Minimally Invasive Trans-Facet Spinal Surgery

FIELD OF THE DISCLOSURE

The present disclosure relates generally to spinal surgery and more particularly to techniques for performing minimally invasive trans-facet spinal surgery.

BACKGROUND OF THE DISCLOSURE

Spinal surgery often involves addressing conditions including stenosis, herniated discs, fractures, spinal deformities, spondylolisthesis, or degenerative disc diseases. Access to the effected spinal anatomy can involve removing all or part of the inferior articular process and/or superior articular process. These processes form the zygapophyseal facet joints which constitute key components of the posterior spinal column, providing stability while allowing movement between vertebrae. In the context of lumbar fusion surgery, for example, conventional approaches include posterior lumbar interbody fusion (PLIF), trans-foraminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), direct lateral interbody fusion (DLIF), and extreme lateral interbody fusion (XLIF), among others. Although these approaches may be suitable in certain instances, they may present certain drawbacks, including exposure of the neural elements, risk of nerve root injury, risk of epidural scarring or arachnoiditis, risk of infection, and significant disturbance of the paraspinal muscles. A need therefore exists for improved techniques for performing spinal surgeries that may overcome one or more of these drawbacks associated with existing approaches.

SUMMARY OF THE DISCLOSURE

The present disclosure provides techniques for performing trans-facet spinal surgery that preserve aspects of both the inferior articular process of a vertebra and the superior articular process of a vertebra.

In one implementation, a method for performing trans-facet spinal surgery may include forming an access corridor through an aspect of a facet joint of a patient between an inferior articular process of a vertebra and a superior articular process of a vertebra such that an aspect of the inferior articular process is preserved on a medial side of the access corridor and an aspect of the superior articular process is preserved on a lateral side of the access corridor.

In some implementations, the method may include removing disc material from a disc space of the patient via one or more instruments advanced through the access corridor. In some implementations, the disc space corresponds to a region defined by a target intervertebral disc disposed behind the facet joint.

In some implementations, the method may include advancing an interbody device into the access corridor. In some implementations, the method may further include advancing the interbody device into the disc space.

In some implementations, the method may include placing a graft material within the access corridor. In some implementations, the method may further include advancing the graft material into the disc space. In some implementations, the graft material is housed within the interbody device.

In some implementations, the interbody device is a cage. In further implementations, the interbody device is a pouch.

In some implementations, forming the access corridor includes forming an entry point of the access corridor in a middle aspect of the facet joint midway between the inferior articular process and the superior articular process.

In some implementations, forming the access corridor includes forming an entry point of the access corridor at a position closer to one of the inferior articular process and the superior articular process than the other of the inferior articular process and the superior articular process.

In some implementations, the entry point of the access corridor is surrounded by bone on all sides. In some implementations, the method does not include performing a total facetectomy. In some implementations, the method does not include performing a partial facetectomy.

In some implementations, forming the access corridor includes using a robotic system, MRI assisted navigation, CT assisted navigation, O-Arm assisted navigation, or fluoroscopic assisted navigation, or any combination thereof.

In some implementations, forming the access corridor includes advancing a first drill bit through the aspect of the facet joint and advancing a first threaded tap through the aspect of the facet joint, wherein the first threaded tap has a greater diameter than the first drill bit. In some implementations, advancing the first threaded tap through the aspect of the facet joint includes advancing the first threaded tap into a posterior third of the disc space. In some implementations, forming the access corridor further includes advancing a second threaded tap through the aspect of the facet joint, wherein the second threaded tap has a greater diameter than the first threaded tap and advancing a second drill bit through the aspect of the facet joint, wherein the second drill bit has a greater diameter than the second threaded tap. In some implementations, advancing the second threaded tap through the aspect of the facet joint includes advancing the second threaded tap into the posterior third of the disc space. In some implementations, the one or more instruments includes one or more shavers, rongeurs, or curettes.

In some implementations, the interbody device is expandable from a compact configuration to an expanded configuration, and advancing the interbody device through the access corridor and into the disc space includes advancing the interbody device through the access corridor and into the disc space while the interbody device is in the compact configuration.

In some implementations, expanding the interbody device from the compact configuration to the expanded configuration within the disc space.

In some implementations, the interbody device has first maximum transverse and vertical dimensions when the interbody device is in the compact configuration and second maximum transverse and vertical dimensions when the interbody device is in the expanded configuration, and the access corridor has third maximum transverse and vertical dimensions, wherein at least one of the third maximum transverse and vertical dimensions is greater than the first maximum transverse dimension and/or the first maximum vertical dimension and less than the second maximum transverse dimension and/or the second maximum vertical dimension.

In some implementations, expanding the interbody device from the compact configuration to the expanded configuration includes placing graft material within the interbody device. In some implementations, placing graft material within the interbody device includes placing graft material within the interbody device before advancing the interbody device through the access corridor and into the disc space. In some implementations, the method further includes expanding the interbody device within the disc space, wherein placing graft material within the interbody device includes placing graft material within the interbody device after expanding the interbody device within the disc space. In some implementations, expanding the interbody device from the compact configuration to the expanded configuration includes incrementally adding additional graft material within the interbody device. In some implementations, placing graft material within the access corridor includes placing graft material between the interbody device and an entry point of the access corridor. In some implementations, the method further includes expanding the interbody device within the disc space, wherein placing graft material within the access corridor includes placing graft material within the access corridor after expanding the interbody device within the disc space.

In some implementations, forming the access corridor includes forming the access corridor through the facet joint without exposing the exiting nerve root above the disc space. In some implementations, forming the access corridor includes forming the access corridor through the facet joint without exposing the thecal sac.

In some implementations, the access corridor is formed in a lumbar vertebra of the patient. In some implementations, the access corridor is formed in a thoracic vertebra of the patient. In some implementations, the access corridor is formed in a cervical vertebra of the patient.

These and other aspects and improvements of the present disclosure will become apparent to one of ordinary skill in the art upon review of the following detailed description when taken in conjunction with the several drawings and the appended claims.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A illustrates a lumbar portion of a spine, showing facet joints of the spine. FIG. 1B is a radiographic image showing a facet joint of a spine.

FIGS. 2A, 2B, 2C, and 2D illustrate trajectories for a trans-facet approach in accordance with implementations of the disclosure.

FIG. 3 illustrates an adjusted trajectory for a trans-facet approach in accordance with implementations of the disclosure.

FIG. 4A illustrates placement of a Schanz pin in accordance with implementations of the disclosure. FIG. 4B illustrates attachment of a robotic arm to the Schanz pin.

FIGS. 5A and 5B illustrate fluoroscopic images being obtained in accordance with implementations of the disclosure.

FIG. 6A illustrates marking of a skin incision site in accordance with implementations of the disclosure. FIGS. 6B, 6C, and 6D illustrate introduction of a local anesthetic in accordance with implementations of the disclosure.

FIG. 7 illustrates a skin incision being made in accordance with implementations of the disclosure.

FIGS. 8A and 8B illustrate placement of a one-step navigated dissector-dilator in accordance with implementations of the disclosure.

FIG. 9 illustrates placement of a navigated drill into a pedicle in accordance with implementations of the disclosure.

FIG. 10 illustrates placement of a navigated tap into the pedicle in accordance with implementations of the disclosure.

FIG. 11 illustrates placement of a K-wire into the pedicle in accordance with implementations of the disclosure.

FIG. 12 illustrates the K-wire being tapped into position in the pedicle in accordance with implementations of the disclosure.

FIGS. 13A, 13B, 13C, 13D, 13E, and 13F illustrate placement of additional K-wires into additional pedicles in accordance with implementations of the disclosure.

FIGS. 14A, 14B, 14C, 14D, and 14E illustrate introduction of a navigated drill into one of the pedicles in accordance with implementations of the disclosure.

FIGS. 15A and 15B illustrate introduction of a navigated tap into one of the pedicles in accordance with implementations of the disclosure.

FIGS. 16A, 16B, 16C, and 16D illustrate the navigated tap being advanced through the middle aspect of the fact joint and into the posterior third of the disc space in accordance with implementations of the disclosure.

FIGS. 17A, 17B, and 17C illustrate placement of a K-wire and a first navigated dilator of a minimal access tube system in accordance with implementations of the disclosure.

FIGS. 18A and 18B illustrate placement of larger dilators of the minimal access tube system in accordance with implementations of the disclosure.

FIGS. 19A and 19B illustrate placement of a minimal access tube of the minimal access tube system in accordance with implementations of the disclosure. FIGS. 19C and 19D illustrate the minimal access tube being fixed in position to a Jackson table via a FlexArm in accordance with implementations of the disclosure. FIGS. 19E and 19F illustrate the larger dilators being removed in accordance with implementations of the disclosure.

FIGS. 20A and 20B illustrate a microscope being introduced into the field to visualize the entry point area of the access corridor through the minimal access tube in accordance with implementations of the disclosure.

FIGS. 21A and 21B illustrate inspection of the access corridor using a dissector in accordance with implementations of the disclosure.

FIGS. 22A, 22B, and 22C illustrate positioning of the robotic arm guide towards the facet joint in accordance with implementations of the disclosure.

FIGS. 23A and 23B illustrate placement of a reducer dilator tube through the robotic arm guide and introduction of a drill with an acorn drill bit through the reducer dilator tube in accordance with implementations of the disclosure.

FIG. 24A illustrates the drill being used to drill into the facet joint in accordance with implementations of the disclosure. FIG. 24B illustrates an opening created by the drill in accordance with implementations of the disclosure. FIGS. 24C and 24D illustrate introduction of a navigated dissector into the opening to confirm the approach in accordance with implementations of the disclosure.

FIGS. 25A, 25B, 25C, and 25D illustrate sequential introduction of two distractors to open up the collapsed disc space in accordance with implementations of the disclosure.

FIG. 26 illustrates placement of a shaver into the disc space in accordance with implementations of the disclosure.

FIG. 27 illustrates introduction of a pituitary rongeur to remove the shaved off cartilaginous endplates and degenerated disc material in accordance with implementations of the disclosure.

FIGS. 28A, 28B, 28C, 28D, and 28E illustrate placement of ring curettes to curette the remaining portions of the cartilaginous endplates in accordance with implementations of the disclosure.

FIGS. 29A, 29B, and 29C illustrate placement of a wedge trial or sizing instrument into the disc space to determine a size of a cage to be used in accordance with implementations of the disclosure.

FIGS. 30A and 30B illustrate an expandable cage as may be used in accordance with implementations of the disclosure.

FIGS. 31A, 31B, 31C, and 31D illustrate placement of the expandable cage into the disc space in accordance with implementations of the disclosure.

FIGS. 32A, 32B, 32C, 32D, and 32E illustrate expansion of the expandable cage within the disc space and filling of the expanded cage with graft material in accordance with implementations of the disclosure.

FIGS. 33A and 33B illustrate placement of additional graft material behind the expanded cage up to the entry point of the facet joint in accordance with implementations of the disclosure.

FIGS. 34A and 34B illustrate placement of pedicle screws and rods in accordance with implementations of the disclosure.

FIGS. 35A and 35B illustrate introduction of the drill with the acorn drill bit through the reducer dilator tube in accordance with implementations of the disclosure.

FIGS. 36A and 36B illustrate sequential introduction of the distractors to open up the collapsed disc space in accordance with implementations of the disclosure.

FIG. 37 illustrates placement of the shaver into the disc space in accordance with implementations of the disclosure.

FIGS. 38A and 38B illustrate the shaver being used to shave the anterior-most portion of the disc space as well as the middle and posterior aspects of the disc space in accordance with implementations of the disclosure.

FIGS. 39A and 39B illustrate the pituitary rongeur being used to remove the shaved off cartilaginous endplates and degenerated disc material in accordance with implementations of the disclosure.

FIGS. 40A, 40B, and 40C illustrate the ring curettes being used to curette the remaining portions of the cartilaginous endplates in accordance with implementations of the disclosure.

FIGS. 41, 42, and 43 illustrate the wedge trial or sizing instrument being used to determine a size of a cage to be used in accordance with implementations of the disclosure.

FIGS. 44A, 44B, 44C, and 44D illustrate placement of the expandable cage into the disc space in accordance with implementations of the disclosure.

FIG. 45 illustrates expansion of the expandable cage within the disc space and filling of the expanded cage with graft material in accordance with implementations of the disclosure.

FIG. 46 illustrates placement of pedicle screws and rods in accordance with implementations of the disclosure.

FIG. 47A illustrates a Phantom ML minimal access tube as may be used in accordance with implementations of the disclosure. FIGS. 47B and 47C illustrate placement of Flare Hawk expandable cages, pedicle screws, and rods in accordance with implementations of the disclosure. FIGS. 47D, 47E, 47F, 47G, 47H, and 47I illustrate placement of VariLift expandable cages, pedicle screws, and rods in accordance with implementations of the disclosure. FIGS. 47J and 47K illustrate placement of VariLift expandable cages in a stand-alone fashion in accordance with implementations of the disclosure.

FIG. 48 illustrates a lumbar portion of a spine, showing facet joints, nerve roots, and the thecal sac of the spine.

FIG. 49 illustrates a lumbar portion of a spine, showing a facet joint of the spine and indicating how a PLIF may necessitate a medial partial facetectomy.

FIG. 50 illustrates a lumbar portion of a spine, showing a facet joint of the spine and indicating how a TLIF may necessitate a lateral partial facetectomy.

FIGS. 51A, 51B, and 51C, illustrate model trajectories for a trans-facet approach in accordance with implementations of the disclosure.

FIGS. 52A, 52B, and 52C, illustrate model trajectories for a trans-facet approach in accordance with implementations of the disclosure.

DETAILED DESCRIPTION OF THE DISCLOSURE

In the following description, specific details are set forth describing some implementations consistent with the present disclosure. Numerous specific details are set forth in order to provide a thorough understanding of the implementations. It will be apparent, however, to one skilled in the art that some implementations may be practiced without some or all of these specific details. The specific implementations disclosed herein are meant to be illustrative but not limiting. One skilled in the art may realize other elements that, although not specifically described here, are within the scope and the spirit of this disclosure. In addition, to avoid unnecessary repetition, one or more features shown and described in association with one implementation may be incorporated into other implementations unless specifically described otherwise or if the one or more features would make an implementation non-functional. In some instances, well known methods, procedures, and components have not been described in detail so as not to unnecessarily obscure aspects of the implementations.

The detailed description is set forth with reference to the accompanying drawings. The drawings are provided for purposes of illustration only and merely depict example implementations of the disclosure. The drawings are provided to facilitate understanding of the disclosure and shall not be deemed to limit the breadth, scope, or applicability of the disclosure. The use of the same reference numerals indicates similar, but not necessarily the same or identical components. Different reference numerals may be used to identify similar components. Various implementations may utilize elements or components other than those illustrated in the drawings, and some elements and/or components may not be present in various implementations. The use of singular terminology to describe a component or clement may, depending on the context, encompass a plural number of such components or elements and vice versa.

Overview

The present disclosure provides a novel approach and technique of minimally invasive trans-facet spinal surgery, which also may be referred to as the “ZLIF” (or “Z-LIF”) operation, designating the access through the zygapophysial joints (FIGS. 1A and 1B). The zygapophyscal joints (also known as apophyscal, facet joints, and Z joints) are synovial articulations formed between the paired superior and inferior articular processes of adjacent vertebrae anywhere from C2-S1. Accordingly, the approach provided herein can be performed on any level of the spinal column at which a zygapophyseal joint is located.

As described herein, the ZLIF operation employs the highest standards of minimally invasive surgery. As further described herein, in some implementations, the operation can be performed in conjunction with the extreme accuracy and sophistication of a robotic system. In some implementations, this approach may utilize a navigation system and/or live fluoroscopy to verify targets. The approach may be confirmed with direct vision using intraoperative microscopy or endoscopy. Moreover, this approach may provide for the highest safety and protection for the neural elements. Advantageously, the approach provided herein reduces the risk of compromising the sovereignty of exiting nerve roots and the thecal sac by reducing exposure of the nerve roots. Accordingly, employment of the provided approach not only reduces the risk of nerve root injury, but also the risk of subsequent epidural scarring or arachnoiditis. Furthermore, the provide approach utilizes very small minimal access tubes and microsurgical instruments so as to respect the paraspinal muscles. Advantageously, for most patients, surgeries performed using the provided approach may be performed as outpatient. Compared to existing approaches, the operative time may be reduced, and the risk of infection may be minimal to nonexistent. Unlike PLIF and TLIF procedures (described further herein), exposure of the nerve roots is minimal or even non-existent. Unlike ALIF, DLIF, and XLIF procedures, the provided approach minimizes involvement of the peritoneal structures and the lumbosacral plexus is minimal or nonexistent. In summary, the only soft tissue structures encountered via the provided approach are skin, subcutaneous tissue, paraspinal muscles, and, in some implementations, disc elements. This approach provides is well-suited for performance at least partially in conjunction with a robotic system.

Still other benefits and advantages of the trans-facet surgical approach provided herein provided herein over existing approaches will be appreciated by those of ordinary skill in the art from the following description and the appended drawings.

Example Surgical Technique

It is contemplated herein that the trans-facet approach can be used in any number of spinal surgical procedures. For example, the approach may be used to form an access corridor through the facet joint (i.e., a “trans-facet access corridor”) in order to facilitate intervention of conditions including stenosis, herniated discs, fractures, spinal deformities, spondylolisthesis, or degenerative disc diseases. For example, in some instances, spinal fusion is recommended to alleviate some of the effects (e.g., pain, numbness, muscle weakness) associated with various spinal pathologies.

Trans-Facet Lumbar Interbody Fusion

Provided herein is one implementation of the present approach in the context of interbody lumbar fusion. However, it is contemplated herein that the approach can be performed in the context of any number of other spinal surgeries, including fusion of thoracic or cervical vertebrae, as well as surgeries that do not involve fusion, such as spinal decompression surgery.

In some aspects, patient selection is important to the success of any surgical procedure. In some implementations, the present technique has been employed on patients with severe intractable discogenic lower back pain with degenerative disc disease as well as grade 1 spondylolisthesis, both congenital and degenerative. Accordingly, in some implementations, the approach is suitable for accessing the disc spaces of L3-4, L4-5, and L5-S1. As used herein the term “disc space” corresponds to a region defined by a target intervertebral disc disposed behind the facet joint. In further implementations, the approach may be suitable for patients needing fusion who also have mild or moderate spinal stenosis, with or without claudication pain. In those patients, indirect decompression occurs with restoration of disc height with concomitant widening of the foramina of the nerve roots. In yet further implementations, the present technique may be suitable in the presence of severe spinal stenosis, where in addition to the indirect decompression mentioned above, this approach allows for decompression of the spinal canal. This is brought about by microsurgical drilling of the medial wall of the facet joint, with or without excision of the adjacent ligamentum flavum and decompression of the distally exiting nerve root (which may be referred to as “ZLIF plus”). Most of these patients may undergo lumbosacral MRIs or post myelogram CT scans prior to the decisions to proceed with surgery. A few days prior to surgery, a lumbosacral CT scan with a navigation protocol may be performed with the patient in the prone position.

Optionally, various robotic systems may be used to facilitate the present approach. For example, the Mazor Robotic System has been used successfully for the approach. Other robotic systems are available and may be considered. Surgical planning may be performed using the Mazor planning software to which the preoperative lumbar CT scan performed with the patient in the prone position is uploaded. Along with planning for the trans-facet approach into the disc space (also referred to herein as the “interspace”), the surgeon also may plan for placement of the pedicle screw wires. The trajectory of the approach into the facet joint area generally may depend on the axial and sagittal CT scan cuts after correlating them with the T1 and T2 MRI images or post myelogram axial CT images. It may be advantageous to identify the lateral edge of the thecal sac within the spinal canal as well as to determine the exact location of the exiting nerve root above the disc space. In some implementations, a trajectory then may be outlined on the axial cut passing through the entry point on the middle portion of the facet joint midway between the inferior articular process of the vertebra above and the superior articular process of the vertebra below. In some implementations, the entry point may be closer to one of the inferior articular process of the vertebra or superior articular process of the vertebra than the other of the inferior articular process of the vertebra or superior articular process. The trajectory also may be made to pass towards the target, which may be located 0 to 8 millimeters across the midline area at the anterior aspect of the disc space (FIGS. 2A-D). The trajectory then may be adjusted to pass parallel to the inferior aspect of the disc space immediately above the superior endplate of the vertebra below (FIG. 3). This may keep the trajectory as far as possible from the exiting nerve root superiorly, which may be especially important in a case of grade 1 spondylolisthesis in which the exiting nerve root is closer to the disc space than in a case without spondylolisthesis.

The patient then may undergo general anesthesia and be placed in the prone position well-padded on a Jackson table. The Mazor Robotic System or other robotic system then may be fixed to the table on the right side of the patient on the right side of the hip region. The skin overlying the whole of the lumbosacral region may be prepped adequately. A Schanz pin may be placed into the right posterior superior iliac spine (FIG. 4A). The robotic arm then may be attached to the pin (FIG. 4B) and scan the operative field. Fluoroscopic images may be obtained in the AP, lateral, and oblique trajectories (FIGS. 5A and 5B) and blended with the preoperative CT scan images to adjust for any minimal changes brought about by positioning of the patient as well as adjusting for any changes in the degree of lordosis. The robotic arm then may be moved to execute the plan. The surgeon first may place pedicle screw wires before proceeding with the trans-facet access into the disc space. Through the robotic arm guide, the site of the skin incision may be marked (FIG. 6A). The surgeon may introduce a local anesthetic to infiltrate the whole track from skin to target using an 18 Gauge spinal needle (FIGS. 6B-D). A skin incision then may be made (FIG. 7), followed by placement of a one-step navigated dissector-dilator to the target (FIGS. 8A and 8B).

A navigated drill (FIG. 9) followed by a navigated 4 mm tap then may be placed into the pedicle (FIG. 10), followed by placement of a K-wire (FIG. 11). The K-wire may be lightly tapped into position (FIG. 12). The other K-wires then may be placed in a similar fashion on both sides (FIGS. 13A-F). In some implementations, the robotic arm guide then may be directed towards the target in the middle aspect of the facet joint, as described above, and following the trajectory created by the plan, as mentioned above. After infiltration with the local anesthetic and making the skin incision, the navigated one step dissector-dilator then may be advanced to the target. This may be followed by introducing a navigated drill (FIGS. 14A-E), followed by navigated taps, starting with a 4.5 mm tap (FIGS. 15A and 15B), followed by a 5.5 mm tap, a 6.5 mm tap, and finally a 7.5 mm tap. The taps may be watched with navigation to pass through the middle aspect of the facet joint as well as to enter the posterior third of the disc space (FIGS. 16A-D). This may be followed by placement of a K-wire, followed by placement of the first navigated dilator of a minimal access tube system (FIG. 17A). That dilator then may be advanced with a mallet towards the deeper portion of the facet joint so as to direct the following dilators and the metric tube in the correct accurate trajectory. Fluoroscopy in the AP, Lateral, and Oblique trajectories then may be utilized to make sure radiologically that there is no encroachment on the neural elements (FIGS. 17A-C). The larger dilators then may be placed (FIGS. 18A and 18B), after which an appropriate minimal access tube may be placed (FIGS. 19A and 19B). In some implementations, larger tubes of 16 to 18 mm diameter may be used. In some implementations, 14 mm diameter tubes (FIG. 19A) may be used, which may allow for excellent visualization with the intraoperative microscope, for minimal dissection of the paraspinal muscles, and for the introduction of all necessary instruments. In some implementations, a radiolucent 13 mm diameter tube may be used. The tube then may be fixed in position to a Jackson table via a FlexArm (FIGS. 19C and 19D) to maintain the proper trajectory. The larger dilators may be removed first, followed by the smallest dilator (FIGS. 19E and 19F). The pedicle screw K-wires then may be deflected away using Ellis clamps so as not to interfere with further movements of the robotic arm guide or with movements of the microscope or other instruments (FIG. 20A).

A microscope (or endoscope) then may be brought into the field from the left side of the patient beside the left shoulder to visualize the entry point area through the access tube (FIGS. 20A and 20B). The surgeon then may introduce an angled dissector or a ball-tip dissector through the 7.5 mm tapped area to feel the spirals created all around to ensure the accuracy of the approach and to make sure that the bony surroundings are not compromised (FIGS. 21A and 21B). The microscope then may be moved away, keeping the stand in its position, and the robotic arm guide then may be brought back again directed towards the facet target (FIGS. 22A-C). The surgeon then may introduce a 12 mm reducer dilator tube through the robotic arm guide and through the access tube to fine tune its trajectory (FIG. 23). Lateral fluoroscopy then may be employed from this point onwards. The C-arm stand may be brought in from the right side of the patient at shoulder level underneath the table and moved downwards to view the approach into the facet joint and the disc space. The Midas Rex drill with a 9 mm diameter Acorn drill bit then may be introduced through the 12 mm reducer tube directed towards the target (FIGS. 23A, 23B, 35A, and 35B), drilling into the facet joint under fluoroscopy (FIG. 24A). The 12 mm reducer tube and the robotic arm guide then may be set aside, and the microscope may be brought again into the field. The microscope may be raised upwards to allow for the instrumentation to be introduced while still visualizing the entry point.

Through the opening created by the Midas Rex (FIG. 24B), the surgeon then may introduce a navigated dissector (FIG. 24C) which may be visualized on the navigation screen confirming the accuracy of the approach (FIG. 24D). The surgeon then may sequentially introduce 6 mm and 7 mm distractors to open up the collapsed disc space (FIGS. 25A-D, 36A, and 36B), followed by placement of an 8 mm shaver (FIGS. 26 and 37). The surgeon may shave the anterior-most portion of the interspace as well as the middle and posterior aspects of the interspace (FIGS. 38A and 38B).

In some implementations, an interbody device may be inserted into the disc space following the removal of disc material from the disc space. For example, a cage can be inserted into the disc space. In some implementations, the cage can be expandable. For example, the cage can be inserted into the disc space in a collapsed configuration and then expanded into an expanded configuration. In some implementations, the cage can be expanded by progressively placing graft material into the cage. In various implementations, placement of the cage into the disc space facilitates fusion of the vertebrae adjacent the cage.

In further implementations, the interbody device may be a flexible pouch. In some implementations, the flexible pouch can accommodate placement of graft material therein. In some implementations, the flexible pouch can be expanded from a collapsed configuration to an expanded configuration by progressively placing graft material into the flexible pouch. In some implementations, the pouch can be placed into the disc space following removal of disc material from the disc space. Accordingly, the flexible pouch (and graft material contained therein) can facilitate fusion of the vertebrae adjacent the flexible pouch.

Advantageously, in some implementations, the cage need not be expandable. This is because the approach provided herein preserves bony tissue surrounding the trans-facet access corridor. Thus, the cage may be capable of maintaining a stable position within the access corridor by biting into walls of the access corridor.

Furthermore, while in some implementations, forming the trans-facet access corridor involves accessing the disc space itself (e.g. in order to access the disc space), in other implementations, the trans-facet access corridor does not extend into the disc space. In such implementations, a device such as a medical device such as a cage, a flexible pouch, and/or a graft material can be placed within the trans-facet access corridor but not into the disc space. In such cases, the medical device or graft material may be any of the interbody devices described herein or may be another medical device or material not suitable for implantation within the disc space.

Depending on the size of the interbody device used, the surgeon may also introduce 9 mm and 10 mm shavers only in the area of the facet joint to allow for placement of the interbody device. Larger size shavers may also need to be used inside the interspace depending on the disc height, however care should be taken not to violate the bony endplates. An expandable shaver may also be utilized. A pituitary rongeur then may be introduced under fluoroscopy to remove the shaved off cartilaginous endplates and degenerated disc material (FIGS. 27, 39A, and 39B), followed by placement of ring curettes to curette the remaining portions of the cartilaginous endplates (FIGS. 28A-E and 40A-C). This may be an advantageous step to ensure successful bony fusion. The pituitary rongeur may be used again to remove all curetted material.

The next step may be to use a wedge trial or sizing instrument inside the disc space to determine the exact size of the interbody device to be used (FIGS. 29A-C, 41, 42, 43). In some implementations, the surgeon may select among different sizes of expandable PEEK and titanium cages (FIGS. 30A and 30B) for the interbody device. The present approach may allow for placement of 7×7 mm cages up to 10×10 mm interbody devices upon entry into the interspace, with the ability to expand up to 15 mm in height and 11 mm in width, with lordosis ranging from 0 to 12 degrees. Before placement of the interbody device, the surgeon may introduce graft material, such as Mastergraft blocks, inside the interspace way anteriorly. The interbody device may be advanced into the interspace after being prefilled with graft material, such as Grafton (FIGS. 31A-D and 44A-D). After expansion of the cage within the interspace (FIGS. 32A, 32D, and 45), the interbody device then may be filled again with Grafton (FIGS. 32B, 32C, 32E, and 45). ZLIF plus then may be executed at this stage in patients with severe spinal stenosis with the use of a diamond drill under direct microscopic or endoscopic vision. The surgeon may also elect at this stage to excise the ligamentum flavum and/or directly decompress the distal nerve root as indicated. Mastergraft then may be placed behind the interbody device all the way up to the entry point of the facet joint, achieving interbody fusion behind the interbody device as well as facet fusion (FIGS. 33A and 33B). The latter step may be eliminated if the nerve root itself is exposed subsequent to the decompression so as not to cause any chance of the resultant facet fusion causing any compression or irritation of the nerve root. The access tube then may be removed. The surgeon then may be place pedicle screws, such as Solera Sextant percutaneous pedicle screws, and percutaneous rods around the pedicle screw wires introduced previously as outlined above (FIGS. 34A, 34B, 46).

As mentioned above, different minimal access tubes of different sizes may be used for the present technique. In some implementations, a 13 mm diameter radiolucent Phantom ML tube (FIG. 47A may be used. This is the smallest diameter tube currently in the market that is large enough to allow for placement of the desired rectangular and cylindrical expandable cages. It is at the same time small enough to prevent any muscle creep from the paraspinal muscles. Additionally, it is radiolucent and thus allows for fluoroscopic images to be obtained even through the tube itself. Further, it is the smallest tube available that allows for excellent microscopic visualization as well as endoscopic visualization. It has its own side lights for enhanced visualization. This tube also has its own reducer dilator tube that allows for an exact fit for the Midas Rex 9 mm Acorn drill bit attachment.

Various different sizes and types of interbody devices may be used for the present technique. For example, expandable rectangular and cylindrical cages that are small enough to pass through a 10 mm diameter opening in the mid-facet region may be advantageous for safety and function. In some implementations, a 7×7 mm expandable rectangular cage may be used. For example, the 7×7 mm Flare Hawk cage, which expands well in height and width and can maintain lordosis, may be used. The Flare Hawk cage has been used successfully as a single cage crossing the midline at L4-5 and L5-S1 as well as bilaterally at L3-4 (FIGS. 47B and 47C). In some implementations, the 10 mm expandable titanium VariLift cage may be used. It also expands in height and width and can maintain lordosis. The VariLift cage has been used successfully, mostly with pedicle screws (FIGS. 47D-I) as well as in a stand-alone fashion (FIGS. 47J and 47K).

Various systems of pedicle screws and rods may be used in conjunction with the ZLIF procedure. In some implementations, the Sextant pedicle screw system may be used. This screw system is minimally invasive and also easy to remove using the minimal access tubes.

Additional Examples

As described above, the trans-facet approach provided herein can include forming an access corridor through the facet joint between the superior articular process of the vertebra below, and the inferior articular process of a vertebra above the disc space. The trans-facet approach can be performed at any level in the spine. In specific examples, the access corridor according to the trans-facet approach described herein can be formed in any vertebra from the second cervical vertebra (C2) to the sacrum (S1).

In some implementation, the access corridor extends along a generally straight trajectory traversing the inside of the facet joint without exposing surrounding neural elements, such as the exiting nerve roots and the thecal sac. Advantageously, the trans-facet access corridor is separated from the thecal sac and the exiting nerve roots by remaining bony elements of the superior and inferior articular processes that are preserved during and after formation of the trans-facet access corridor. Moreover, the trans-facet access corridor can be separated from the thecal sac medially by the ligamentum flavum, and separated from the exiting nerve root laterally by the facet joint capsule.

The articulation between one superior articular process of the vertebra below the disc space and the inferior articular process of the vertebra above the disc space have different orientations in different regions of the spine. In the lumbar region, the articulation is generally vertically aligned along the sagittal plane. However, in the cervical and thoracic regions of the spinal column, the orientation of the articulation favors the coronal plane. Furthermore, the sizes of the facet joints vary along the spinal column, with facet joints positioned within the cervical and thoracic regions being relatively smaller than those positioned in the lumbar and sacral regions. These variations in the orientation and relative sizes of the facet joints correspond to variations in the trajectory and orientation of the trans-facet access corridor.

Furthermore, while in some examples the entry point of the trans-facet access corridor is located midway between the inferior articular process and superior articular process, it is contemplated herein that the entry point can be located closer to one or the other of the inferior articular process or superior articular process. For example, in some implementations, preoperative planning informed by the above-referenced anatomical factors can be implemented to determine the percentage of drilling through one articular process versus the other. Such off-midline entry points are consistent with the approach provided herein, so long as aspects of both the inferior articular process and superior articular process remain on either side of the access point. Specifically, in some examples, the trans-facet access corridor is surrounded by bone on all sides, with the possible exception of the planar region formed at the synovial joint interface of the inferior articular process and superior articular process themselves. Therefore, in various implementations, the approach provided herein does not include performing a total facetectomy or even a partial (e.g., medial or lateral) facetectomy.

For example, in some implementations, the entry point may be offset from a midpoint between the inferior articular process and superior articular process such that a range from 1% to 99% of the material removed to form the access corridor is removed from one of the inferior articular process or the superior articular process. For example, in some implementations, the access point can be disposed such that 10% of the material removed to form the access corridor is removed from one of the inferior articular process or the superior articular process and 90% of the material is removed from the other of the inferior articular process or the superior articular process. In some implementations, the access point can be disposed such that 20% of the material removed to form the access corridor is removed from one of the inferior articular process or the superior articular process and 80% of the material is removed from the other of the inferior articular process or the superior articular process. In some implementations, the access point can be disposed such that 30% of the material removed to form the access corridor is removed from one of the inferior articular process or the superior articular process and 70% of the material is removed from the other of the inferior articular process or the superior articular process. In some implementations, the access point can be disposed such that 40% of the material removed to form the access corridor is removed from one of the inferior articular process or the superior articular process and 60% of the material is removed from the other of the inferior articular process or the superior articular process. Furthermore, as described herein, in some implementations, the access point can be disposed midway between the inferior articular process and the superior articular process such that 50% of the material removed to form the access corridor is removed from one of the inferior articular process or the superior articular process and 50% of the material is removed from the other of the inferior articular process or the superior articular process. As described herein, any ratio is consistent with this disclosure so long as the access corridor is surrounded degrees by bony elements of the superior and/or inferior articular processes (with the possible exception of the planar region formed at the synovial joint interface of the inferior articular process and superior articular process themselves).

As provided herein, the trans-facet access corridor can be formed in thoracic vertebrae. In some implementations, the trans-facet access corridor can be utilized to perform an interbody fusion of thoracic vertebra in a technique referred to herein as Tran-Facet Posterior Thoracic Interbody Fusion (or “ZLIF-T”). FIGS. 51A-51C illustrate exemplary model trajectories of the ZLIF-T approach. Specifically, FIG. 51A shows the entry point of the access corridor being formed at the facet joint midway between the inferior articular process of the fifth thoracic vertebra (T5) and the superior articular process of the sixth thoracic vertebra (T6). A K-wire is shown inserted into the access corridor, thus illustrating the trajectory of the access corridor.

FIG. 51B shows an enlarged view of the facet joint and the entry point of the access corridor illustrated in FIG. 51A. Specifically, in this implementation, the entry point of the access corridor is positioned closer to the superior articular process than the inferior articular process. As shown, about 90% of the material removed to form the access corridor is removed from the superior articular process and about 10% of the material removed to form the access corridor is removed from the inferior articular process. In further implementations, this ratio can range from between 1% and 99%, so long as bony material surrounds the entry point of the access corridor as described herein. Furthermore, as described herein, the access point can be positioned closer to either one of the superior articular process or inferior articular process. As shown, bony material surrounds the entry point and neural structures are thereby safely separated from the access corridor.

FIG. 51C shows a yet further enlarged view of the entry point of the access corridor illustrated in FIGS. 51A-51B. Accordingly, FIG. 51C further shows various structures surrounding the facet joint that are preserved using the approach described herein and shows the entry point of the access corridor being offset from the midpoint of the facet joint.

In some implementations, the ZLIF-T technique can include robotic assistance. In some implementations, the ZLIF-T follows a similar technique as described above with respect to the ZLIF approach, such as in preoperative planning and trajectory of the access corridor. In further implementations, the techniques described with respect to the ZLIF technique may include additional steps for adapting the approach to the ZLIF-T technique. For example, in some implementations, the robotic system can be attached to a Schanz pin placed into one or more of the upper lumbar or lower thoracic pedicles (i.e., a “thoracolumbar pedicle”) to improve the reach of a robotic arm of a robotic surgical assistance device. In some implementations, placement of the Schanz pin can occur using fluoroscopy imaging.

As provided herein, the trans-facet access corridor can be formed in cervical vertebrae. In some implementations, the trans-facet access corridor can be utilized to perform an interbody fusion of cervical vertebra in a technique referred to herein as Tran-Facet Posterior Cervical Interbody Fusion (or “ZLIF-C”). FIGS. 52A-52C illustrate exemplary model trajectories of the ZLIF-C approach. Specifically, FIG. 52A shows the entry point of the access corridor being formed at the facet joint approximately midway between the inferior articular process of the fifth cervical vertebra (C5) and the superior articular process of the sixth cervical vertebra (C6). As shown, bony material surrounds the entry point and neural structures are thereby safely separated from the access corridor. A K-wire is shown inserted into the access corridor, thus illustrating the trajectory of the access corridor. FIG. 52B shows an anterior view of a disc opposite the facet joint shown in FIG. 52A. In the illustrated implementation, the access corridor extends into the disc space of the target disc. FIG. 52C shows a lateral view of C5 and C6 with the access corridor extending into the disc space of the target disc. Furthermore, FIG. 52C shows various structures surrounding the facet joint are preserved using the approach described herein. Specifically, FIGS. 52A-52C show various neural elements and the vertebral artery being protected. For example, in various specific implementations provided herein (and shown in FIGS. 52B-52C), the vertebral artery is consistently lateral to the access corridor, with the uncovertebral joint separating the vertebral artery from the access corridor.

In some implementations, the ZLIF-C technique can include robotic assistance. In some implementations, the ZLIF-C follows a similar technique as described above with respect to the ZLIF approach, such as in preoperative planning and trajectory of the access corridor. In further implementations, the techniques described with respect to the ZLIF technique may include additional steps for adapting the approach to the ZLIF-C technique. For example, in some implementations, preoperative planning can include performing a cervical MRI or cervical myelogram and post-myelogram CT scan. In further implementations, it may be preferable to perform a preoperative cervical CT angiography with the patient in the prone position to assist in identifying the vertebral arteries in order to plan a safe approach. Additionally, in some implementations, the robotic system can be attached to a Schanz pin placed into one or more of the upper lumbar or lower thoracic pedicles (i.e., a “thoracolumbar pedicle”) to improve the reach of a robotic arm of a robotic surgical assistance device. In some implementations, placement of the Schanz pin can occur using fluoroscopy imaging, as described above in reference to the ZLIF-T technique. Furthermore, in some implementations, it can be beneficial to stabilize the patient's neck, for example, in a Mayfield head holder.

Discussion

With the creation of a corridor within the facet joint using the present technique, the surgeon may protect the nerve root above it as well as the thecal sac medial to it (FIG. 48). The surgeon may be most successful in the approach to a disc space when he/she does not even have to encounter any of the neural elements, which is the case with the present technique. Not only does that eliminate the chance of nerve root injury but also even the development of epidural scarring or arachnoiditis. With this novel trans-facet approach, the surgeon may enter into the middle of the facet joint between (e.g., midway between) the superior and inferior articular processes, creating a corridor towards the disc space. This leaves a few millimeters of circumferential bony protection between the exposure and the nerve roots above and below. In addition, there is an additional 1 to 2 mm of the fibrous capsule of the facet joint especially superiorly. The safety of this approach may be enhanced by the size of the facet joints, which are sometimes hypertrophied in those patients. Basically, the larger the facet joint, the safer this technique is. The safety is further enhanced by using a narrow corridor and the use of a smaller expandable cage. The technology of expandable interbody peck and titanium cages has allowed surgeons to create such a narrow corridor into the disc space. Not only do we now have expandable cages in terms of height, but we also have expandable cages in terms of width. With the current instrumentation available today, the surgeon can use 13 mm, 14 mm, and 16 mm minimal access tubes. Visualization through the tube via microscopy or endoscopy may be employed for safety. In the last 21 cases performed by the present inventor, visualization via microscopy did not reveal the exposure of any of the nerve roots or the thecal sac. This evidences that the present technique renders itself to the use of a strictly percutaneous exposure.

Accuracy of the approach depends on a preoperative Lumbar MRI or post myelogram CT scan to study the anatomy of the approach. A preoperative Lumbar CT scan with the patient in the prone position may be preferable. An accurate robotic system fixed to the table and/or the floor may be particularly advantageous. The patient well fixed into the Jackson table also may be important. A navigation system and navigated instruments also are advantageous, along with live fluoroscopy with AP, lateral, and oblique trajectories to verify the approach. Navigation helps to verify the robotic approach; however, it is not 100% accurate. Finally, it is advantageous to visualize the approach by an intra-operative microscope or endoscopy.

As described herein, the present trans-facet technique, implemented in the context of interbody fusion (e.g., posterior lumbar interbody fusion) is favorable compared to other techniques involving the facet joints. For example, PLIF invariably necessitates a medial partial facetectomy (FIG. 49) with a hemilaminectomy performed as well as drilling of the medial aspect of the inferior articular process. Furthermore, TLIF may or may not need a lateral partial facetectomy (FIG. 50). TLIF procedures are also done using a total facetectomy whether open or via a tubular system. This may further expose the neural elements which can be subject to injury or scarring. These distinctions relative to the presently described trans-facet approach are particularly pronounced where the entry point for the access corridor is formed in the middle aspect of the facet joint midway between the superior and inferior articular processes.

The PLIF technique requires exposure of the thecal sac as well as the shoulder of the lower exiting nerve root with some degree of retraction of the latter (FIG. 49). The TLIF technique through Kambin's triangle involves at least exposure of and perhaps some degree of retraction of the upper exiting nerve root (FIG. 50). Both PLIF and TLIF therefore put those nerve roots at risk of injury at worst, and at best the high chance of epidural scarring and fibrosis with subsequent neuropathic pain.

In some implementations, the use of robotic technology has allowed surgeons to save operative time without compromising accuracy. In such examples, the planning portion of the procedure can be carried out a few days before surgery as opposed to using an intraoperative CT or O arm and perform the planning during surgery. If a robotic system is not available, however, the use of a CT or MRI or O-Arm guided navigation may be a good alternative and may be considered an integral element in this surgery. As technology develops further and with the advent of more navigated instrumentation, the surgeon may be able to eliminate fluoroscopy altogether and further reduce radiation exposure to the surgeons as well as the OR crew. The present approach provides for an excellent potential for the development of an elaborate highly intelligent autonomous robotic system, hopefully in the near future.

Although specific implementations of the disclosure have been described, one of ordinary skill in the art will recognize that numerous other modifications and alternative implementations are within the scope of the disclosure. For example, while various illustrative examples and structures have been described in accordance with implementations of the disclosure, one of ordinary skill in the art will appreciate that numerous other modifications to the illustrative examples and structures described herein are also within the scope of this disclosure.

Although embodiments have been described in language specific to structural features and/or methodological acts, it is to be understood that the disclosure is not necessarily limited to the specific features or acts described. Rather, the specific features and acts are disclosed as illustrative forms of implementing the embodiments. Conditional language, such as, 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 could include, while other embodiments do not include, certain features, elements, and/or steps. Thus, such conditional language is not generally intended to imply that features, elements, and/or steps are in any way required for one or more embodiments.

Exemplary Aspects

In view of the described processes and compositions, hereinbelow are described certain more particularly described aspects of the disclosures. These particularly recited aspects should not, however, be interpreted to have any limiting effect on any different claims containing different or more general teachings described herein, or that the “particular” aspects are somehow limited in some way other than the inherent meanings of the language and formulas literally used therein.

Example 1: A method for performing spinal surgery, the method comprising: forming an access corridor through an aspect of a facet joint of a patient between an inferior articular process of a vertebra and a superior articular process of a vertebra such that an aspect of the inferior articular process is preserved on a medial side of the access corridor and an aspect of the superior articular process is preserved on a lateral side of the access corridor.

Example 2: A method for performing spinal surgery according to any example herein, particularly example 1, further comprising removing disc material from a disc space of the patient via one or more instruments advanced through the access corridor, wherein the disc space corresponds to a region defined by a target intervertebral disc disposed behind the facet joint.

Example 3: A method for performing spinal surgery according to any example herein, particularly example 2, further comprising advancing an interbody device into the access corridor.

Example 4: A method for performing spinal surgery according to any example herein, particularly example 3, further comprising advancing the interbody device into the disc space.

Example 5: A method for performing spinal surgery according to any example herein, particularly examples 2-4, further comprising placing a graft material within the access corridor.

Example 6: A method for performing spinal surgery according to any example herein, particularly example 5, further comprising advancing the graft material into the disc space.

Example 7: A method for performing spinal surgery according to any example herein, particularly examples 5-6, wherein the graft material is housed within the interbody device.

Example 8: A method for performing spinal surgery according to any example herein, particularly examples 2-7, wherein the interbody device is a cage.

Example 9: A method for performing spinal surgery according to any example herein, particularly examples 2-7, wherein the interbody device is a pouch.

Example 10: A method for performing spinal surgery according to any example herein, particularly examples 1-9, wherein forming the access corridor comprises forming an entry point of the access corridor in a middle aspect of the facet joint midway between the inferior articular process and the superior articular process.

Example 11: A method for performing spinal surgery according to any example herein, particularly examples 1-9, wherein forming the access corridor comprises forming an entry point of the access corridor at a position closer to one of the inferior articular process and the superior articular process than the other of the inferior articular process and the superior articular process.

Example 12: A method for performing spinal surgery according to any example herein, particularly examples 10-11, wherein the entry point of the access corridor is surrounded by bone on all sides.

Example 13: A method for performing spinal surgery according to any example herein, particularly examples 1-12, wherein the method does not include performing a total facetectomy.

Example 14: A method for performing spinal surgery according to any example herein, particularly examples 1-13, wherein the method does not include performing a partial facetectomy.

Example 15: A method for performing spinal surgery according to any example herein, particularly examples 1-14, wherein forming the access corridor comprises using a robotic system, MRI assisted navigation, CT assisted navigation, O-Arm assisted navigation, or fluoroscopic assisted navigation, or any combination thereof.

Example 16: A method for performing spinal surgery according to any example herein, particularly examples 1-15, wherein forming the access corridor comprises: advancing a first drill bit through the aspect of the facet joint; and advancing a first threaded tap through the aspect of the facet joint, wherein the first threaded tap has a greater diameter than the first drill bit.

Example 17: A method for performing spinal surgery according to any example herein, particularly example 16, wherein advancing the first threaded tap through the aspect of the facet joint comprises advancing the first threaded tap into a posterior third of the disc space.

Example 18: A method for performing spinal surgery according to any example herein, particularly example 17, wherein forming the access corridor further comprises: advancing a second threaded tap through the aspect of the facet joint, wherein the second threaded tap has a greater diameter than the first threaded tap; and advancing a second drill bit through the aspect of the facet joint, wherein the second drill bit has a greater diameter than the second threaded tap.

Example 19: A method for performing spinal surgery according to any example herein, particularly example 18, wherein advancing the second threaded tap through the aspect of the facet joint comprises advancing the second threaded tap into the posterior third of the disc space.

Example 20: A method for performing spinal surgery according to any example herein, particularly examples 2-19, wherein the one or more instruments comprises one or more shavers, rongeurs, or curettes.

Example 21: A method for performing spinal surgery according to any example herein, particularly examples 3-20, wherein the interbody device is expandable from a compact configuration to an expanded configuration, and wherein advancing the interbody device through the access corridor and into the disc space comprises advancing the interbody device through the access corridor and into the disc space while the interbody device is in the compact configuration.

Example 22: A method for performing spinal surgery according to any example herein, particularly example 21, further comprising expanding the interbody device from the compact configuration to the expanded configuration within the disc space.

Example 23: A method for performing spinal surgery according to any example herein, particularly examples 21-22, wherein the interbody device has first maximum transverse and vertical dimensions when the interbody device is in the compact configuration and second maximum transverse and vertical dimensions when the interbody device is in the expanded configuration, and wherein the access corridor has third maximum transverse and vertical dimensions, wherein at least one of the third maximum transverse and vertical dimensions is greater than the first maximum transverse dimension and/or the first maximum vertical dimension and less than the second maximum transverse dimension and/or the second maximum vertical dimension.

Example 24: A method for performing spinal surgery according to any example herein, particularly examples 21-23, wherein expanding the interbody device from the compact configuration to the expanded configuration comprises placing graft material within the interbody device.

Example 25: A method for performing spinal surgery according to any example herein, particularly example 24, wherein placing graft material within the interbody device comprises placing graft material within the interbody device before advancing the interbody device through the access corridor and into the disc space.

Example 26: A method for performing spinal surgery according to any example herein, particularly example 24, further comprising expanding the interbody device within the disc space, wherein placing graft material within the interbody device comprises placing graft material within the interbody device after expanding the interbody device within the disc space.

Example 27: A method for performing spinal surgery according to any example herein, particularly example 24, wherein expanding the interbody device from the compact configuration to the expanded configuration comprises incrementally adding additional graft material within the interbody device.

Example 28: A method for performing spinal surgery according to any example herein, particularly examples 5-27, wherein placing graft material within the access corridor comprises placing graft material between the interbody device and an entry point of the access corridor.

Example 29: A method for performing spinal surgery according to any example herein, particularly examples 27-28, further comprising expanding the interbody device within the disc space, wherein placing graft material within the access corridor comprises placing graft material within the access corridor after expanding the interbody device within the disc space.

Example 30: A method for performing spinal surgery according to any example herein, particularly examples 1-29, wherein forming the access corridor comprises forming the access corridor through the facet joint without exposing the exiting nerve root above the disc space.

Example 31: A method for performing spinal surgery according to any example herein, particularly examples 1-30, wherein forming the access corridor comprises forming the access corridor through the facet joint without exposing the thecal sac.

Example 32: A method for performing spinal surgery according to any example herein, particularly examples 1-30, wherein the access corridor is formed in a lumbar vertebra of the patient.

Example 33. A method for performing spinal surgery according to any example herein, particularly examples 1-30, wherein the access corridor is formed in a thoracic vertebra of the patient.

Example 34: A method for performing spinal surgery according to any example herein, particularly examples 1-30, wherein the access corridor is formed in a cervical vertebra of the patient.

In view of the many possible aspects to which the principles of the disclosed disclosure can be applied, it should be recognized that the illustrated aspects are only preferred examples of the disclosure and should not be taken as limiting the scope of the disclosure. Rather, the scope of the disclosure is defined by the following claims. We, therefore, claim as our disclosure all that comes within the scope and spirit of these claims.

	Number	Date	Country
	63142228	Jan 2021	US
	63166966	Mar 2021	US

	Number	Date	Country
Parent	17586769	Jan 2022	US
Child	18428295		US

	Number	Date	Country
Parent	18428295	Jan 2024	US
Child	18953873		US

Minimally Invasive Trans-Facet Spinal Surgery

Information

Publication Number

Date Filed

Date Published

Inventors

CPC

International Classifications

Abstract

Description

Claims

CROSS-REFERENCE TO RELATED APPLICATIONS

Provisional Applications (2)

Continuations (1)

Continuation in Parts (1)