al. | Feb 1997 | A |
| 5606974 | Castellano et al. | Mar 1997 | A |
| 5609151 | Mulier et al. | Mar 1997 | A |
| 5620479 | Diederich | Apr 1997 | A |
| 5628317 | Starkebaum et al. | May 1997 | A |
| 5630426 | Shmulewitz et al. | May 1997 | A |
| 5630837 | Crowley | May 1997 | A |
| 5643319 | Green et al. | Jul 1997 | A |
| 5647871 | Levine et al. | Jul 1997 | A |
| 5658278 | Imran et al. | Aug 1997 | A |
| 5672173 | Gough et al. | Sep 1997 | A |
| 5681282 | Eggers et al. | Oct 1997 | A |
| 5683366 | Eggers et al. | Nov 1997 | A |
| 5685839 | Baker et al. | Nov 1997 | A |
| 5687729 | Schaetzle | Nov 1997 | A |
| 5693052 | Weaver | Dec 1997 | A |
| 5697281 | Eggers et al. | Dec 1997 | A |
| 5697536 | Eggers et al. | Dec 1997 | A |
| 5697882 | Eggers et al. | Dec 1997 | A |
| 5697909 | Eggers et al. | Dec 1997 | A |
| 5697927 | Imran et al. | Dec 1997 | A |
| 5700262 | Acosta et al. | Dec 1997 | A |
| 5718231 | Chen et al. | Feb 1998 | A |
| 5720286 | Chapelon et al. | Feb 1998 | A |
| 5720287 | Chapelon et al. | Feb 1998 | A |
| 5722403 | McGee et al. | Mar 1998 | A |
| 5725494 | Brisken | Mar 1998 | A |
| 5728062 | Brisken | Mar 1998 | A |
| 5730706 | Garnies | Mar 1998 | A |
| 5733315 | Burdette et al. | Mar 1998 | A |
| 5735280 | Sherman et al. | Apr 1998 | A |
| 5735811 | Brisken | Apr 1998 | A |
| 5735846 | Fleischman et al. | Apr 1998 | A |
| 5735847 | Gough et al. | Apr 1998 | A |
| 5738680 | Mueller et al. | Apr 1998 | A |
| 5741249 | Moss et al. | Apr 1998 | A |
| 5743904 | Edwards | Apr 1998 | A |
| 5746737 | Saadat | May 1998 | A |
| 5752969 | Cunci et al. | May 1998 | A |
| 5755663 | Johnson et al. | May 1998 | A |
| 5762066 | Law et al. | Jun 1998 | A |
| 5762616 | Talish | Jun 1998 | A |
| 5766153 | Eggers et al. | Jun 1998 | A |
| 5766231 | Erickson et al. | Jun 1998 | A |
| 5776092 | Farin et al. | Jul 1998 | A |
| 5785705 | Baker | Jul 1998 | A |
| 5800378 | Edwards et al. | Sep 1998 | A |
| 5800429 | Edwards | Sep 1998 | A |
| 5800432 | Swanson | Sep 1998 | A |
| 5807237 | Tindel | Sep 1998 | A |
| 5807391 | Wijkamp | Sep 1998 | A |
| 5807392 | Eggers | Sep 1998 | A |
| 5807395 | Mulier et al. | Sep 1998 | A |
| 5810764 | Eggers et al. | Sep 1998 | A |
| 5817021 | Reichenberger | Oct 1998 | A |
| 5824021 | Rise | Oct 1998 | A |
| 5840031 | Crowley | Nov 1998 | A |
| 5843019 | Eggers et al. | Dec 1998 | A |
| 5843021 | Edwards et al. | Dec 1998 | A |
| 5844092 | Presta et al. | Dec 1998 | A |
| 5846218 | Brisken et al. | Dec 1998 | A |
| 5849011 | Jones et al. | Dec 1998 | A |
| 5855576 | LeVeen et al. | Jan 1999 | A |
| 5860951 | Eggers et al. | Jan 1999 | A |
| 5865788 | Edwards et al. | Feb 1999 | A |
| 5865801 | Houser | Feb 1999 | A |
| 5868740 | LeVeen et al. | Feb 1999 | A |
| 5871469 | Eggers et al. | Feb 1999 | A |
| 5871470 | McWha | Feb 1999 | A |
| 5871481 | Kannenberg et al. | Feb 1999 | A |
| 5873855 | Eggers et al. | Feb 1999 | A |
| 5873877 | McGaffigan et al. | Feb 1999 | A |
| 5876398 | Mulier et al. | Mar 1999 | A |
| 5888198 | Eggers et al. | Mar 1999 | A |
| 5891095 | Eggers et al. | Apr 1999 | A |
| 5895370 | Edwards et al. | Apr 1999 | A |
| 5902272 | Eggers et al. | May 1999 | A |
| 5902308 | Murphy | May 1999 | A |
| 5904681 | West, Jr. | May 1999 | A |
| 5906613 | Mulier et al. | May 1999 | A |
| 5916213 | Haissaguerre et al. | Jun 1999 | A |
| 5916214 | Cosio | Jun 1999 | A |
| 5919188 | Shearon et al. | Jul 1999 | A |
| 5931805 | Brisken | Aug 1999 | A |
| 5935123 | Edwards et al. | Aug 1999 | A |
| 5938582 | Ciamacco et al. | Aug 1999 | A |
| 5941722 | Chen | Aug 1999 | A |
| 5941876 | Nardella et al. | Aug 1999 | A |
| 5944715 | Goble et al. | Aug 1999 | A |
| 5948007 | Starkebaum et al. | Sep 1999 | A |
| 5948008 | Daikuzono | Sep 1999 | A |
| 5954716 | Sharkey et al. | Sep 1999 | A |
| 5964727 | Edwards et al. | Oct 1999 | A |
| 5967988 | Briscoe et al. | Oct 1999 | A |
| 5976105 | Marcove et al. | Nov 1999 | A |
| 5983141 | Sluijter et al. | Nov 1999 | A |
| 5997497 | Nita et al. | Dec 1999 | A |
| 6001095 | de la Rama et al. | Dec 1999 | A |
| 6007533 | Casscells et al. | Dec 1999 | A |
| 6007570 | Sharkey et al. | Dec 1999 | A |
| 6012457 | Lesh | Jan 2000 | A |
| 6014588 | Fitz | Jan 2000 | A |
| 6016452 | Kasevich | Jan 2000 | A |
| 6016809 | Mulier et al. | Jan 2000 | A |
| 6017356 | Frederick et al. | Jan 2000 | A |
| 6019776 | Preissman et al. | Feb 2000 | A |
| 6022334 | Edwards et al. | Feb 2000 | A |
| 6024733 | Eggers et al. | Feb 2000 | A |
| 6024740 | Lesh et al. | Feb 2000 | A |
| 6030374 | McDaniel | Feb 2000 | A |
| 6030402 | Thompson et al. | Feb 2000 | A |
| 6032673 | Langberg et al. | Mar 2000 | A |
| 6032674 | Eggers et al. | Mar 2000 | A |
| 6033411 | Preissman et al. | Mar 2000 | A |
| 6035238 | Ingle et al. | Mar 2000 | A |
| 6038480 | Hrdlicka et al. | Mar 2000 | A |
| 6045532 | Eggers et al. | Apr 2000 | A |
| 6046187 | Berde et al. | Apr 2000 | A |
| 6047214 | Mueller et al. | Apr 2000 | A |
| 6050995 | Durgin | Apr 2000 | A |
| 6053172 | Hovda et al. | Apr 2000 | A |
| 6053909 | Shadduck | Apr 2000 | A |
| 6063078 | Wittkampf | May 2000 | A |
| 6063079 | Hovda et al. | May 2000 | A |
| 6066134 | Eggers et al. | May 2000 | A |
| 6068642 | Johnson et al. | May 2000 | A |
| 6071279 | Whayne et al. | Jun 2000 | A |
| 6073051 | Sharkey et al. | Jun 2000 | A |
| 6074352 | Hynynen et al. | Jun 2000 | A |
| 6086585 | Hovda et al. | Jul 2000 | A |
| 6090105 | Zepeda et al. | Jul 2000 | A |
| 6095149 | Sharkey et al. | Aug 2000 | A |
| 6099499 | Ciamacco | Aug 2000 | A |
| 6099514 | Sharkey et al. | Aug 2000 | A |
| 6102046 | Weinstein et al. | Aug 2000 | A |
| 6104957 | Alo et al. | Aug 2000 | A |
| 6105581 | Eggers et al. | Aug 2000 | A |
| 6106454 | Berg et al. | Aug 2000 | A |
| 6109268 | Thapliyal et al. | Aug 2000 | A |
| 6112122 | Schwardt et al. | Aug 2000 | A |
| 6113597 | Eggers et al. | Sep 2000 | A |
| 6117101 | Diederich et al. | Sep 2000 | A |
| 6117109 | Eggers et al. | Sep 2000 | A |
| 6117128 | Gregory | Sep 2000 | A |
| 6120467 | Schallhorn | Sep 2000 | A |
| 6120502 | Michelson | Sep 2000 | A |
| 6122549 | Sharkey et al. | Sep 2000 | A |
| 6126682 | Ashley et al. | Oct 2000 | A |
| 6137209 | Dahlberg et al. | Oct 2000 | A |
| 6139545 | Utley et al. | Oct 2000 | A |
| 6142992 | Cheng et al. | Nov 2000 | A |
| 6143019 | Motamedi et al. | Nov 2000 | A |
| 6146380 | Racz et al. | Nov 2000 | A |
| 6149620 | Baker et al. | Nov 2000 | A |
| 6159194 | Eggers et al. | Dec 2000 | A |
| 6159208 | Hovda et al. | Dec 2000 | A |
| 6161048 | Sluijter et al. | Dec 2000 | A |
| 6164283 | Lesh | Dec 2000 | A |
| 6165172 | Farley et al. | Dec 2000 | A |
| 6168593 | Sharkey et al. | Jan 2001 | B1 |
| 6169924 | Meloy et al. | Jan 2001 | B1 |
| 6171239 | Humphrey | Jan 2001 | B1 |
| 6176857 | Ashley | Jan 2001 | B1 |
| 6179824 | Eggers et al. | Jan 2001 | B1 |
| 6179836 | Eggers et al. | Jan 2001 | B1 |
| 6179858 | Squire et al. | Jan 2001 | B1 |
| 6183469 | Thapliyal et al. | Feb 2001 | B1 |
| 6190381 | Olsen et al. | Feb 2001 | B1 |
| 6190383 | Schmaltz et al. | Feb 2001 | B1 |
| 6193715 | Wrublewski et al. | Feb 2001 | B1 |
| 6203542 | Ellsberry et al. | Mar 2001 | B1 |
| 6206842 | Tu et al. | Mar 2001 | B1 |
| 6210393 | Brisken | Apr 2001 | B1 |
| 6210402 | Olsen et al. | Apr 2001 | B1 |
| 6210415 | Bester | Apr 2001 | B1 |
| 6216704 | Ingle | Apr 2001 | B1 |
| 6221038 | Brisken | Apr 2001 | B1 |
| 6224592 | Eggers et al. | May 2001 | B1 |
| 6228046 | Brisken | May 2001 | B1 |
| 6228078 | Eggers et al. | May 2001 | B1 |
| 6228082 | Baker et al. | May 2001 | B1 |
| 6231516 | Keilman et al. | May 2001 | B1 |
| 6231528 | Kaufman et al. | May 2001 | B1 |
| 6231571 | Ellman et al. | May 2001 | B1 |
| 6231615 | Preissman | May 2001 | B1 |
| 6233488 | Hess | May 2001 | B1 |
| 6235020 | Cheng et al. | May 2001 | B1 |
| 6235024 | Tu | May 2001 | B1 |
| 6238391 | Olsen et al. | May 2001 | B1 |
| 6238393 | Mulier et al. | May 2001 | B1 |
| 6241665 | Negus et al. | Jun 2001 | B1 |
| 6241725 | Cosman | Jun 2001 | B1 |
| 6245064 | Lesh | Jun 2001 | B1 |
| 6246912 | Sluijter et al. | Jun 2001 | B1 |
| 6248345 | Goldenheim et al. | Jun 2001 | B1 |
| 6254553 | Lidgren et al. | Jul 2001 | B1 |
| 6254599 | Lesh et al. | Jul 2001 | B1 |
| 6254600 | Willink et al. | Jul 2001 | B1 |
| 6258086 | Ashley et al. | Jul 2001 | B1 |
| 6259952 | Sluijter | Jul 2001 | B1 |
| 6261311 | Sharkey et al. | Jul 2001 | B1 |
| 6264650 | Hovda et al. | Jul 2001 | B1 |
| 6264651 | Underwood et al. | Jul 2001 | B1 |
| 6264652 | Eggers et al. | Jul 2001 | B1 |
| 6264659 | Ross et al. | Jul 2001 | B1 |
| 6267770 | Truwit | Jul 2001 | B1 |
| 6270498 | Michelson | Aug 2001 | B1 |
| 6277112 | Underwood et al. | Aug 2001 | B1 |
| 6277122 | McGahan et al. | Aug 2001 | B1 |
| 6280441 | Ryan | Aug 2001 | B1 |
| 6283961 | Underwood et al. | Sep 2001 | B1 |
| 6287114 | Meller et al. | Sep 2001 | B1 |
| 6287272 | Brisken et al. | Sep 2001 | B1 |
| 6287304 | Eggers et al. | Sep 2001 | B1 |
| 6290715 | Sharkey et al. | Sep 2001 | B1 |
| 6292699 | Simon et al. | Sep 2001 | B1 |
| 6296619 | Brisken et al. | Oct 2001 | B1 |
| 6296636 | Cheng et al. | Oct 2001 | B1 |
| 6296638 | Davison et al. | Oct 2001 | B1 |
| 6305378 | Lesh et al. | Oct 2001 | B1 |
| 6309387 | Eggers et al. | Oct 2001 | B1 |
| 6309420 | Preissman | Oct 2001 | B1 |
| 6312408 | Eggers et al. | Nov 2001 | B1 |
| 6312426 | Goldberg et al. | Nov 2001 | B1 |
| 6319241 | King et al. | Nov 2001 | B1 |
| 6322549 | Eggers et al. | Nov 2001 | B1 |
| 6348055 | Preissman | Feb 2002 | B1 |
| 6355032 | Hovda et al. | Mar 2002 | B1 |
| 6356790 | Maguire et al. | Mar 2002 | B1 |
| 6361531 | Hissong | Mar 2002 | B1 |
| 6363937 | Hovda et al. | Apr 2002 | B1 |
| 6368292 | Ogden et al. | Apr 2002 | B1 |
| 6379351 | Thapliyal et al. | Apr 2002 | B1 |
| 6383190 | Preissman | May 2002 | B1 |
| 6391025 | Weinstein et al. | May 2002 | B1 |
| 6416507 | Eggers et al. | Jul 2002 | B1 |
| 6416508 | Eggers et al. | Jul 2002 | B1 |
| 6423059 | Hanson et al. | Jul 2002 | B1 |
| 6426339 | Berde et al. | Jul 2002 | B1 |
| 6428491 | Weiss | Aug 2002 | B1 |
| 6432103 | Ellsberry et al. | Aug 2002 | B1 |
| 6436060 | Talish | Aug 2002 | B1 |
| 6436098 | Michelson | Aug 2002 | B1 |
| 6447448 | Ishikawa et al. | Sep 2002 | B1 |
| 6451013 | Bays et al. | Sep 2002 | B1 |
| 6454727 | Burbank et al. | Sep 2002 | B1 |
| 6461350 | Underwood et al. | Oct 2002 | B1 |
| 6461354 | Olsen et al. | Oct 2002 | B1 |
| 6464695 | Hovda et al. | Oct 2002 | B2 |
| 6468270 | Hovda et al. | Oct 2002 | B1 |
| 6468274 | Alleyne et al. | Oct 2002 | B1 |
| 6470220 | Kraus et al. | Oct 2002 | B1 |
| 6478793 | Cosman et al. | Nov 2002 | B1 |
| 6482201 | Olsen et al. | Nov 2002 | B1 |
| 6485271 | Tack | Nov 2002 | B1 |
| 6487446 | Hill et al. | Nov 2002 | B1 |
| 6491893 | Babich | Dec 2002 | B1 |
| 6493592 | Leonard et al. | Dec 2002 | B1 |
| 6494902 | Hoey et al. | Dec 2002 | B2 |
| 6500173 | Underwood et al. | Dec 2002 | B2 |
| 6505075 | Weiner | Jan 2003 | B1 |
| 6524261 | Talish et al. | Feb 2003 | B2 |
| 6527759 | Tachibana et al. | Mar 2003 | B1 |
| 6537306 | Burdette et al. | Mar 2003 | B1 |
| 6540741 | Underwood et al. | Apr 2003 | B1 |
| 6544261 | Ellsberry et al. | Apr 2003 | B2 |
| 6557559 | Eggers et al. | May 2003 | B1 |
| 6558385 | McClurken et al. | May 2003 | B1 |
| 6558390 | Cragg | May 2003 | B2 |
| 6560486 | Osorio et al. | May 2003 | B1 |
| 6562033 | Shah et al. | May 2003 | B2 |
| 6575968 | Eggers et al. | Jun 2003 | B1 |
| 6575969 | Rittman, III et al. | Jun 2003 | B1 |
| 6575979 | Cragg | Jun 2003 | B1 |
| 6578579 | Burnside et al. | Jun 2003 | B2 |
| 6582423 | Thapliyal et al. | Jun 2003 | B1 |
| 6585656 | Masters | Jul 2003 | B2 |
| 6589237 | Woloszko et al. | Jul 2003 | B2 |
| 6592559 | Pakter et al. | Jul 2003 | B1 |
| 6595990 | Weinstein et al. | Jul 2003 | B1 |
| 6599288 | Maguire et al. | Jul 2003 | B2 |
| 6602248 | Sharps et al. | Aug 2003 | B1 |
| 6607502 | Maguire et al. | Aug 2003 | B1 |
| 6607529 | Jones et al. | Aug 2003 | B1 |
| 6608502 | Aoki et al. | Aug 2003 | B2 |
| 6622731 | Daniel et al. | Sep 2003 | B2 |
| 6632193 | Davison et al. | Oct 2003 | B1 |
| 6632220 | Eggers et al. | Oct 2003 | B1 |
| 6645202 | Pless et al. | Nov 2003 | B1 |
| 6648883 | Francischelli et al. | Nov 2003 | B2 |
| 6659106 | Hovda et al. | Dec 2003 | B1 |
| 6663627 | Francischelli et al. | Dec 2003 | B2 |
| 6673063 | Brett | Jan 2004 | B2 |
| 6689086 | Nita et al. | Feb 2004 | B1 |
| 6689125 | Keith et al. | Feb 2004 | B1 |
| 6692450 | Coleman | Feb 2004 | B1 |
| 6699240 | Francischelli | Mar 2004 | B2 |
| 6699242 | Heggeness | Mar 2004 | B2 |
| 6709432 | Ferek-Patric | Mar 2004 | B2 |
| 6718208 | Hill et al. | Apr 2004 | B2 |
| 6723087 | O'Neill et al. | Apr 2004 | B2 |
| 6726684 | Woloszko et al. | Apr 2004 | B1 |
| 6736810 | Hoey et al. | May 2004 | B2 |
| 6736835 | Pellegrino et al. | May 2004 | B2 |
| 6745079 | King | Jun 2004 | B2 |
| 6746447 | Davison et al. | Jun 2004 | B2 |
| 6749604 | Eggers et al. | Jun 2004 | B1 |
| 6758846 | Goble et al. | Jul 2004 | B2 |
| 6770071 | Woloszko et al. | Aug 2004 | B2 |
| 6772012 | Ricart et al. | Aug 2004 | B2 |
| 6773431 | Eggers et al. | Aug 2004 | B2 |
| 6795737 | Gielen et al. | Sep 2004 | B2 |
| 6827715 | Francischelli et al. | Dec 2004 | B2 |
| 6827716 | Ryan et al. | Dec 2004 | B2 |
| 6832996 | Woloszko et al. | Dec 2004 | B2 |
| 6837887 | Woloszko et al. | Jan 2005 | B2 |
| 6837888 | Ciarrocca et al. | Jan 2005 | B2 |
| 6852091 | Edwards et al. | Feb 2005 | B2 |
| 6863672 | Reiley et al. | Mar 2005 | B2 |
| 6875219 | Arramon et al. | Apr 2005 | B2 |
| 6881214 | Cosman et al. | Apr 2005 | B2 |
| 6896674 | Woloszko et al. | May 2005 | B1 |
| 6896675 | Leung et al. | May 2005 | B2 |
| 6907884 | Pellegrino | Jun 2005 | B2 |
| 6915806 | Pacek et al. | Jul 2005 | B2 |
| 6922579 | Taimisto et al. | Jul 2005 | B2 |
| 6923813 | Phillips et al. | Aug 2005 | B2 |
| 6936046 | Hissong et al. | Aug 2005 | B2 |
| 6955674 | Eick et al. | Oct 2005 | B2 |
| 6960204 | Eggers et al. | Nov 2005 | B2 |
| 6962589 | Mulier et al. | Nov 2005 | B2 |
| 6974453 | Woloszko et al. | Dec 2005 | B2 |
| 6980849 | Sasso | Dec 2005 | B2 |
| 6989010 | Francischelli et al. | Jan 2006 | B2 |
| 6997941 | Sharkey et al. | Feb 2006 | B2 |
| 7048743 | Miller et al. | May 2006 | B2 |
| 7065408 | Herman et al. | Jun 2006 | B2 |
| 7090672 | Underwood et al. | Aug 2006 | B2 |
| 7104989 | Skarda | Sep 2006 | B2 |
| 7131969 | Hovda et al. | Nov 2006 | B1 |
| 7177678 | Osorio et al. | Feb 2007 | B1 |
| 7179255 | Lettice et al. | Feb 2007 | B2 |
| 7186234 | Dahla et al. | Mar 2007 | B2 |
| 7192428 | Eggers et al. | Mar 2007 | B2 |
| 7201731 | Lundquist et al. | Apr 2007 | B1 |
| 7201750 | Eggers et al. | Apr 2007 | B1 |
| 7211055 | Diederich et al. | May 2007 | B2 |
| 7217268 | Eggers et al. | May 2007 | B2 |
| 7250048 | Francischelli et al. | Jul 2007 | B2 |
| 7258690 | Sutton et al. | Aug 2007 | B2 |
| 7270659 | Ricart et al. | Sep 2007 | B2 |
| 7270661 | Dahla et al. | Sep 2007 | B2 |
| 7276063 | Davison et al. | Oct 2007 | B2 |
| 7294127 | Leung et al. | Nov 2007 | B2 |
| 7305264 | Larson et al. | Dec 2007 | B2 |
| 7306596 | Hillier et al. | Dec 2007 | B2 |
| 7318823 | Sharps et al. | Jan 2008 | B2 |
| 7326203 | Papineau et al. | Feb 2008 | B2 |
| 7331956 | Hovda et al. | Feb 2008 | B2 |
| 7331957 | Woloszko et al. | Feb 2008 | B2 |
| RE40156 | Sharps et al. | Mar 2008 | E |
| 7346391 | Osorio et al. | Mar 2008 | B1 |
| 7386350 | Vilims | Jun 2008 | B2 |
| 7387625 | Hovda et al. | Jun 2008 | B2 |
| 7393351 | Woloszko et al. | Jul 2008 | B2 |
| 7422585 | Eggers et al. | Sep 2008 | B1 |
| 7429262 | Woloszko et al. | Sep 2008 | B2 |
| 7435247 | Woloszko et al. | Oct 2008 | B2 |
| 7435250 | Francischelli et al. | Oct 2008 | B2 |
| 7442191 | Hovda et al. | Oct 2008 | B2 |
| 7468059 | Eggers et al. | Dec 2008 | B2 |
| 7480533 | Cosman et al. | Jan 2009 | B2 |
| 7502652 | Gaunt et al. | Mar 2009 | B2 |
| 7503921 | Siegal | Mar 2009 | B2 |
| 7507236 | Eggers et al. | Mar 2009 | B2 |
| 7546164 | King | Jun 2009 | B2 |
| 7553307 | Bleich et al. | Jun 2009 | B2 |
| 7553309 | Buysse et al. | Jun 2009 | B2 |
| 7555343 | Bleich | Jun 2009 | B2 |
| 7593778 | Chandran et al. | Sep 2009 | B2 |
| 7645277 | McClurken et al. | Jan 2010 | B2 |
| 7678111 | Mulier et al. | Mar 2010 | B2 |
| 7708733 | Sanders et al. | May 2010 | B2 |
| 7738968 | Bleich | Jun 2010 | B2 |
| 7740631 | Bleich et al. | Jun 2010 | B2 |
| 7749218 | Pellegrino et al. | Jul 2010 | B2 |
| 7749220 | Schmaltz et al. | Jul 2010 | B2 |
| 7819826 | Diederich et al. | Oct 2010 | B2 |
| 7819869 | Godara et al. | Oct 2010 | B2 |
| 7824398 | Woloszko et al. | Nov 2010 | B2 |
| 7824404 | Godara et al. | Nov 2010 | B2 |
| 7846156 | Malis et al. | Dec 2010 | B2 |
| 7850685 | Kunis et al. | Dec 2010 | B2 |
| 7857813 | Schmitz et al. | Dec 2010 | B2 |
| 7896870 | Arless et al. | Mar 2011 | B2 |
| 7901403 | Woloszko et al. | Mar 2011 | B2 |
| 7909827 | Reiley et al. | Mar 2011 | B2 |
| 7914526 | Lehmann et al. | Mar 2011 | B2 |
| 7917222 | Osorio et al. | Mar 2011 | B1 |
| 7918849 | Bleich et al. | Apr 2011 | B2 |
| 7918874 | Siegal | Apr 2011 | B2 |
| 7945331 | Vilims | May 2011 | B2 |
| 7951140 | Arless et al. | May 2011 | B2 |
| 7959634 | Sennett | Jun 2011 | B2 |
| 7963915 | Bleich | Jun 2011 | B2 |
| 8021401 | Carl et al. | Sep 2011 | B2 |
| 8025688 | Diederich et al. | Sep 2011 | B2 |
| 8034052 | Podhajsky | Oct 2011 | B2 |
| 8062290 | Buysse et al. | Nov 2011 | B2 |
| 8066702 | Rittman, III et al. | Nov 2011 | B2 |
| 8083736 | McClurken et al. | Dec 2011 | B2 |
| 8100896 | Podhajsky | Jan 2012 | B2 |
| 8128633 | Linderman et al. | Mar 2012 | B2 |
| 8162933 | Francischelli et al. | Apr 2012 | B2 |
| 8172846 | Brunnett et al. | May 2012 | B2 |
| 8182477 | Orszulak et al. | May 2012 | B2 |
| 8192424 | Woloszko et al. | Jun 2012 | B2 |
| 8192435 | Bleich et al. | Jun 2012 | B2 |
| 8265747 | Rittman, III et al. | Sep 2012 | B2 |
| 8282628 | Paul et al. | Oct 2012 | B2 |
| 8292887 | Woloszko et al. | Oct 2012 | B2 |
| 8323279 | Dahla et al. | Dec 2012 | B2 |
| 8348946 | McClurken et al. | Jan 2013 | B2 |
| 8355799 | Marion et al. | Jan 2013 | B2 |
| 8361067 | Pellegrino | Jan 2013 | B2 |
| 8414509 | Diederich et al. | Apr 2013 | B2 |
| 8414571 | Pellegrino et al. | Apr 2013 | B2 |
| 8419730 | Pellegrino et al. | Apr 2013 | B2 |
| 8419731 | Pellegrino | Apr 2013 | B2 |
| 8425507 | Pellegrino et al. | Apr 2013 | B2 |
| 8444640 | Demarais et al. | May 2013 | B2 |
| 8454594 | Demarais et al. | Jun 2013 | B2 |
| 8475449 | Werneth et al. | Jul 2013 | B2 |
| 8486063 | Werneth et al. | Jul 2013 | B2 |
| 8504147 | Deem et al. | Aug 2013 | B2 |
| 8535309 | Pellegrino et al. | Sep 2013 | B2 |
| 8579903 | Carl | Nov 2013 | B2 |
| 8597301 | Mitchell | Dec 2013 | B2 |
| 8613744 | Pellegrino et al. | Dec 2013 | B2 |
| 8617156 | Werneth et al. | Dec 2013 | B2 |
| 8623014 | Pellegrino et al. | Jan 2014 | B2 |
| 8628528 | Pellegrino et al. | Jan 2014 | B2 |
| 8644941 | Rooney et al. | Feb 2014 | B2 |
| 8657814 | Werneth et al. | Feb 2014 | B2 |
| 8676309 | Deem et al. | Mar 2014 | B2 |
| 8690884 | Linderman et al. | Apr 2014 | B2 |
| 8747359 | Pakter et al. | Jun 2014 | B2 |
| 8747398 | Behnke | Jun 2014 | B2 |
| 8758349 | Germain et al. | Jun 2014 | B2 |
| 8771276 | Linderman | Jul 2014 | B2 |
| 8774913 | Demarais et al. | Jul 2014 | B2 |
| 8774924 | Weiner | Jul 2014 | B2 |
| 8795270 | Drake | Aug 2014 | B2 |
| 8808161 | Gregg et al. | Aug 2014 | B2 |
| 8808284 | Pellegrino et al. | Aug 2014 | B2 |
| 8821488 | Stewart et al. | Sep 2014 | B2 |
| 8845631 | Werneth et al. | Sep 2014 | B2 |
| 8864760 | Kramer et al. | Oct 2014 | B2 |
| 8882755 | Leung et al. | Nov 2014 | B2 |
| 8882759 | Manley et al. | Nov 2014 | B2 |
| 8882764 | Pellegrino et al. | Nov 2014 | B2 |
| 8894658 | Linderman et al. | Nov 2014 | B2 |
| 8915949 | Diederich et al. | Dec 2014 | B2 |
| 8926620 | Chasmawala et al. | Jan 2015 | B2 |
| 8968288 | Brannan | Mar 2015 | B2 |
| 8989859 | Deem et al. | Mar 2015 | B2 |
| 8992522 | Pellegrino et al. | Mar 2015 | B2 |
| 8992523 | Pellegrino | Mar 2015 | B2 |
| 9017325 | Pellegrino et al. | Apr 2015 | B2 |
| 9023038 | Pellegrino et al. | May 2015 | B2 |
| 9028488 | Goshayeshgar | May 2015 | B2 |
| 9028538 | Paul et al. | May 2015 | B2 |
| 9039701 | Pellegrino et al. | May 2015 | B2 |
| 9044245 | Condie et al. | Jun 2015 | B2 |
| 9044254 | Ladtkow et al. | Jun 2015 | B2 |
| 9044575 | Beasley et al. | Jun 2015 | B2 |
| 9095359 | Robert et al. | Aug 2015 | B2 |
| 9113896 | Mulier et al. | Aug 2015 | B2 |
| 9113911 | Sherman | Aug 2015 | B2 |
| 9113925 | Smith et al. | Aug 2015 | B2 |
| 9119647 | Brannan | Sep 2015 | B2 |
| 9119650 | Brannan et al. | Sep 2015 | B2 |
| 9125671 | Germain et al. | Sep 2015 | B2 |
| 9131597 | Taft et al. | Sep 2015 | B2 |
| 9151680 | Brannan | Oct 2015 | B2 |
| 9155895 | Wacnik et al. | Oct 2015 | B2 |
| 9161735 | Bradford et al. | Oct 2015 | B2 |
| 9161805 | Isenberg | Oct 2015 | B2 |
| 9161814 | Brannan et al. | Oct 2015 | B2 |
| 9168078 | Linderman et al. | Oct 2015 | B2 |
| 9168085 | Juzkiw | Oct 2015 | B2 |
| 9173676 | Pellegrino et al. | Nov 2015 | B2 |
| 9173700 | Godara et al. | Nov 2015 | B2 |
| 9179970 | Utley et al. | Nov 2015 | B2 |
| 9186197 | McKay | Nov 2015 | B2 |
| 9192308 | Brannan et al. | Nov 2015 | B2 |
| 9198684 | Arthur et al. | Dec 2015 | B2 |
| 9226756 | Teisen et al. | Jan 2016 | B2 |
| 9238139 | Degiorgio et al. | Jan 2016 | B2 |
| 9241729 | Juntz et al. | Jan 2016 | B2 |
| 9241760 | Godara et al. | Jan 2016 | B2 |
| 9247992 | Ladtkow et al. | Feb 2016 | B2 |
| 9247993 | Ladtkow et al. | Feb 2016 | B2 |
| 9248278 | Crosby et al. | Feb 2016 | B2 |
| 9248289 | Bennett et al. | Feb 2016 | B2 |
| 9254168 | Palanker | Feb 2016 | B2 |
| 9254386 | Lee et al. | Feb 2016 | B2 |
| 9259241 | Pellegrino et al. | Feb 2016 | B2 |
| 9259248 | Leuthardt et al. | Feb 2016 | B2 |
| 9259269 | Ladtkow et al. | Feb 2016 | B2 |
| 9259569 | Brounstein et al. | Feb 2016 | B2 |
| 9259577 | Kaula et al. | Feb 2016 | B2 |
| 9265522 | Pellegrino et al. | Feb 2016 | B2 |
| 9265557 | Sherman et al. | Feb 2016 | B2 |
| 9277969 | Brannan et al. | Mar 2016 | B2 |
| 9282988 | Goshayeshgar | Mar 2016 | B2 |
| 9289607 | Su et al. | Mar 2016 | B2 |
| 9295517 | Peyman et al. | Mar 2016 | B2 |
| 9295841 | Fang et al. | Mar 2016 | B2 |
| 9301723 | Brannan et al. | Apr 2016 | B2 |
| 9301804 | Bonn | Apr 2016 | B2 |
| 9302117 | De Vincentiis | Apr 2016 | B2 |
| 9308036 | Robinson | Apr 2016 | B2 |
| 9308045 | Kim et al. | Apr 2016 | B2 |
| 9314252 | Schaller et al. | Apr 2016 | B2 |
| 9314613 | Mashiach | Apr 2016 | B2 |
| 9314618 | Imran et al. | Apr 2016 | B2 |
| 9333144 | Baxter et al. | May 2016 | B2 |
| 9333339 | Weiner | May 2016 | B2 |
| 9333361 | Li et al. | May 2016 | B2 |
| 9333373 | Imran | May 2016 | B2 |
| 9339655 | Carbunaru | May 2016 | B2 |
| 9345530 | Ballakur et al. | May 2016 | B2 |
| 9345537 | Harrison et al. | May 2016 | B2 |
| 9345538 | Deem et al. | May 2016 | B2 |
| 9351739 | Mahoney et al. | May 2016 | B2 |
| 9358067 | Lee et al. | Jun 2016 | B2 |
| 9358396 | Holley | Jun 2016 | B2 |
| 9364286 | Werneth et al. | Jun 2016 | B2 |
| 9370348 | Tally et al. | Jun 2016 | B2 |
| 9370392 | Sharonov | Jun 2016 | B2 |
| 9370398 | Ladtkow et al. | Jun 2016 | B2 |
| 9375274 | Reid | Jun 2016 | B2 |
| 9375275 | Lee et al. | Jun 2016 | B2 |
| 9375278 | Robert et al. | Jun 2016 | B2 |
| 9375279 | Brannan | Jun 2016 | B2 |
| 9375283 | Arts et al. | Jun 2016 | B2 |
| 9381024 | Globerman et al. | Jul 2016 | B2 |
| 9381045 | Donner et al. | Jul 2016 | B2 |
| 9381050 | Lee et al. | Jul 2016 | B2 |
| 9381359 | Parramon et al. | Jul 2016 | B2 |
| 9387094 | Manrique et al. | Jul 2016 | B2 |
| 9393416 | Rooney et al. | Jul 2016 | B2 |
| 9398931 | Wittenberger et al. | Jul 2016 | B2 |
| 9399144 | Howard | Jul 2016 | B2 |
| 9403038 | Tyler | Aug 2016 | B2 |
| 9409023 | Burdick et al. | Aug 2016 | B2 |
| 9414884 | Faehndrich et al. | Aug 2016 | B2 |
| 9421064 | Pellegrino et al. | Aug 2016 | B2 |
| 9421123 | Lee et al. | Aug 2016 | B2 |
| 9421371 | Pless et al. | Aug 2016 | B2 |
| 9421378 | Lian et al. | Aug 2016 | B2 |
| 9439693 | Childs et al. | Sep 2016 | B2 |
| 9439721 | Werneth et al. | Sep 2016 | B2 |
| 9445859 | Pageard | Sep 2016 | B2 |
| 9446229 | Omar-Pasha | Sep 2016 | B2 |
| 9446235 | Su et al. | Sep 2016 | B2 |
| 9452286 | Cowan et al. | Sep 2016 | B2 |
| 9456836 | Boling et al. | Oct 2016 | B2 |
| 9457182 | Koop | Oct 2016 | B2 |
| 9468485 | Wittenberger et al. | Oct 2016 | B2 |
| 9468495 | Kunis et al. | Oct 2016 | B2 |
| 9474906 | Sachs et al. | Oct 2016 | B2 |
| 9486279 | Pellegrino | Nov 2016 | B2 |
| 9486447 | Peterson et al. | Nov 2016 | B2 |
| 9486621 | Howard et al. | Nov 2016 | B2 |
| 9492657 | Gerber | Nov 2016 | B2 |
| 9492664 | Peterson | Nov 2016 | B2 |
| 9504372 | Kim | Nov 2016 | B2 |
| 9504518 | Condie et al. | Nov 2016 | B2 |
| 9504530 | Hartmann et al. | Nov 2016 | B2 |
| 9504818 | Moffitt et al. | Nov 2016 | B2 |
| 9511229 | Bradley | Dec 2016 | B2 |
| 9511231 | Kent et al. | Dec 2016 | B1 |
| 9517200 | Bleier | Dec 2016 | B2 |
| 9526507 | Germain | Dec 2016 | B2 |
| 9526551 | Linderman | Dec 2016 | B2 |
| 9532828 | Condie et al. | Jan 2017 | B2 |
| 9549772 | Carl | Jan 2017 | B2 |
| 9550041 | Bedell | Jan 2017 | B2 |
| 9555037 | Podhajsky | Jan 2017 | B2 |
| 9566449 | Perryman et al. | Feb 2017 | B2 |
| 9572976 | Howard et al. | Feb 2017 | B2 |
| 9572986 | Moffitt | Feb 2017 | B2 |
| 9579518 | Gertner | Feb 2017 | B2 |
| 9597148 | Olson | Mar 2017 | B2 |
| RE46356 | Pellegrino et al. | Apr 2017 | E |
| 9610117 | Germain | Apr 2017 | B2 |
| 9649116 | Germain | May 2017 | B2 |
| 9687255 | Sennett et al. | Jun 2017 | B2 |
| 9724107 | Pellegrino et al. | Aug 2017 | B2 |
| 9724151 | Edidin | Aug 2017 | B2 |
| 9730707 | Sasaki et al. | Aug 2017 | B2 |
| 9770280 | Diederich et al. | Sep 2017 | B2 |
| 9775627 | Patel et al. | Oct 2017 | B2 |
| 9782221 | Srinivasan | Oct 2017 | B2 |
| 9795802 | Mohamed et al. | Oct 2017 | B2 |
| 9848944 | Sutton et al. | Dec 2017 | B2 |
| 20010001314 | Davison et al. | May 2001 | A1 |
| 20010001811 | Burney et al. | May 2001 | A1 |
| 20010020167 | Woloszko et al. | Sep 2001 | A1 |
| 20010023348 | Ashley et al. | Sep 2001 | A1 |
| 20010025176 | Ellsberry et al. | Sep 2001 | A1 |
| 20010025177 | Woloszko et al. | Sep 2001 | A1 |
| 20010027295 | Dulak et al. | Oct 2001 | A1 |
| 20010029370 | Hodva et al. | Oct 2001 | A1 |
| 20010029373 | Baker et al. | Oct 2001 | A1 |
| 20010032001 | Ricart et al. | Oct 2001 | A1 |
| 20010047167 | Heggeness | Nov 2001 | A1 |
| 20010049522 | Eggers et al. | Dec 2001 | A1 |
| 20010049527 | Cragg | Dec 2001 | A1 |
| 20010051802 | Woloszko et al. | Dec 2001 | A1 |
| 20010053885 | Gielen et al. | Dec 2001 | A1 |
| 20010056280 | Underwood et al. | Dec 2001 | A1 |
| 20020016600 | Cosman | Feb 2002 | A1 |
| 20020019626 | Sharkey et al. | Feb 2002 | A1 |
| 20020026186 | Woloszko et al. | Feb 2002 | A1 |
| 20020052600 | Davison et al. | May 2002 | A1 |
| 20020068930 | Tasto et al. | Jun 2002 | A1 |
| 20020095144 | Carl | Jul 2002 | A1 |
| 20020095151 | Dahla et al. | Jul 2002 | A1 |
| 20020095152 | Ciarrocca et al. | Jul 2002 | A1 |
| 20020099366 | Dahla et al. | Jul 2002 | A1 |
| 20020111661 | Cross et al. | Aug 2002 | A1 |
| 20020115945 | D'Luzansky et al. | Aug 2002 | A1 |
| 20020120259 | Lettice et al. | Aug 2002 | A1 |
| 20020147444 | Shah et al. | Oct 2002 | A1 |
| 20020151885 | Underwood et al. | Oct 2002 | A1 |
| 20020188284 | To et al. | Dec 2002 | A1 |
| 20020188290 | Sharkey et al. | Dec 2002 | A1 |
| 20020193708 | Thompson et al. | Dec 2002 | A1 |
| 20020193789 | Underwood et al. | Dec 2002 | A1 |
| 20030009164 | Woloszko et al. | Jan 2003 | A1 |
| 20030014047 | Woloszko et al. | Jan 2003 | A1 |
| 20030014088 | Fang et al. | Jan 2003 | A1 |
| 20030028147 | Aves et al. | Feb 2003 | A1 |
| 20030028189 | Woloszko et al. | Feb 2003 | A1 |
| 20030040742 | Underwood et al. | Feb 2003 | A1 |
| 20030055418 | Tasto et al. | Mar 2003 | A1 |
| 20030069569 | Burdette et al. | Apr 2003 | A1 |
| 20030083592 | Faciszewski | May 2003 | A1 |
| 20030084907 | Pacek et al. | May 2003 | A1 |
| 20030097126 | Woloszko et al. | May 2003 | A1 |
| 20030097129 | Davison et al. | May 2003 | A1 |
| 20030130655 | Woloszko et al. | Jul 2003 | A1 |
| 20030139652 | Kang et al. | Jul 2003 | A1 |
| 20030158545 | Hovda et al. | Aug 2003 | A1 |
| 20030181963 | Pellegrino et al. | Sep 2003 | A1 |
| 20030208194 | Hovda et al. | Nov 2003 | A1 |
| 20030216725 | Woloszko et al. | Nov 2003 | A1 |
| 20030216726 | Eggers et al. | Nov 2003 | A1 |
| 20030225364 | Kraft | Dec 2003 | A1 |
| 20040006339 | Underwood et al. | Jan 2004 | A1 |
| 20040024399 | Sharps et al. | Feb 2004 | A1 |
| 20040054366 | Davison et al. | Mar 2004 | A1 |
| 20040064023 | Thomas et al. | Apr 2004 | A1 |
| 20040064136 | Crombie et al. | Apr 2004 | A1 |
| 20040064137 | Pellegrino | Apr 2004 | A1 |
| 20040068242 | McGuckin, Jr. | Apr 2004 | A1 |
| 20040087937 | Eggers et al. | May 2004 | A1 |
| 20040116922 | Hovda et al. | Jun 2004 | A1 |
| 20040120891 | Hill et al. | Jun 2004 | A1 |
| 20040133124 | Bates et al. | Jul 2004 | A1 |
| 20040162559 | Arramon | Aug 2004 | A1 |
| 20040186544 | King | Sep 2004 | A1 |
| 20040193151 | To et al. | Sep 2004 | A1 |
| 20040220577 | Cragg et al. | Nov 2004 | A1 |
| 20040225228 | Ferree | Nov 2004 | A1 |
| 20040230190 | Dahla et al. | Nov 2004 | A1 |
| 20050004634 | Ricart et al. | Jan 2005 | A1 |
| 20050010095 | Stewart et al. | Jan 2005 | A1 |
| 20050010203 | Edwards et al. | Jan 2005 | A1 |
| 20050010205 | Hovda et al. | Jan 2005 | A1 |
| 20050055096 | Serhan et al. | Mar 2005 | A1 |
| 20050177210 | Leung et al. | Aug 2005 | A1 |
| 20050177211 | Leung et al. | Aug 2005 | A1 |
| 20050182417 | Pagano | Aug 2005 | A1 |
| 20050192564 | Cosman et al. | Sep 2005 | A1 |
| 20050209659 | Pellegrino et al. | Sep 2005 | A1 |
| 20050234445 | Conquergood et al. | Oct 2005 | A1 |
| 20050261754 | Woloszko | Nov 2005 | A1 |
| 20050267552 | Conquergood et al. | Dec 2005 | A1 |
| 20050278007 | Godara | Dec 2005 | A1 |
| 20050283148 | Janssen et al. | Dec 2005 | A1 |
| 20060004369 | Patel et al. | Jan 2006 | A1 |
| 20060064101 | Arramon | Mar 2006 | A1 |
| 20060095026 | Ricart et al. | May 2006 | A1 |
| 20060095028 | Bleich | May 2006 | A1 |
| 20060106375 | Werneth | May 2006 | A1 |
| 20060106376 | Godara et al. | May 2006 | A1 |
| 20060122458 | Bleich | Jun 2006 | A1 |
| 20060129101 | McGuckin | Jun 2006 | A1 |
| 20060178670 | Woloszko et al. | Aug 2006 | A1 |
| 20060206128 | Conquergood et al. | Sep 2006 | A1 |
| 20060206129 | Conquergood et al. | Sep 2006 | A1 |
| 20060206130 | Conquergood et al. | Sep 2006 | A1 |
| 20060206132 | Conquergood et al. | Sep 2006 | A1 |
| 20060206133 | Conquergood et al. | Sep 2006 | A1 |
| 20060206134 | Conquergood et al. | Sep 2006 | A1 |
| 20060206166 | Weiner | Sep 2006 | A1 |
| 20060229625 | Truckai et al. | Oct 2006 | A1 |
| 20060253117 | Hovda et al. | Nov 2006 | A1 |
| 20060259026 | Godara et al. | Nov 2006 | A1 |
| 20060264957 | Cragg et al. | Nov 2006 | A1 |
| 20060265014 | Demarais et al. | Nov 2006 | A1 |
| 20060276749 | Selmon et al. | Dec 2006 | A1 |
| 20070027449 | Godara et al. | Feb 2007 | A1 |
| 20070055316 | Godara et al. | Mar 2007 | A1 |
| 20070118142 | Krueger et al. | May 2007 | A1 |
| 20070129715 | Eggers et al. | Jun 2007 | A1 |
| 20070142791 | Yeung et al. | Jun 2007 | A1 |
| 20070142842 | Krueger et al. | Jun 2007 | A1 |
| 20070149966 | Dahla et al. | Jun 2007 | A1 |
| 20070179497 | Eggers et al. | Aug 2007 | A1 |
| 20070260237 | Sutton et al. | Nov 2007 | A1 |
| 20080004621 | Dahla et al. | Jan 2008 | A1 |
| 20080004675 | King et al. | Jan 2008 | A1 |
| 20080009847 | Ricart et al. | Jan 2008 | A1 |
| 20080021447 | Davison et al. | Jan 2008 | A1 |
| 20080021463 | Georgy | Jan 2008 | A1 |
| 20080058707 | Ashley et al. | Mar 2008 | A1 |
| 20080065062 | Leung et al. | Mar 2008 | A1 |
| 20080091207 | Truckai et al. | Apr 2008 | A1 |
| 20080114364 | Goldin et al. | May 2008 | A1 |
| 20080119844 | Woloszko et al. | May 2008 | A1 |
| 20080119846 | Rioux | May 2008 | A1 |
| 20080132890 | Woloszko et al. | Jun 2008 | A1 |
| 20080161804 | Rioux et al. | Jul 2008 | A1 |
| 20080275458 | Bleich et al. | Nov 2008 | A1 |
| 20080281322 | Sherman et al. | Nov 2008 | A1 |
| 20080294166 | Goldin et al. | Nov 2008 | A1 |
| 20090030308 | Bradford et al. | Jan 2009 | A1 |
| 20090069807 | Eggers et al. | Mar 2009 | A1 |
| 20090105775 | Mitchell et al. | Apr 2009 | A1 |
| 20090112278 | Wingeier et al. | Apr 2009 | A1 |
| 20090118731 | Young et al. | May 2009 | A1 |
| 20090131867 | Liu et al. | May 2009 | A1 |
| 20090131886 | Liu et al. | May 2009 | A1 |
| 20090149878 | Truckai et al. | Jun 2009 | A1 |
| 20090222053 | Gaunt et al. | Sep 2009 | A1 |
| 20090312764 | Marino | Dec 2009 | A1 |
| 20100010392 | Skelton et al. | Jan 2010 | A1 |
| 20100016929 | Prochazka | Jan 2010 | A1 |
| 20100023006 | Ellman | Jan 2010 | A1 |
| 20100023065 | Welch et al. | Jan 2010 | A1 |
| 20100082033 | Germain | Apr 2010 | A1 |
| 20100094269 | Pellegrino et al. | Apr 2010 | A1 |
| 20100114098 | Carl | May 2010 | A1 |
| 20100145424 | Podhajsky et al. | Jun 2010 | A1 |
| 20100179556 | Scribner et al. | Jul 2010 | A1 |
| 20100185082 | Chandran et al. | Jul 2010 | A1 |
| 20100185161 | Pellegrino et al. | Jul 2010 | A1 |
| 20100211076 | Germain et al. | Aug 2010 | A1 |
| 20100222777 | Sutton et al. | Sep 2010 | A1 |
| 20100261989 | Boseck et al. | Oct 2010 | A1 |
| 20100261990 | Gillis et al. | Oct 2010 | A1 |
| 20100298832 | Lau et al. | Nov 2010 | A1 |
| 20100324506 | Pellegrino et al. | Dec 2010 | A1 |
| 20110022133 | Diederich et al. | Jan 2011 | A1 |
| 20110034884 | Pellegrino et al. | Feb 2011 | A9 |
| 20110040362 | Godara et al. | Feb 2011 | A1 |
| 20110077628 | Hoey et al. | Mar 2011 | A1 |
| 20110087314 | Diederich et al. | Apr 2011 | A1 |
| 20110118735 | Abou-Marie et al. | May 2011 | A1 |
| 20110196361 | Vilims | Aug 2011 | A1 |
| 20110206260 | Bergmans et al. | Aug 2011 | A1 |
| 20110264098 | Cobbs | Oct 2011 | A1 |
| 20110276001 | Schultz et al. | Nov 2011 | A1 |
| 20110295261 | Germain | Dec 2011 | A1 |
| 20110319765 | Gertner et al. | Dec 2011 | A1 |
| 20120029420 | Vilims | Feb 2012 | A1 |
| 20120136346 | Condie et al. | May 2012 | A1 |
| 20120136348 | Condie et al. | May 2012 | A1 |
| 20120172858 | Harrison et al. | Jul 2012 | A1 |
| 20120172859 | Condie et al. | Jul 2012 | A1 |
| 20120196251 | Taft et al. | Aug 2012 | A1 |
| 20120197344 | Taft et al. | Aug 2012 | A1 |
| 20120203219 | Evans et al. | Aug 2012 | A1 |
| 20120226273 | Nguyen et al. | Sep 2012 | A1 |
| 20120239050 | Linderman | Sep 2012 | A1 |
| 20120265186 | Burger et al. | Oct 2012 | A1 |
| 20120330180 | Pellegrino et al. | Dec 2012 | A1 |
| 20120330300 | Pellegrino et al. | Dec 2012 | A1 |
| 20120330301 | Pellegrino et al. | Dec 2012 | A1 |
| 20130006232 | Pellegrino et al. | Jan 2013 | A1 |
| 20130006233 | Pellegrino et al. | Jan 2013 | A1 |
| 20130012933 | Pellegrino et al. | Jan 2013 | A1 |
| 20130012935 | Pellegrino et al. | Jan 2013 | A1 |
| 20130012936 | Pellegrino et al. | Jan 2013 | A1 |
| 20130012951 | Linderman | Jan 2013 | A1 |
| 20130079810 | Isenberg | Mar 2013 | A1 |
| 20130103022 | Sutton et al. | Apr 2013 | A1 |
| 20130231654 | Germain | Sep 2013 | A1 |
| 20130261507 | Diederich et al. | Oct 2013 | A1 |
| 20130324994 | Pellegrino et al. | Dec 2013 | A1 |
| 20130324996 | Pellegrino et al. | Dec 2013 | A1 |
| 20130324997 | Pellegrino et al. | Dec 2013 | A1 |
| 20130345765 | Brockman et al. | Dec 2013 | A1 |
| 20140031715 | Sherar et al. | Jan 2014 | A1 |
| 20140039500 | Pellegrino et al. | Feb 2014 | A1 |
| 20140046245 | Comacchia | Feb 2014 | A1 |
| 20140066913 | Sherman | Mar 2014 | A1 |
| 20140088575 | Loeb | Mar 2014 | A1 |
| 20140148801 | Asher et al. | May 2014 | A1 |
| 20140148805 | Stewart et al. | May 2014 | A1 |
| 20140171942 | Werneth et al. | Jun 2014 | A1 |
| 20140221967 | Childs et al. | Aug 2014 | A1 |
| 20140236144 | Krueger et al. | Aug 2014 | A1 |
| 20140243943 | Rao et al. | Aug 2014 | A1 |
| 20140257265 | Godara et al. | Sep 2014 | A1 |
| 20140271717 | Goshayeshgar et al. | Sep 2014 | A1 |
| 20140276728 | Goshayeshgar et al. | Sep 2014 | A1 |
| 20140276744 | Arthur et al. | Sep 2014 | A1 |
| 20140288544 | Diederich et al. | Sep 2014 | A1 |
| 20140288546 | Sherman et al. | Sep 2014 | A1 |
| 20140296850 | Condie et al. | Oct 2014 | A1 |
| 20140316405 | Pellegrino et al. | Oct 2014 | A1 |
| 20140324051 | Pellegrino et al. | Oct 2014 | A1 |
| 20140336630 | Woloszko et al. | Nov 2014 | A1 |
| 20140336667 | Pellegrino et al. | Nov 2014 | A1 |
| 20140364842 | Werneth et al. | Dec 2014 | A1 |
| 20150005614 | Heggeness et al. | Jan 2015 | A1 |
| 20150005767 | Werneth et al. | Jan 2015 | A1 |
| 20150045783 | Edidin | Feb 2015 | A1 |
| 20150057658 | Sutton et al. | Feb 2015 | A1 |
| 20150065945 | Zarins et al. | Mar 2015 | A1 |
| 20150073515 | Turovskiy et al. | Mar 2015 | A1 |
| 20150157402 | Kunis et al. | Jun 2015 | A1 |
| 20150164546 | Pellegrino et al. | Jun 2015 | A1 |
| 20150196358 | Goshayeshgar | Jul 2015 | A1 |
| 20150216588 | Deem et al. | Aug 2015 | A1 |
| 20150231417 | Metcalf et al. | Aug 2015 | A1 |
| 20150272655 | Condie et al. | Oct 2015 | A1 |
| 20150297246 | Patel et al. | Oct 2015 | A1 |
| 20150335349 | Pellegrino et al. | Nov 2015 | A1 |
| 20150335382 | Pellegrino et al. | Nov 2015 | A1 |
| 20150342660 | Nash | Dec 2015 | A1 |
| 20150342670 | Pellegrino et al. | Dec 2015 | A1 |
| 20150359586 | Heggeness | Dec 2015 | A1 |
| 20150374432 | Godara et al. | Dec 2015 | A1 |
| 20150374992 | Crosby et al. | Dec 2015 | A1 |
| 20150374995 | Foreman et al. | Dec 2015 | A1 |
| 20160000601 | Burger et al. | Jan 2016 | A1 |
| 20160001096 | Mishelevich | Jan 2016 | A1 |
| 20160002627 | Bennett et al. | Jan 2016 | A1 |
| 20160008593 | Cairns | Jan 2016 | A1 |
| 20160008618 | Omar-Pasha | Jan 2016 | A1 |
| 20160008628 | Morries et al. | Jan 2016 | A1 |
| 20160016012 | Youn et al. | Jan 2016 | A1 |
| 20160022988 | Thieme et al. | Jan 2016 | A1 |
| 20160022994 | Moffitt et al. | Jan 2016 | A1 |
| 20160024208 | MacDonald et al. | Jan 2016 | A1 |
| 20160029930 | Plumley et al. | Feb 2016 | A1 |
| 20160030276 | Spanyer | Feb 2016 | A1 |
| 20160030408 | Levin | Feb 2016 | A1 |
| 20160030748 | Edgerton et al. | Feb 2016 | A1 |
| 20160030765 | Towne et al. | Feb 2016 | A1 |
| 20160051831 | Lundmark et al. | Feb 2016 | A1 |
| 20160059007 | Koop | Mar 2016 | A1 |
| 20160074068 | Patwardhan | Mar 2016 | A1 |
| 20160074279 | Shin | Mar 2016 | A1 |
| 20160074661 | Lipani | Mar 2016 | A1 |
| 20160081716 | Boling et al. | Mar 2016 | A1 |
| 20160095721 | Schell et al. | Apr 2016 | A1 |
| 20160106985 | Zhu | Apr 2016 | A1 |
| 20160106994 | Crosby et al. | Apr 2016 | A1 |
| 20160113704 | Godara et al. | Apr 2016 | A1 |
| 20160115173 | Bois et al. | Apr 2016 | A1 |
| 20160136310 | Bradford et al. | May 2016 | A1 |
| 20160144182 | Bennett et al. | May 2016 | A1 |
| 20160144187 | Caparso et al. | May 2016 | A1 |
| 20160158551 | Kent et al. | Jun 2016 | A1 |
| 20160166835 | De Ridder | Jun 2016 | A1 |
| 20160175586 | Edgerton et al. | Jun 2016 | A1 |
| 20160199097 | Linderman et al. | Jul 2016 | A1 |
| 20160213927 | McGee et al. | Jul 2016 | A1 |
| 20160220393 | Slivka et al. | Aug 2016 | A1 |
| 20160220638 | Dony et al. | Aug 2016 | A1 |
| 20160220672 | Chalasani et al. | Aug 2016 | A1 |
| 20160228131 | Brockman et al. | Aug 2016 | A1 |
| 20160228696 | Imran et al. | Aug 2016 | A1 |
| 20160235471 | Godara et al. | Aug 2016 | A1 |
| 20160235474 | Prisco et al. | Aug 2016 | A1 |
| 20160243353 | Ahmed | Aug 2016 | A1 |
| 20160246944 | Jain et al. | Aug 2016 | A1 |
| 20160250469 | Kim et al. | Sep 2016 | A1 |
| 20160250472 | Carbunaru | Sep 2016 | A1 |
| 20160262830 | Werneth et al. | Sep 2016 | A1 |
| 20160271405 | Angara et al. | Sep 2016 | A1 |
| 20160278791 | Pellegrino et al. | Sep 2016 | A1 |
| 20160278846 | Harrison et al. | Sep 2016 | A1 |
| 20160279190 | Watts et al. | Sep 2016 | A1 |
| 20160279408 | Grigsby et al. | Sep 2016 | A1 |
| 20160279411 | Rooney et al. | Sep 2016 | A1 |
| 20160279441 | Imran | Sep 2016 | A1 |
| 20160302925 | Keogh et al. | Oct 2016 | A1 |
| 20160310739 | Burdick et al. | Oct 2016 | A1 |
| 20160317053 | Srivastava | Nov 2016 | A1 |
| 20160317211 | Harrison et al. | Nov 2016 | A1 |
| 20160317621 | Bright | Nov 2016 | A1 |
| 20160324541 | Pellegrino et al. | Nov 2016 | A1 |
| 20160324677 | Hyde et al. | Nov 2016 | A1 |
| 20160325100 | Lian et al. | Nov 2016 | A1 |
| 20160339251 | Kent et al. | Nov 2016 | A1 |
| 20160354093 | Pellegrino et al. | Dec 2016 | A1 |
| 20160354233 | Sansone et al. | Dec 2016 | A1 |
| 20160367797 | Eckermann | Dec 2016 | A1 |
| 20160367823 | Cowan et al. | Dec 2016 | A1 |
| 20160375259 | Davis et al. | Dec 2016 | A1 |
| 20170001026 | Schwarz et al. | Jan 2017 | A1 |
| 20170007277 | Drapeau et al. | Jan 2017 | A1 |
| 20170014169 | Dean et al. | Jan 2017 | A1 |
| 20170027618 | Lee et al. | Feb 2017 | A1 |
| 20170028201 | Howard | Feb 2017 | A1 |
| 20170035483 | Crainich et al. | Feb 2017 | A1 |
| 20170036009 | Hughes et al. | Feb 2017 | A1 |
| 20170036025 | Sachs et al. | Feb 2017 | A1 |
| 20170036033 | Perryman et al. | Feb 2017 | A9 |
| 20170042834 | Westphal et al. | Feb 2017 | A1 |
| 20170049503 | Cosman | Feb 2017 | A1 |
| 20170049507 | Cosman | Feb 2017 | A1 |
| 20170049513 | Cosman | Feb 2017 | A1 |
| 20170050017 | Cosman | Feb 2017 | A1 |
| 20170050021 | Cosman | Feb 2017 | A1 |
| 20170050024 | Bhadra et al. | Feb 2017 | A1 |
| 20170628198 | Degiorgio et al. | Feb 2017 | |
| 20170119461 | Godara et al. | May 2017 | A1 |
| 20170128080 | Torrie | May 2017 | A1 |
| 20170135742 | Lee et al. | May 2017 | A1 |
| 20170181788 | Dastjerdi et al. | Jun 2017 | A1 |
| 20170266419 | Goshayeshgar | Sep 2017 | A1 |
| 20180021048 | Pellegrino et al. | Jan 2018 | A1 |
| 20180042656 | Edidin | Feb 2018 | A1 |
| Number | Date | Country |
|---|---|---|
| 0040658 | Dec 1981 | EP |
| 0584959 | Mar 1994 | EP |
| 0597463 | May 1994 | EP |
| WO9834550 | Aug 1998 | EP |
| 0880938 | Dec 1998 | EP |
| 1013228 | Jun 2000 | EP |
| 1059067 | Dec 2000 | EP |
| 1059087 | Dec 2000 | EP |
| 2965782 | Jan 2016 | EP |
| 6-47058 | Feb 1994 | JP |
| 10-290806 | Nov 1998 | JP |
| 2001-037760 | Feb 2001 | JP |
| 2005-169012 | Jun 2005 | JP |
| WO9636289 | Nov 1996 | WO |
| WO9827876 | Jul 1998 | WO |
| WO9919025 | Apr 1999 | WO |
| WO9944519 | Sep 1999 | WO |
| WO9948621 | Sep 1999 | WO |
| WO0021448 | Apr 2000 | WO |
| WO0033909 | Jun 2000 | WO |
| WO 0049978 | Aug 2000 | WO |
| WO 0056237 | Sep 2000 | WO |
| WO0067648 | Nov 2000 | WO |
| WO0067656 | Nov 2000 | WO |
| WO0101877 | Jan 2001 | WO |
| WO0145579 | Jun 2001 | WO |
| WO0157655 | Aug 2001 | WO |
| WO 0157655 | Aug 2001 | WO |
| WO0205699 | Jan 2002 | WO |
| WO0205897 | Jan 2002 | WO |
| WO0228302 | Apr 2002 | WO |
| WO2002026319 | Apr 2002 | WO |
| WO02054941 | Jul 2002 | WO |
| WO02067797 | Sep 2002 | WO |
| WO02096304 | Dec 2002 | WO |
| WO2006044794 | Apr 2006 | WO |
| WO2007001981 | Jan 2007 | WO |
| WO2007008954 | Jan 2007 | WO |
| WO0731264 | Mar 2007 | WO |
| WO08001385 | Jan 2008 | WO |
| WO08008522 | Jan 2008 | WO |
| WO08121259 | Oct 2008 | WO |
| WO2008140519 | Nov 2008 | WO |
| WO2008141104 | Nov 2008 | WO |
| WO2009042172 | Apr 2009 | WO |
| WO2009076461 | Jun 2009 | WO |
| WO2011157714 | Dec 2011 | WO |
| WO 2012065753 | Mar 2012 | WO |
| WO2013134452 | Sep 2013 | WO |
| WO2013168006 | Nov 2013 | WO |
| Entry |
|---|
| A Novel Approach for Treating Chronic Lower Back Pain, Abstract for Presentation at North American Spine Society 26th Annual Meeting in Chicago, IL on Nov. 4, 2011. |
| Antonacci, M. Darryl et al.; Innervation of the Human Vertebral Body: A Histologic Study; Journal of Spinal Disorder, vol. 11, No. 6, pp. 526-531, 1998 Lippincott Williams & Wilkins, Philadelphia. |
| Arnoldi, Carl C.; Intraosseous Hypertension—A Possible Cause of Low Back Pain?; Clinical Orthopedics and Related Research, No. 115, Mar.-Apr. 1976. |
| Bailey, Jeannie F., “Innervation Patterns of PGP 9.5—Positive Nerve Fibers within the Human Lumbar Vertebra, Journal of Anatomy”, (2011) 218, pp. 263-270, San Francisco, California. |
| Becker, Stephan, et al., “Ablation of the basivertebral nerve for treatment of back pain: a clinical study,” The Spine Journal, vol. 17, pp. 218-223 (Feb. 2017). |
| Bergeron et al., “Fluoroscopic-guided radiofrequency ablation of the basivertebral nerve: application and analysis with multiple imaging modalities in an ovine model,” Thermal Treatment of Tissue: Energy Delivery and Assessment III, edited by Thomas P. Ryan, Proceedings of SPIE, vol. 5698 (SPIE, Bellingham, WA, 2005) pp. 156-167. |
| Bogduk, Nikolai, et al.; Technical Limitations to the efficacy of Radiofrequency Neurotomy for Spinal Pain; Neurosurgery vol. 20, No. 4, 1987. |
| Bogduk, N., The anatomy of the lumbar intervertebral disc syndrome, Med J. Aust. 1976, vol. 1, No. 23, pp. 878-881. |
| Choy, Daniel SS.J. et al.; Percutaneous Laser Disc Decompression, A New Therapeutic Modality; Spine vol. 17, No. 8, 1992. |
| Cosrnan, E.R. et al., Theoretical Aspects of Radiofrequency Lesions in the Dorsal Root Entry Zone. Neurosurgery, vol. 1, No. 6, 1984, pp. 945-950. |
| Deardorff, Dana L. et al.; Ultrasound applicators with internal cooling for interstitial thermal therapy; SPIE vol. 3594, 1999. |
| Dupuy, D.E. et al. Radiofrequency ablation of spinal tumors: Temperature distribution in the spinal canal AJR, vol. 175, pp. 1263-1266, Nov. 2000. |
| Dupuy, Damian E.; Radiofrequency Ablation: An Outpatient Percutaneous Treatment; Medicine and Health/Rhode Island vol. 82, No. 6, Jun. 1999. |
| Deramond, H. et al., Temperature Elevation Caused by Bone Cement Polymerization During Vertebroplasty, Bone, Aug. 1999, pp. 17S-21S, vol. 25, No. 2, Supplement. |
| Diederich, C. J, et al., “IDTT Therapy in Cadaveric Lumbar Spine: Temperature and thermal dose distributions, Thermal Treatment of Tissue: Energy Delivery and Assessment,” Thomas P. Ryan, Editor, Proceedings of SPIE vol. 4247:104-108 (2001). |
| Diederich, Chris J. et al.; Ultrasound Catheters for Circumferential Cardiac Ablation; SPIE vol. 3594 (1999). |
| Esses, Stephen I. et al,; Intraosseous Vertebral Body Pressures; Spine vol. 17 No. 6 Supplement 1992. |
| FDA Response to 510(k) Submission by Relievant Medsystems, Inc, submitted on Sep. 27, 2007 (date stamped on Oct. 5, 2007) and associated documents. |
| Fras M.D., Christian et al., “Substance P-containing Nerves within the Human Vertebral Body: An Immunohistochemical Study of the Basivertebral Nerve”, The Spine Journal 3, 2003, pp. 63-67. |
| Goldberg, S.N. et al., Tissue ablation with radiofrequency: Effect of probe size, gauge, duration, and temperature on lesion volume, Acad. Radiol., vol. 2, pp. 399-404 (1995). |
| Hanai, Kenji et al.; Simultaneous Measurement of Intraosseous and Cerebrospinal Fluid Pressures in the Lumbar Region; Spine vol. 10, No. 1, 1985. |
| Heggeness, Michael H. et al., The Trabecular Anatomy of Thoracolumbar Vertebrae: Implications for Burst Fractures, Journal of Anatomy, 1997, pp. 309-312, vol. 191, Great Britain. |
| Heggeness, Michael H. et al, Discography Causes End Plate Deflection; Spine vol. 18, No. 8, pp. 1050-1053, 1993, J.B. Lippincott Company. |
| Heggeness, M. et al Ablation of the Basivertebral Nerve for the Treatment of Back Pain: A Pilot Clinical Study; The Spine Journal, 2011, vol. 11, Issue 10, Supplement, pp. S65-S66, ISSN 1529-9430. |
| Hoopes et al., “Radiofrequency Ablation of the Basivertebral Nerve as a Potential Treatment of Back Pain: Pathologic Assessment in an Ovine Model,” Thermal Treatment of Tissue: Energy Delivery and Assessment III, edited by Thomas P. Ryan, Proceedings of SPIE, vol. 5698 (SPIE, Bellingham, WA, 2005) pp. 168-180. |
| Houpt, Jonathan C. et al.; Experimental Study of Temperature Distributions and Thermal Transport During Radiofrequency Current Therapy of the Intervertebral Disc; Spine vol. 21, No. 15, pp. 1808-1813, 1996, Lippincott-Raven Publishers. |
| Kleinstueck, Frank S. et al.; Acute Biomechanical and Histological Effects of Intradiscal Electrothermal Therapy on Human Lumbar Discs; Spine vol. 26, No. 20, pp. 2198-2207; 2001, Lippincott Williams & Wilkins, Inc. |
| Kopecky, Kenyon K. et al. “Side-Exiting Coaxial Needle for Aspiration Biopsy”—AJR—1996; 167, pp. 661-662. |
| Lehmann, Justus F. et al.; Selective Heating Effects of Ultrasound in Human Beings; Archives of Physical Medicine & Rehabilitation Jun. 1966. |
| Letcher, Frank S. et al.; The Effect of Radiofrequency Current and Heat on Peripheral Nerve Action Potential in the Cat; U.S. Naval Hospital, Philadelphia, PA. (1968). |
| Lundskog, Jan; Heat and Bone Tissue—/an experimental investigation of the thermal properties of bone tissue and threshold levels for thermal injury; Scandinavian Journal of Plastic and Reconstructive Surgery Supplemental 9, From the Laboratory of Experimental Biology, Department of anatomy, University of Gothenburg, Gothenburg, Sweden, Goteborg 1972. |
| Martin, J.B. et al., Vertebroplasty: Clinical Experience and Follow-up Results, Bone, Aug. 1999, pp. 11S-15S, vol. 25, No. 2, Supplement. |
| Massad, Malek M.D. et al.; Endoscopic Thoracic Sympathectomy: Evaluation of Pulsatile Laser, Non-Pulsatile Laser, and Radiofrequency-Generated Thermocoagulation; Lasers in Surgery and Medicine; 1991; pp. 18-25. |
| Mehta, Mark et al.; The treatment of chronic back pain; Anaesthesia, 1979, vol. 34, pp. 768-775. |
| Nau, William H., Ultrasound interstitial thermal therapy (USITT) in the prostate; SPIE vol. 3594, Jan. 1999. |
| Rashbaum, Ralph F.; Radiofrequency Facet Denervation a Treatment alternative in Refractory Low Back Pain with or without Leg Pain; Orthopedic Clinics of North America—vol. 14, No. 3, Jul. 1983. |
| Rosenthal, D.I., Seminars in Musculoskeletal Radiology, vol. 1, No. 2., pp. 265-272 (1997). |
| Ryan et al., “Three-Dimensional Finite Element Simulations of Vertebral Body Thermal Treatment,” Thermal Treatment of Tissue: Energy Delivery and Assessment III, edited by Thomas P. Ryan, Proceedings of SPIE, vol. 5698 (SPIE, Bellingham, WA, 2005) pp. 137-155. |
| Shealy, C. Norman; Percutaneous radiofrequency denervation of spinal facets Treatment for chronic back pain and sciatica; Journal of Neurosurgery/vol. 43/Oct. 1975. |
| Sherman, Mary S.; The Nerves of Bone, The Journal of Bone and Joint Surgery, Apr. 1963, pp. 522-528, vol. 45-A, No. 3. |
| Solbiati, L. et al. Hepatic metastases: Percutaneous radio-frequency ablation with cooled-tip electrodes, Interventional Radiology, vol. 205, No. 2, pp. 367-373 (1997). |
| Stanton, Terry, “Can Nerve Ablation Reduce Chronic Back Pain ?” AAOS Now Jan. 2012. |
| The AVAmax System—Cardinal Health Special Procedures, Lit. No. 25P0459-01—www.cardinal.com (copyright 2007). |
| Tillotson, L. et al. Controlled thermal injury of bone: Report of a percutaneous technique using radiofrequency electrode and generator. Investigative Radiology, Nov. 1989, pp. 888-892. |
| Troussier, B. et al.; Percutaneous Intradiscal Radio-Frequency Thermocoagulation a Cadaveric Study; Spine vol. 20, No. 15, pp. 1713-1718, 1995, Lippincott-Raven Publishers. |
| Ullrich, Jr., Peter F., “Lumbar Spinal Fusion Surgery” Jan. 9, 2013, Spine-Health (available via wayback machine Internet archive at http://web.archive.org/web/20130109095419/http://www/spine-health.com/treatment/spinal-fusion/lumbar-spinal-fusion-surgery). |
| Number | Date | Country | |
|---|---|---|---|
| 20170202613 A1 | Jul 2017 | US |
| Number | Date | Country | |
|---|---|---|---|
| 61100553 | Sep 2008 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 10260879 | Sep 2002 | US |
| Child | 11123766 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 14673172 | Mar 2015 | US |
| Child | 15344284 | US | |
| Parent | 13923798 | Jun 2013 | US |
| Child | 14673172 | US | |
| Parent | 13615300 | Sep 2012 | US |
| Child | 13923798 | US | |
| Parent | 13612541 | Sep 2012 | US |
| Child | 13615300 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 12683555 | Jan 2010 | US |
| Child | 13612541 | US | |
| Parent | 12566895 | Sep 2009 | US |
| Child | 12683555 | US | |
| Parent | 11123766 | May 2005 | US |
| Child | 12566895 | US |
