Patent Application
20060135959
The present invention relates to a nuclectomy method for creating a nuclear cavity in an annulus located in an intervertebral disc space and for preparing the nuclear cavity to receive an intervertebral prosthesis.
The intervertebral discs, which are located between adjacent vertebrae in the spine, provide structural support for the spine as well as the distribution of forces exerted on the spinal column. An intervertebral disc consists of three major components: cartilage endplates, nucleus pulpous, and annulus fibrosus. The central portion, the nucleus pulpous or nucleus, is relatively soft and gelatinous; being composed of about 70 to 90% water. The nucleus pulpous has a high proteoglycan content and contains a significant amount of Type II collagen and chondrocytes. Surrounding the nucleus is the annulus fibrosus, which has a more rigid consistency and contains an organized fibrous network of approximately 40% Type I collagen, 60% Type II collagen, and fibroblasts. The annular portion serves to provide peripheral mechanical support to the disc, afford torsional resistance, and contain the softer nucleus while resisting its hydrostatic pressure.
Intervertebral discs, however, are susceptible to a number of injuries. Disc herniation occurs when the nucleus begins to extrude through an opening in the annulus, often to the extent that the herniated material impinges on nerve roots in the spine or spinal cord. The posterior and posterio-lateral portions of the annulus are most susceptible to attenuation or herniation, and therefore, are more vulnerable to hydrostatic pressures exerted by vertical compressive forces on the intervertebral disc. Various injuries and deterioration of the intervertebral disc and annulus fibrosus are discussed by Osti et al., Annular Tears and Disc Degeneration in the Lumbar Spine, J. Bone and Joint Surgery, 74-B(5), (1982) pp. 678-682; Osti et al., Annulus Tears and Intervertebral Disc Degeneration, Spine, 15(8) (1990) pp. 762-767; Kamblin et al., Development of Degenerative. Spondylosis of the Lumbar Spine after Partial Discectomy, Spine, 20(5) (1995) pp. 599-607.
Many treatments for intervertebral disc injury have involved the use of nuclear prostheses or disc spacers. A variety of prosthetic nuclear implants are known in the art. For example, U.S. Pat. No. 5,047,055 (Bao et al.) teaches a swellable hydrogel prosthetic nucleus. Other devices known in the art, such as intervertebral spacers, use wedges between vertebrae to reduce the pressure exerted on the disc by the spine. Intervertebral disc implants for spinal fusion are known in the art as well, such as disclosed in U.S. Pat. Nos. 5,425,772 (Brantigan) and 4,834,757 (Brantigan).
Further approaches are directed toward fusion of the adjacent vertebrate, e.g., using a cage in the manner provided by Sulzer. Sulzer's BAK® Interbody Fusion System involves the use of hollow, threaded cylinders that are implanted between two or more vertebrae. The implants are packed with bone graft to facilitate the growth of vertebral bone. Fusion is achieved when adjoining vertebrae grow together through and around the implants, resulting in stabilization.
Apparatuses and/or methods intended for use in disc repair have also been described but none appear to have been further developed, and certainly not to the point of commercialization. See, for instance, French Patent Appl. No. FR 2 639 823 (Garcia) and U.S. Pat. No. 6,187,048 (Milner et al.). Both references differ in several significant respects from each other and from the apparatus and method described below. For instance, neither reference teaches switching the flow of biomaterial between discrete operating parameters or methods of detecting ruptures in the mold. Further, neither reference teaches shunting an initial portion of a curing biomaterial in the course of delivering the biomaterial to the disc space.
Prosthetic implants formed of biomaterials that can be delivered and cured in situ, using minimally invasive techniques to form a prosthetic nucleus within an intervertebral disc have been described in U.S. Pat. Nos. 5,556,429 (Felt) and 5,888,220 (Felt et al.), and U.S. Patent Publication No. U.S. 2003/0195628 (Felt et al.), the disclosures of which are incorporated herein by reference. The disclosed method includes, for instance, the steps of inserting a collapsed mold apparatus (which in a preferred embodiment is described as a “mold”) through an opening within the annulus, and filling the mold to the point that the mold material expands with a flowable biomaterial that is adapted to cure in situ and provide a permanent disc replacement. Related methods are disclosed in U.S. Pat. No. 6,224,630 (Bao et al.), entitled “Implantable Tissue Repair Device” and U.S. Pat. No. 6,079,868 (Rydell), entitled “Static Mixer”.
The present invention relates to a nuclectomy method for removing at least a portion of a nucleus from an annulus to create a nuclear cavity in an intervertebral disc space and for preparing the nuclear cavity to receive an intervertebral prosthesis. A plurality of regions in at least a portion of the nucleus and a sequence for removing the a plurality of the regions are identified. At least one annulotomy is formed in the annulus along an annular axis to provide access to a nucleus. A portion of the nucleus in a first region in the sequence is removed using at least a first surgical tool. A portion of the nucleus from a second region in the sequence is removed using at least a second surgical tool. An evaluation mold is positioned in the nuclear cavity and a fluid is delivered to the evaluation mold so that the mold substantially fills the nuclear cavity. The evaluation mold is used to estimate the quantity of nucleus material removed as well as the position of the mold within the nuclear cavity. The evaluation mold can also be used to estimate the geometry of the nuclectomy. One or more of the removing steps are optionally repeated as necessary until an adequate amount of the nucleus is removed from the annulus.
The present invention is also directed to identifying a sequence of regions within at least a portion of the nucleus and removing a portion of the nucleus through the annulotomy according to the sequence. An evaluation mold is positioned in the nuclear cavity and a fluid is delivered to the evaluation mold so that the mold substantially fills the nuclear cavity. The evaluation mold is used to estimate the quantity of nucleus material removed. Some or all of the sequence is repeated as necessary until an adequate amount of the nucleus is removed from the annulus. In an embodiment where primary and secondary annulotomies are formed, a separate removal sequence is preferably identified for each of the annulotomies.
In one embodiment, the step of removing is repeated until at least 70%, and more preferably at least 80%, and most preferably at least 90% of the nucleus is removed from the annulus. In another embodiment, the step of removing is repeated until the nuclear cavity is centered within the annulus and/or the nuclear cavity is symmetrical relative to the midline of the spine.
The present method includes dividing the nucleus into two or more regions and using at least one surgical tool to sequentially remove the nuclear material from each region. The method includes selecting the surgical tools from a group including for example a straight rongeur, an up-biting rongeur, a modified Wilde-style rongeur, a curved rongeur, or other surgical tools know to those in the art. The annulotomy can be located at the posterior, the posterolateral, the anterolateral, and the anterior side of the annulus.
The step of evaluating the annulus optionally includes positioning an evaluation mold in the nuclear cavity and delivering a fluid to the evaluation mold so that the mold substantially fills the nuclear cavity. In one embodiment, the fluid is removed from the evaluation mold. The quantity of fluid delivered to and/or removed from the evaluation mold is measured and the evaluation mold is removed from the annulus. The estimated volume of the nucleus is compared with the quantity of fluid to determine the percentage of the nucleus removed from the annulus. In one embodiment, the total volume of the nucleus is estimated by imaging.
In another embodiment, the fluid is delivered under sufficient pressure to distract the intervertebral disc space. One or both of the fluid and the evaluation mold may optionally have radiopaque properties. The intervertebral disc space containing the evaluation mold and the fluid is optionally subject to imaging. In another embodiment, the intervertebral disc space containing the evaluation mold and the fluid is imaged and the distraction of the intervertebral disc space is determined. Alternatively, imaging can be used to determine whether the mold substantially fills the annulus and/or the geometry of the nuclear cavity.
The present invention is also directed to positioning an evaluation mold in the nuclear cavity and delivering a fluid under pressure to the evaluation mold sufficient to distract the intervertebral disc space. The volume of fluid in the evaluation mold is held constant for a period of time. Additional fluid is added to the evaluation mold when the pressure in the mold drops to a predetermined level. The steps of delivering, holding and adding additional fluid is preferably repeated for a plurality of cycles.
The present invention is also directed to positioning an evaluation mold in the nuclear cavity and continuously delivering a fluid to the evaluation mold at a constant pressure. The rate at which the fluid is delivered to the evaluation mold is measured. The compliance of the intervertebral disc space is then estimated as a function of the changing rate at which the fluid is delivered.
In one embodiment, the method includes forming primary and secondary annulotomies in the annulus. A portion of the nucleus is removed through the primary annulotomy using at least a first surgical tool and a portion of the nucleus is removed through the secondary annulotomy using at least a second surgical tool.
In another embodiment, a first plurality of regions are identified in at least a portion of the nucleus. A first sequence for removing the first plurality of regions through the primary annulotomy is also identified. A second plurality of regions is identified in at least a portion of the nucleus. A second sequence for removing the second plurality of regions through the secondary annulotomy is also identified. A portion of the nucleus is removed through the primary annulotomy according to the first sequence and a portion of the nucleus is removed through the secondary annulotomy according to the second sequence.
The present nuclectomy method is the preferred precursor procedure to implanting certain intervertebral prosthesis. In one embodiment, the intervertebral prosthesis is a mold fluidly coupled to a delivery cannula. A flowable biomaterial is delivered through a cannula into the mold located in the annulus. The delivered biomaterial is allowed to cure a sufficient amount to permit the cannula to be removed. Various implant procedures, implant molds, and biomaterials related to intervertebral disc replacement suitable for use with the present invention are disclosed in U.S. Pat. Nos. 5,556,429 (Felt); 6,306,177 (Felt, et al.); 6,248,131 (Felt, et al.); 5,795,353 (Felt); 6,079,868 (Rydell); 6,443,988 (Felt, et al.); 6,140,452 (Felt, et al.); 5,888,220 (Felt, et al.); 6,224,630 (Bao, et al.), and U.S. patent application Ser. Nos. 10/365,868 and 10/365,842, all of which are hereby incorporated by reference.
The present invention is also directed to a biomaterial injection system that delivers the fluid to the evaluation mold. In one embodiment, the apparatus includes a reservoir containing the fluid coupled to the evaluation mold, at least one sensor adapted to monitor at least one injection condition of the fluid, and a controller. The controller is optionally programmed to monitor the at least one sensor and to control the flow of the fluid into and out of the evaluation mold. The controller is preferably programmed to remove the fluid from the evaluation mold and to measure the amount of fluid removed from the evaluation mold. The fluid and/or the evaluation mold optionally have radiopaque properties. In one embodiment, the fluid is a liquid.
In one embodiment, the controller is programmed to estimate the volume of biomaterial required to fill the nuclear cavity by comparing the amount of fluid injected into and/or removed from the evaluation mold with an estimated volume of the annulus measured using imaging techniques.
In another embodiment, the controller is programmed to deliver a fluid under pressure to the evaluation mold sufficient to distract the intervertebral disc space, to hold the volume of fluid in the evaluation mold constant for a period of time, and to add additional fluid to the evaluation mold when the pressure in the mold drops to a predetermined level. The controller is preferably programmed to repeat the steps a plurality of cycles and estimate the compliance of the intervertebral disc space or spinal unit.
In another embodiment, the controller is programmed to continuously deliver a fluid to the evaluation mold at a predetermined driving pressure, to measure the rate at which the fluid is delivered to the evaluation mold, and to estimate the compliance of the intervertebral disc space as a function of the changing rate at which the fluid is delivered.
As used herein the following words and terms shall have the meanings ascribed below:
“biomaterial” will generally refer to a material that is capable of being introduced to the site of a joint and cured to provide desired physical-chemical properties in vivo. In one embodiment the term will refer to a material that is capable of being introduced to a site within the body using minimally invasive mechanism, and cured or otherwise modified in order to cause it to be retained in a desired position and configuration. Generally such biomaterials are flowable in their uncured form, meaning they are of sufficient viscosity to allow their delivery through a delivery tube of on the order of about 1 mm to about 6 mm inner diameter, and preferably of about 2 mm to about 3 mm inner diameter. Such biomaterials are also curable, meaning that they can be cured or otherwise modified, in situ, at the tissue site, in order to undergo a phase or chemical change sufficient to retain a desired position and configuration;
“cure” and inflections thereof, will generally refer to any chemical transformation (e.g., reacting or cross-linking), physical transformation (e.g., hardening or setting), and/or mechanical transformation (e.g., drying or evaporating) that allows the biomaterial to change or progress from a first physical state or form (generally liquid or flowable) that allows it to be delivered to the site, into a more permanent second physical state or form (generally solid) for final use in vivo. When used with regard to the method of the invention, for instance, “curable” can refer to uncured biomaterial, having the potential to be cured in vivo (as by catalysis or the application of a suitable energy source), as well as to the biomaterial in the process of curing. As further described herein, in selected embodiments the cure of a biomaterial can generally be considered to include three stages, including (a) the onset of gelation, (b) a period in which gelation occurs and the biomaterial becomes sufficiently tack-free to permit shaping, and (c) complete cure to the point where the biomaterial has been finally shaped for its intended use.
“minimally invasive mechanism” refers to a surgical mechanism, such as microsurgical, percutaneous, or endoscopic or arthroscopic surgical mechanism, that can be accomplished with minimal disruption to the annular wall (e.g., incisions of less than about 4 cm and preferably less than about 2 cm). In some embodiments, minimally invasive mechanisms also refers to minimal disruption of the pertinent musculature, for instance, without the need for open access to the tissue injury site or through minimal skin incisions. Such surgical mechanism are typically accomplished by the use of visualization such as fiberoptic or microscopic visualization, and provide a post-operative recovery time that is substantially less than the recovery time that accompanies the corresponding open surgical approach.
“mold” will generally refer to the portion or portions of an apparatus of the invention used to receive, constrain, shape and/or retain a flowable biomaterial in the course of delivering and curing the biomaterial in situ. A mold may include or rely upon natural tissues (such as the annular shell of an intervertebral disc) for at least a portion of its structure, conformation or function. The mold, in turn, is responsible, at least in part, for determining the position and final dimensions of the cured prosthetic implant. As such, its dimensions and other physical characteristics can be predetermined to provide an optimal combination of such properties as the ability to be delivered to a site using minimally invasive mechanism, filled with biomaterial, prevent moisture contact, and optionally, then remain in place as or at the interface between cured biomaterial and natural tissue. In one embodiment the mold material can itself become integral to the body of the cured biomaterial. The mold can be elastic or inelastic, permanent or bio-reabsorbable, porous or non-porous.
Intervertebral disc space refers generally to the space between adjacent vertebrae. The embodiments illustrated herein are equally applicable to both a complete disc replacement and to a full or partial nucleus replacement. A replacement disc refers to both a complete disc replacement and to a full or partial nucleus replacement.
The reservoir 3 is adapted to hold the biomaterial 23, and in some embodiments, the reservoir 3 heats and/or mixes the biomaterial 23. In some embodiments, the biomaterial 23 is pretreated before use. The biomaterial 23 can either be pretreated before being placed in the reservoir 3 or the pretreatment can be performed in the reservoir 3. For example, the biomaterial 23 can be heated, mechanically agitated, or both, such as heating in a rotating oven before being placed in the reservoir 3. For some polyurethane biomaterials, for example, sealed packages of biomaterial 23 are heated while rotating in an oven at about 75° C. for about 3 hours, maintained at 75° C. degrees C without rotating for an additional 3 hours, and then kept in the oven at about 37° C. until surgical implantation. During the second 3 hour period, the package of biomaterial 23 is preferably retained in the oven without rotating and in an upright position during heating so that bubbles rise to the top. The flowable biomaterial 23 containing the bubbles is preferably purged before it reaches the mold, as will be discussed below.
A chamber 5 is optionally located in-line between the reservoir 3 and the mold 13. The chamber 5 can be used to heat, mix and/or stage the biomaterial 23. In some embodiments, the chamber 5 can be used to initiate curing of the biomaterial 23, such as for example by exposing the biomaterial 23 to an ultraviolet light source or a heat source 5b.
An actuator 21 is mechanically coupled to the reservoir to expel the biomaterial 23 from the reservoir 3 and into the delivery tube 11. The actuator 21 can be a pneumatic or hydraulic cylinder, a mechanical drive such as an electric motor with a ball screw, a drive screw or belt, or a variety of other mechanisms well know to those of skill in the art. Control by the controller 15 of the injection pressure, flow rate, and volume of the biomaterial are typically the primary operating parameters used to create the desired injection profile. Other possible operating parameters that can be controlled by the controller 15 include releasing biomaterial 23 through one or more of the purge devices 7a, 7b, biomaterial temperature, biomaterial viscosity, and the like.
As used herein, “operating parameter” refers to one or more independent variables that can be controlled during the injection of biomaterial. The operating parameters can be linear, non-linear, continuous, discontinuous, or any other configuration necessary to achieve the desired injection profile. The operating parameter can also be modified real-time based on feedback from the sensors monitoring the injection conditions. For example, a control algorithm, such as Proportional Integral Derivative (PID) control, can be used to evaluate the injection condition data in light of the desired injection profile.
For embodiments where the actuator 21 is a pneumatic cylinder, it should be noted that many hospitals and clinics do not have sources of compressed air greater than 50 pounds per square inch (hereinafter “psi”). Thus, in some embodiments the pneumatic cylinder needs to magnify the available compressed air source by a factor of about 3. Thus, an initial pressure of about 50 psi becomes about 150 psi in the reservoir 3.
The delivery tube 11 preferably includes at least one purge device 7a. In the illustrated embodiment, the purge device 7a is located downstream of the chamber 5. In another embodiment, a secondary purge device 7b is located closer to the mold 13. The purge devices 7a and 7b are referred to collectively as “7”. Suitable purge devices can include but are not limited to, reservoirs, three-way valve systems, and the like. The purge devices 7 can divert or redirect the flow of biomaterial 23 aside in order to purge a portion, which can include an initial portion that may be inadequately mixed or contain bubbles. The purge devices 7 can also be employed if there is a system failure, such as rupture of a mold 13, to quickly divert biomaterial from the intervertebral disc space.
The purge devices 7a, 7b can be operated manually or automatically. In the preferred embodiment one or both are operated by controller 15 and/or using the mechanism in
In the illustrated embodiment, the biomaterial injection system 1 preferably includes one or more sensors 9a, 9b, 9c, 9d, 9e, 9f, 9g and 9h (referred to collectively as “9”) located at strategic locations in the present biomaterial injection system 1. In the illustrated embodiment, sensor 9a is located between the reservoir 3 and the chamber 5. Sensor 9b is located between the chamber 5 and the purge device 7a. Another sensor 9c is located downstream of the purge device 7a. Sensor 9d is located close to the mold 13. In the preferred embodiment, the sensor 9d is located as close to the mold 13 as possible. The pressure sensor 9g is located substantially in the mold 13. The sensor 9h is optionally located in the intervertebral disc space 19, but outside the mold 13. The sensor 9e is located in the reservoir 3 and the sensor 9f is located in the actuator 21.
Each of the individual sensors 9 can measure any one of a plurality of injection conditions, such as for example biomaterial color, biomaterial viscosity, pressure, quantity and/or size of air bubbles in the biomaterial, flow rate, temperature, total volume, duration of the flow of the biomaterial 23, or any other injection condition that characterizes a proper injection profile. As used herein, “injection condition” refers to one or more dependent variables that are effected by one or more operating parameters. An “injection profile” refers to values of one or more injection conditions evaluated over time. An exemplary injection profile is illustrated in
Output from the sensors 9 is preferably delivered to controller 15. The controller 15 preferably attaches a time/date stamp to all injection condition data. Not all of the sensors 9 necessarily perform the same function. For example, the sensors 9a and 9d may monitor pressure, while the sensor 9b monitors temperature and the sensor 9c monitors flow.
The sensors 9 can be in-line with the delivery tube 11, fluidly coupled to the delivery tube 11, coupled to the delivery tube 11 by a diaphragm, or engaged with the delivery tube using a variety of other techniques. The sensors 9 may be disposable or reusable. A suitable pressure sensor 9 can include any device or system adapted to measure or indicate fluid pressure within a surgical fluid system and adapted for attachment to a delivery mechanism 11. Examples of suitable pressure sensors include, but are not limited to, those involving a suitable combination of pressure gauge, electronic pressure transducer and/or force transducer components. Such components that can be adapted to permit the accurate and substantially real time measurement of pressure in a remote fluid, by shunting a sample of such fluid, can also be used particularly where the fluid is itself undergoing a change in properties in the course of its ongoing cure.
The various components of the biomaterial injection system 1 are preferably fabricated from polymeric or other materials that provide an optimal combination of properties such as compatibility with the biomaterial 23 and the ability to be sterilized and/or to be disposable.
Operation of the actuator 21 is preferably monitored and/or directed by the controller 15. The controller 15 preferably permits manual override of any of the automated functions. Output from the sensors 9 is preferably delivered to the controller 15 to create a closed-loop feed back system, although an open loop system is possible. The controller 15 preferably includes a processor and a memory device. The controller 15 can be a special purpose computer, a general purpose computer such as a personal computer, independent signal conditioning circuits, threshold comparator circuits and switch circuits. In some embodiments, the controller 15 is a user interface to effect manual control of the system 1.
The controller 15 preferably includes one or more displays 16 that communicate injection conditions to the operator or surgical staff. The controller 15 can also provide audio indications of the injection condition data shown on the displays 16. In another embodiment, the surgical staff manually overrides the operation of the controller 15 so as to permit one or more operating parameters to be controlled manually based on data obtained from the displays 16.
As illustrated in
The mixing of the two or more components 23a, 23b of the biomaterial 23 can initiate a chemical curing reaction. Although the reservoir of
Alternatively, the biomaterial may be a single component system that can be located in one or more of the compartments 37a, 37b. Single component biomaterials can be cured using, for example, ultraviolet light, ultrasonic energy, mechanical agitation, or heat. In one embodiment, the chamber 5 can optionally include an ultraviolet light source, a heater, or any other device or source of energy that initiates the curing process of the biomaterial 23.
As biomaterial is delivered to the inlet 72 under pressure, it is advanced through the passageway 78 into the chamber 76. The volume of the chamber 76 is designed to accommodate the optimum amount of biomaterial 23 that is typically purged prior to delivery to the mold 13. Once the chamber 76 is filled with biomaterial 23, force 88 is applied to the piston 80. As the piston 80 is driven toward surface 90 on housing 92 by the pressure of the biomaterial 23, connecting member 94 displaces the valve 82 along with the piston 80. Vent hole 81 allows air to escape from behind the piston 80 as it advances in the housing 92.
In another embodiment, the delivery tube 11 is sized to fit the annulotomy 26 formed in the annulus 25 snuggly to allow the biomaterial 23 to be delivered under pressure without leaking. In the embodiment of
As discussed above, the controller 15 preferably monitors and records the injection condition data and attaches a time/date stamp.
By linking the historic injection profiles 20 with the patient's pre-surgical and post-surgical patient parameters, a database is created that can be searched by surgeons for the injection profile 20 that most closely matches the current patient's parameters. Once the optimum profile is selected, it can optionally be downloaded to the controller 15 prior to performing the present method.
Nuclectomy Method and Apparatus
The present invention is also directed to an improved nuclectomy or total nucleus removal (TNR) method and apparatus. Total nucleus removal refers to removal of substantially all of the nucleus from an intervertebral disc. In one embodiment, total nucleus removal is preferably removal of at least 70% of the nucleus, and more preferably at least 80% of the nucleus is removed, and most preferably at least 90% of the nucleus is removed from the intervertebral disc.
The TNR is the preferred precursor procedure for deploying an inflatable nucleus replacement prosthesis. The present TNR methodology permits the nucleus replacement prosthesis to be accurately positioned within the annulus, and optimally symmetrical relative to the midline of the spine.
In one embodiment, the nucleus is divided into a plurality of regions. A preferred sequence for removing the nucleus material from each of the regions is established. The regions are preferably arranged to take into consideration the three-dimensional nature of the nucleus material.
The selection of the regions typically varies with the entry method. For example, posterior entry will require a different arrangement of regions and sequence of nucleus removal from an anterior, posterolateral, anterolateral, or lateral approach. Examples of each are included herein.
At least two different surgical instruments are typically used to remove the nucleus material from at least two of the regions. The surgical instruments are selected for optimum removal of the nucleus material from a given region. In some embodiments, different functions of a multi-function surgical tools can be used to remove the nucleus material from two of the regions. In some embodiments, indicia are provided on the surgical tools to measure depth of penetration into the annulus.
The large angled up-biting rongeur 320 is then used to remove the nucleus 29 on the other side of the annulotomy axis 404 in region 3. In one embodiment, up-biting rongeurs 320 with different jaw widths are used. The small curved rongeur 360 is optionally used to remove any remaining nucleus 29 from region 3. The nuclear cavity is preferably centered in the annulus 25 and symmetrical about the midline 402.
In another embodiment, the nucleus 29 in region 1 surrounding and adjacent to the annulotomy axis 404 is removed using the Modified Wilde-style rongeur 340. The small curved rongeur 360 is then used to remove the nucleus 29 in region 2. Large angled up-biting rongeurs 320 of different widths are used to remove the nucleus 29 in region 3. The large curved rongeur 360 is used to remove any remaining nucleus 29 from region 3. The large angled up-biting rongeurs 320 of different widths are then used to remove the nucleus 29 in region 4.
The straight rongeur 300, Modified Wilde-style rongeur 340, up-biting rongeur 320 or curved rongeur 360 may be used to remove the nucleus 29 adjacent to the annulotomy axis 404 from region 1. The small angled up-biting rongeur 320, small or large curved rongeurs 360 can be used to remove the nucleus from region 2.
The straight rongeur 300, Modified Wilde-style rongeur 340, or a small angled up-biting rongeur 320 may be used to remove the nucleus 29 along the annulotomy axis 404 from region 1. The up-biting rongeur 320 or curved rongeur 360 can be used to remove the nucleus from region 2. The up-biting rongeur 320 or curved rongeur 360 can be used to remove the nucleus from region 3.
The straight rongeur 300, Modified Wilde-style rongeur 340, a curved rongeur, or a large angled up-biting rongeur 320 may be used to remove the nucleus 29 adjacent to the annulotomy axis 404 from region 1. The up-biting rongeur 320 or curved rongeur 360 can be used to remove the nucleus from region 2.
The straight rongeur 300, Modified Wilde-style rongeur 340, and/or a small angled up-biting rongeur 320 may be used to remove the nucleus 29 along the annulotomy axis 404 from region 1. The up-biting rongeur 320 or curved rongeur 360 can be used to remove the nucleus from region 2. The up-biting rongeur 320 or curved rongeur 360 can also be used to remove the nucleus from region 3.
One of the annulotomies 420, 422 can be used to introduce additional instruments into the nucleus 29. In one embodiment additional disc removal instruments such as for example rongeurs, ablation devices, lasers, water jets, graspers, knives, blades, reamers, trephines, curretes, and the like can be used in connection with the present nuclectomy. In another embodiment, visual aids, such as for example endoscopes, microscopes, fiber optic cables, depth probes, rules and the like can be introduced through one of the annulotomies 420, 422. In another embodiment, monitoring devices such as for example thermometers, pressure gauges, volume assessment devices and the like can be introduced.
In yet another embodiment, each of the annulotomies 420, 422 can be used to introduce additional prosthetic devices, such as a multi-part mold to hold biomaterial, attachment devices such as adhesives, therapeutic devices, and the like. The present multi-portal approach is particularly suited for use with the multi-lumen molds disclosed in U.S. patent application Ser. No. 11/268,786 filed Nov. 8, 2005 and entitled Multi-Lumen Mold For Intervertebral Prosthesis And Method Of Using Same, previously incorporated by reference.
In one embodiment, the multi-lumen mold includes a lead catheter or elongated portion that is inserted through the primary annulotomy and that can protruded through the secondary annulotomy. Such elongated portion can optionally be connected to a vacuum source. Alternatively, a stylete or guide could lead the catheter/mold through the primary annulotomy, which can subsequently be removed from the secondary annulotomy. In another embodiment, a rail device separate from the mold and/or catheter could be introduced through the secondary annulotomy to guide the mold into position. This device is typically removed prior to delivery of the biomaterial.
The designation of the primary versus the secondary annulotomies 420, 422 depends on the patient pathology and/or the surgeon's assessment of the case. Disc removal can be performed through the primary and/or secondary annulotomy. The regions, instruments, and sequence may be the same or different between the primary and secondary annulotomies. The regions for each annulotomy 420, 422 can optionally be considered overlapped. In the multi-portal approach, there may be regions that have little or no disc material to be removed, in this case, one would either remove that small amount or move onto the next region. The surgeon can start with either the primary or the secondary annulotomy.
In one embodiment, the surgeon starts by removing the nucleus material from regions adjacent to the primary annulotomy, and then finishes with the secondary annulotomy. Alternatively, the surgeon could remove nucleus material adjacent to some of the primary approach regions, switch to the secondary annulotomy, then back to the primary annulotomy, switching back and forth until the nucleus is adequately removed. The primary and secondary annulotomies need not have the same number regions, and the number of regions given the approach would depend on the surgeon preference, patient pathology, disc removal from a previous entrance, disc removal instruments, or the type of instrument to be used in the various regions.
As illustrated in
Depth markings (see
In all instances above, an additional instrument could be used for region 1, such as for example a trephine or other such coring or reaming device. The trephine would core out a hole (channel) through region one. If only a trephine is used for region 1, then the shape of region 1 would generally be narrower. However, the other instruments listed for the region 1 instruments above, may also be used in combination with the trephine.
Alternatively, region 1 access may also be achieved using a dilation system, as opposed to a coring system (trephine) or other such system whereby material is first removed (such as the rongeurs). For a dilation system, a wire, long needle, or other small diameter rod or tube may be introduced into the disc. Over the top of this rod or other such device, dilators may be introduced into the disc space. A series of dilators may be introduced in this manner, each one larger than the previous one. The dilators displace the disc material so that a core in at least part of region 1 is created. Through this core, other regions, or the remainder of region 1 may be reached.
For any and all the above described approaches and regions, ball probes may be used to help determine the size of the cavity (length, width, height), annular wall thickness, search for loose disc fragments, or assess the uniformity of the nuclectomy cavity.
Although the instruments described herein are basically rongeurs, other instruments or means of disc removal may also be used in the present nuclectomy method. Other such instruments to remove nucleus material include, for example, water or other liquid jets to cut, remove, or debrid tissue; laser ablation; rotary type devices that would work in concert with liquid irrigation and/or vacuum; and vacuum & liquid irrigation alone.
Preliminary Analysis of the Patient
The optimum injection profile and the corresponding injection conditions may vary as a function of patient parameters, such as for example, the patient's weight, age, body mass index, gender, disc height, disc degeneration index, disc compliance and integrity, disease state, general clinical goals, patient-specific clinical goals, and the like. For example, a diseased disc may require a higher injection pressure and a higher termination pressure to restore more disc height and a longer dwell time at the threshold and/or termination pressure. Alternatively, if a bone scan indicates reduced bone density or that the vertebral bodies are otherwise compromised, a lower injection pressure may be indicated. The present invention includes creating an injection profile as a function of patient parameters and clinical goals. In some embodiments, a custom injection profile is created for each patient.
One mechanism for determining whether substantially all of the nuclear material has been removed during the nuclectomy and for selecting the appropriate injection profile for the patient is to conduct an analysis on the annulus 25. Imaging or palpitation of the annulus, preferably after nuclectomy, is optionally performed before the delivery of the biomaterial to assess annular integrity. In one embodiment, an instrument is used that applies a known force or pressure to the annular wall 25 and measures the amount of deflection.
In one embodiment, an evaluation mold 13′ (which may be the same mold or a different mold than the implant mold 13), is inserted into the patient's annulus 25 after the nuclectomy is completed, such as illustrated in
In an alternate embodiment, the contrast medium is injected directly into the annulus 25. The evaluation mold 13′ and/or the mold 13 are then inflated with a fluid and the annulus 25 is imaged as discussed herein.
In some embodiments, the evaluation mold 13′ and/or the delivery tube 11 have radiopaque properties. The radiopaque properties can be provided by constructing the evaluation mold 13′ and/or the delivery tube 11 from a radiopaque material or including radiopaque markings, such as inks, particles, beads, and the like on the evaluation mold 13′ and/or the delivery tube 11 to facilitate imaging. An image, such as an x-ray, MRI, CAT-scan, or ultrasound, is then taken of the patient's intervertebral disc space 19 to check if the nuclectomy (i.e., the nuclear cavity 24) is symmetrical, of adequate size, of the desired geometry and/or if the required amount of distraction has been achieved. This information is used by the surgeon to decide when the proper amount of nucleus material has been removed from the annulus 25.
The volume of contrast medium necessary to fill the nuclear cavity 24 and to achieve the desired amount of distraction, as verified by the image sequence, provides an indication of whether the nucleus has been substantially removed and the volume of biomaterial 23 necessary for the procedure. In another embodiment, imaging is used to estimate the amount of nuclear material needs to be removed. The volume of fluid necessary to fill the evaluation mold 13′ is then compared to the estimated volume measured using imaging techniques and a determination is made whether additional nucleus material should be removed.
In another embodiment illustrated in
The medium 102 is preferably delivered at a pressure sufficient to fully expand the mold 13 into the nuclear cavity 24. The evaluation mold 13′ also serves to position the mold 13 within the annulus 25. As best illustrated in
As illustrated in
Compliance Testing
The evaluation mold 13′ can also be used to measure the compliance of the annulus 25. For example, the evaluation mold 13′ can be pressurized with a fixed volume of saline or a liquid contrast medium to the level anticipated during delivery of the biomaterial. Images of the intervertebral disc space 19 are optionally taken at various pressures to measure the distraction of the adjacent vertebrate 17. After a period of time, such as about three to about five minutes, the tissue surrounding the intervertebral disc space 19 generally relaxes, causing the pressure measured in the evaluation mold 13′ to drop. Additional saline or contrast medium is then introduced into the evaluation mold 13′ to increase the pressure in the intervertebral disc space 19 to the prior level. The tissue surrounding the intervertebral disc space 19 again relaxes as measured by the reduction in pressure within the evaluation mold 13′. By repeating this procedure several times, the surgeon can assess the compliance of the intervertebral disc space 19 and/or the annulus 25, and the likely volume of biomaterial 23 necessary for the procedure.
In another embodiment, compliance is measured by continuously adding a fluid to the evaluation mold 13′ at a rate sufficient to maintain a generally constant pressure in the biomaterial delivery system 1 and/or in the intervertebral disc space. The change in the rate at which fluid needs to be added to maintain a constant pressure provides information that can be used to estimate compliance of the annulus 25 and/or the intervertebral disc space 19.
A healthy, compliant annulus can typically handle several pressurization/relaxation cycles. A diseased annulus 25 may show less relaxation (e.g., less compliance) after being pressurized. Depending upon the status of the annulus 25 and the intervertebral disc space 19, a patient-appropriate injection profile can be selected.
This compliance evaluation can be either controlled manually or by the controller 15. The compliance data collected can be used to determine the operating parameters to produce the injection profile best suited to the patient.
Injection Conditions
The present biomaterial delivery system 1 permits one or more operating parameters to be controlled to achieve the desired injection conditions. The operating parameters may include, for example, biomaterial temperature and viscosity, biomaterial flow rate, biomaterial pressure, volume of biomaterial, distraction pressure, total distraction, and time, such as for example distraction time.
The injection conditions can vary over the course of the medical procedure, so a plurality of injection conditions are preferably monitored and recorded as a function of time. The injection conditions can also be evaluated as a function of any of the other injection conditions, such as for example, pressure as a function of volume or flow. In the present invention, the pressure in the mold 13 is one possible injection condition for determining when to terminate the flow of biomaterial 23. Alternatively, the volume of biomaterial 23 delivered to the mold 13 can also be used for this purpose.
Once an optimum injection profile for the patient is determined (see e.g.,
The injection conditions can be used to signal that the procedure is out of specification. Alternatively, the controller 15 can calculate trends or slopes of the injection conditions to predict whether a particular injection condition will likely be out of specification. As used herein, “out of specification” refers to one or more injection conditions that have deviated from the desired injection profile and/or are exhibiting a trend that indicates a future deviation from the injection profile.
In those situations where the injection conditions can not be brought under control, such as for example if the mold 13 malfunctions, the procedure is aborted and the biomaterial 23 is preferably withdrawn from the patient before it cures. As used herein, “malfunction” refers to ruptures, fractures, punctures, deformities, kinks, bends, or any other defect in the mold or a failure of the biomaterial injection system 1 that results in more or less biomaterial being injected into the patient than would otherwise occur if the system was operating as intended. Alternatively, if the malfunction occurs in a location other than the mold, such as in the delivery tube 11 or if the mold kinks and can not be deployed and expanded to fill the intervertebral disc space, or if the vacuum tube 11′ is obstructed an air in the mold 13 can not be evacuated, less biomaterial will be injected into the mold than is desired.
The controller 15 monitors one or more sensors 9 to determine if the injection conditions are under control. Some of the sensors 9 may also operate independently of the controller 15, such as for example a thermometer. If any one or a combination of the injection conditions are out of specification, a number of corrective actions can be taken. If the deviation from the preferred injection profile is minor, the controller 15 can attempt a correction. During a given medical procedure where the resistance to the flow of biomaterial 23 is essentially fixed, the primary mechanisms for controlling the injection conditions are 1) decreasing, increasing or reversing the drive pressure exerted on the reservoir 3 by the actuator 21; 2) releasing biomaterial 23 through one or more of the purge devices 7a, 7b; and 3) changing the temperature, and hence the viscosity, of the biomaterial 23.
If the deviation is outside a particular threshold, the controller 15 may signal the surgical staff. Alternatively, the surgical staff can monitor the displays 16 for any out of specification injection conditions. The displays 16 preferably highlight the injection condition(s) that have deviated from the preferred injection profile. In those instances where an injection condition is seriously out of specification, the controller 15 will signal that the procedure should be aborted and/or automatically abort the procedure. Typically, the actuator 21 will decrease or reverse the drive pressure on the reservoir 3 in anticipation of aborting the procedure. If the procedure is aborted, any biomaterial 23 in the mold 13 and/or the intervertebral space 19 is removed, either through the purge device 7b or manually by the surgeon. The mold 13 is also removed.
At the beginning of time sequence 81, the biomaterial 23 is immediately upstream of the purge device 7a. During time sequence 81, the biomaterial 23 begins to enter the purge device 7a. During time sequence 82, the biomaterial 23 is filling the purge device. The flow rate 72 is relatively constant and the total volume 76 of biomaterial continues to increase. The sudden increase of injection pressure 74 between the end of time sequence 81 and the beginning of time sequence 82 is the result polymer flow through a shunting valve into the purge device 7a. At time sequence 84, the biomaterial 23 fills the delivery tube 11. Injection pressure 74 increases due to resistance to the flow of biomaterial 23 through the delivery tube 11. At time sequence 91, the biomaterial 23 reaches the folded mold 13, resulting in a rapid increase in injection pressure 74 as the mold unfolds.
At time sequence 85 the biomaterial 23 begins to fill the mold 13. The slight drop in injection pressure 74 is the result of the biomaterial 23 flowing freely into the mold 13. The expanding mold 13 hits the inner wall of the annulus at time sequence 86. The flow rate 72 continues to drop and the total volume 76 of biomaterial 23 continues to increase at a generally constant rate. At time sequence 87, the injection pressure 74 of the biomaterial 23 continues to increase at a different rate as it displaces the vertebrae 17 and distracts the intervertebral disc space 19. The muscles and ligaments attached to the vertebrate 17 are stretched by the injection pressure 74 of the biomaterial 23 in the mold 13.
At time sequence 88, the threshold injection pressure 74 is reached. Time sequence 88 represents the maximum distraction of the intervertebral disc space 19. In the illustrated example, the drive pressure exerted by the actuator 21 on the reservoir 3 during time sequences 81 through 88 is generally constant. Once the injection pressure 74 at time sequence 88 is reached, a transition is triggered where the drive pressure at the actuator 21 is reduced from a first operating parameter to a second operating parameter. As a result, the injection pressure 74 is reduced. The flow rate 72 is about zero and the total volume 76 of biomaterial is at a maximum.
In another embodiment, once the injection pressure 74 at time sequence 88 is reached, a transition is triggered from a first operating parameter to a second operating parameter where the drive pressure at the actuator 21 is held constant for some period of time, such as for example 3-120 seconds. At the end of the dwell time, the drive pressure is reduced from the second operating parameter to a third operating parameter. Again, the injection pressure 74 is reduced and the flow rate 72 is about zero and the total volume 76 of biomaterial is at its final volume.
At time sequence 89 the drive pressure exerted on the biomaterial 23 in the reservoir 3 by the actuator 21 is reduced. This reduction can alternatively be achieved by releasing a portion of the biomaterial 23 through a purge device 7a, 7b. The pressure created in the intervertebral disc space 19 acting on the mold 13 is now greater than the injection pressure 74 of the biomaterial 23 in the biomaterial delivery system 1. Consequently, tension of the muscles and ligaments surrounding the vertebrate 17 provides a compressive force that results in a flow of biomaterial 23 out of the mold 13, as indicated by the negative flow rate 72 during time sequence 89 and a decrease in total volume 93.
At time sequence 90 the injection pressure 74 of the biomaterial 23 is typically constant. The pressure exerted by the mold 13 and biomaterial 23 is nearly in balance with the pressure exerted by the vertebrate 17 on the mold 13. The flow rate 72 and the change in total volume 76 are both about zero. With the system 1 now in stasis, the biomaterial 23 continues to cure. Once the biomaterial 23 is at least partially cured, the delivery tube 11 is removed.
In these embodiments, the biomaterial injection system 1 initially operates at a first operating parameter. When one of the injection conditions reaches a threshold level, such as for example a threshold pressure as measured in the mold 13, the controller 15 switches or transitions to second operating parameter. In an alternate embodiment, the threshold trigger could be flow rate, time, volume or temperature of the biomaterial. In the embodiment of
In another embodiment, the second operating parameter is a dwell cycle where the pressure is maintained at some predetermined level for a predetermined period of time. At the end of the dwell cycle, the controller switches to a third operating parameter, which may include reducing the pressure applied by the actuator 21 on the biomaterial 23 in the reservoir 3.
The relatively high injection pressure provides a number of benefits, including rapid filling of the mold 13 to reduce the chance of leaving voids or under-filled regions. The biomaterial injection system 1 continues to operate at the first operating parameter until one of the injection conditions reaches a threshold level that triggers use of the second operating parameter.
The injection pressure used to determine a suitable threshold typically corresponds to the distraction pressure brought about by the delivery of biomaterial 23 within the disc space 19. The injection condition in this instance is the injection pressure measured at the sensors 9c or 9d, such as for example about 80 psi to about 150 psi. In one embodiment, the injection pressure triggers the controller 15 to transition to the second operation condition. In another embodiment, the second operating condition holds the injection pressure at a predetermined level for a predetermined dwell time.
It is possible to measure the pressures discussed above using any of the sensors 9a-9d and 9g-9h. Doing so would require calibrating the biomaterial injection system 1 so that a measured pressure at one of the sensors 9 is correlated to the actual pressure in the intervertebral disc space 19, such as measured by sensor 9g or 9h. The factors required for such a calibration include the size of the mold 13, the resistance to fluid flow between the reservoir 3 and the mold 13, the flow rate, the viscosity and temperature of the biomaterial 23, the cure time of the biomaterial, and a variety of other factors. For example, with regard to mold size, the transition from the first operating parameter to the second operating parameter occurs when the injection conditions measured at the sensor 9b is about 100 psi to about 125 psi for a mold 13 with a volume of about 2 cubic centimeters; about 105 psi to about 130 psi for a mold 13 with a volume of about 3 cubic centimeters; and about 110 psi to about 135 psi for a mold with a volume of about 4 cubic centimeters.
Initially, the pneumatic actuator 21 is supplied with compressed air through the first pressure regulator 53. When one or more of the sensors 9a-9d detects a threshold pressure, the pressure control switch 51 selects compressed air from the second pressure regulator 55 to drive the pneumatic actuator 21. In one embodiment, the directional control valve 49 is a normally open, four-way valve such as those available under the trade name of Four-Way Valve (SV271) available from Omega Engineering, Inc. Stamford, Conn.
Mold Placement
In a related embodiment, the mold, or a kit that contains or is adapted for use with such a mold, can include tools adapted to position the mold 13 in situ. In one embodiment, the tool is a wire, such as for example the wire shown in
Optionally, and in order to facilitate the placement of the collapsed mold 13 within a sheath, the invention further provides a rod, e.g., a plastic core material or a metal wire, dimensioned to be placed within the mold 13, preferably by extending the rod through the conduit. Once in place, a vacuum can be drawn on the mold 13 through the air passageway in order to collapse the mold 13 around the rod. Simultaneously, the mold 13 can also be twisted or otherwise positioned into a desired conformation to facilitate a particular desired unfolding pattern when later inflated or filled with biomaterial. Provided the user has, or is provided with, a suitable vacuum source, the step of collapsing the mold 13 in this manner can be accomplished at any suitable time, including just prior to use.
In certain embodiments it will be desirable to collapse the mold 13 just prior to its use, e.g., when using mold materials that may tend to stick together or lose structural integrity over the course of extended storage in a collapsed form. Alternatively, such mold materials can be provided with a suitable surface coating, e.g., a covalently or noncovalently bound polymeric coating, in order to improve the lubricity of the surface and thereby minimize the chance that contacting mold surfaces will adhere to each other. In another embodiment, the outer surface of the mold 13 can be coated with a material that bonds to the inner surface of the nuclear cavity 24 in the annulus 25.
Biomaterials
The method of the present invention can be used with any suitable curable biomaterial such as a curable polyurethane composition having a plurality of parts capable of being aseptically processed or sterilized, stablely stored, and mixed at the time of use in order to provide a flowable composition and initiate cure, the parts including: (1) a quasi-prepolymer component comprising the reaction product of one or more polyols, and one or more diisocyanates, optionally, one or more hydrophobic additives, and (2) a curative component comprising one or more polyols, one or more chain extenders, one or more catalysts, and optionally, other ingredients such as an antioxidant, hydrophobic additive, dyes and radiopaque markers. Upon mixing, the biomaterial is sufficiently flowable to permit it to be delivered to the body and fully cured under physiological conditions. A suitable biomaterial also includes component parts that are themselves flowable at injection temperature, or can be rendered flowable, in order to facilitate their mixing and use. Additional discussion of suitable biomaterials can be found in U.S. patent application Ser. Nos. 10/365,868 and 10/365,842, previously incorporated by reference.
The biomaterial used in this invention can also include polyurethane prepolymer components that react in situ to form a solid polyurethane (“PU”). The formed PU, in turn, includes both hard and soft segments. The hard segments are typically comprised of stiffer oligourethane units formed from diisocyanate and chain extender, while the soft segments are typically comprised of more flexible polyol units. These two types of segments will generally phase separate to form hard and soft segment domains because these segments tend to be thermodynamically incompatible with one another.
Those skilled in the relevant art, given the present teaching, will appreciate the manner in which the relative amounts of the hard and soft segments in the formed polyurethane, as well as the degree of phase segregation, can have a significant impact on the final physical and mechanical properties of the polymer. Those skilled in the art will therefore further appreciate the manner in which such polymer compositions can be manipulated to produce cured and curing polymers with a desired combination of properties within the scope of this invention. In some embodiments of the present invention, for instance, the hard segment in the formed PU ranges from about 20% to about 50% by weight and more preferably from about 20% to about 30% by weight and the soft segment from about 50% to about 80% and more preferably from about 70% to about 80% by weight, based on the total composition of the formed PU. Other embodiments may be outside of these ranges.
The biomaterial typically includes a plurality of component parts and employs one or more catalysts. The component parts, including catalyst, can be mixed to initiate cure, and then delivered, set and fully cured under conditions such as time and exotherm sufficient for its desired purpose. Upon the completion of cure, the resultant biomaterial provides an optimal combination of properties for use in repairing or replacing injured or damaged tissue. In a further embodiment, the biomaterial provides an optimal combination of properties such as compatibility and stability, in situ cure capability and characteristics (e.g., extractable levels, biocompatibility, thermal/mechanical properties), mechanical properties (e.g., tensile, tear and fatigue properties), and biostability.
Many mixing devices and methods have been used for biomaterials having a plurality of parts such as bone cement and tissue sealant. Mechanical mixing devices, such as the ones disclosed in U.S. Pat. Nos. 5,797,679 (Grulke, et al.) and 6,042,262 (Hajianpour), have been used for bone cement mixing. These mechanical mixing devices, however, can take a long time to get thorough mixing and can be difficult to operate in sterile field, especially for biomaterials having a plurality of parts with short cure time. On the other hand, some prior art two-part polyurethanes have a gel time of about 30 minutes. Without a proper seal method to seal off the delivery tube, a cure time of 30 minutes can be too long for operating room use.
It is important that mixing of the biomaterial occurs quickly and completely in the operating room in a sterile fashion. Biomaterial with induction times of less than 60 seconds and cure times of less than 5 minutes require a different mixing and delivery device than biomaterials of about 15 minutes of cure time. For biomaterial having two-part issocyanate-based polyurethane biomaterials, due to the sensitivity of NCO to OH ratio to the final properties of the cured biomaterial, there are several features that are important to the final properties of the in situ cured biomaterial. Several factors appear to have an impact on the in situ curable biomaterial mixing and delivery such as the number of mixing elements, purging of the initial volume from the static mixer and the effect of polymer flow during delivery using a static mixer.
The compatibility of the biomaterial can also be achieved by having more than the traditional two parts, e.g., three or more parts, and mixing them all together prior to polymer application. By storing the incompatible components in different cartridges and/or preconditioning each component according to individual requirements, it often can minimize the concern of component incompatibility. One example of a three-part biomaterial is to separate the polyol and chain extender in a two-part biomaterial.
In situ curability is largely dependent on the reaction rate, which can be measured by induction time and cure time. In general, fast cure (short induction time) will improve in situ curability by providing more complete polymerization, less leachable components, and better mechanical properties (e.g., less “cold layer” formed due to the cold surface of the implant). However, induction time should also be balanced with adequate working time needed for biomaterial injection, distraction, to provide enough time to access the injection conditions, identify if the injection conditions fall inside or outside an acceptable range, and if falling outside the acceptable range, halting or reversing the injection process.
Particularly for use in the disc, it has been determined that shorter induction times tend to provide improved biomaterial properties. For such uses, the induction time can be between about 5 and about 60 seconds, for instance, between about 5 and about 30 seconds, and between about 5 and about 15 seconds. By comparison, the total cure time for such biomaterial can be on the order of 5 minutes or less, 3 minutes or less, and one minute or less. In one embodiment of the present invention, however, the cure time can be on the order of about 15 minutes. In either case the cure time can be greater than 15 minutes by adjusting the amount of catalyst used.
The method of the present invention can be used for a variety of applications, including for instance, to provide a balloon-like mold for use preparing a solid or intact prosthesis, e.g., for use in articulating joint repair or replacement and intervertebral disc repair. Alternatively, the method can be used to provide a hollow mold, such as a sleeve-like tubular mold for use in preparing implanted passageways, e.g., in the form of catheters, such as stents, shunts, or grafts.
The present invention also provides a method and system for the repair of natural tissue that involves the delivery of biomaterial using minimally invasive mechanism, the composition being curable in situ in order to provide a permanent replacement for natural tissue. Optionally, the biomaterial is delivered to a mold that is positioned by minimally invasive mechanism and filled with biomaterial composition, which is then cured in order to retain the mold and cured composition in situ.
As can be seen, the annular shell can itself serve as a suitable mold for the delivery and curing of biomaterial. Optionally, the interior surface of the annular shell can be treated or covered with a suitable material in order to enhance its integrity and use as a mold. One or more inflatable devices, such as the molds described herein, can be used to provide molds for the delivery of biomaterial. The same inflatable devices used to distract the joint space can further function as molds for the delivery and curing of biomaterial.
The method of the present invention can also be used to repair other joints, including diarthroidal and amphiarthroidal joints. Examples of suitable diarthroidal joints include the ginglymus (a hinge joint, as in the interphalangeal joints and the joint between the humerus and the ulna); throchoides (a pivot joint, as in superior radio-ulnar articulation and atlanto-axial joint); condyloid (ovoid head with elliptical cavity, as in the wrist joint); reciprocal reception (saddle joint formed of convex and concave surfaces, as in the carpo-metacarpal joint of the thumb); enarthrosis (ball and socket joint, as in the hip and shoulder joints); arthrodia (gliding joint, as in the carpal and tarsal articulations); and facet joints.
Implant Procedure
An illustration of the surgical use of one embodiment of the intervertebral prosthesis system of the invention is as follows
Patents and patent applications disclosed herein, including those cited in the Background of the Invention, are hereby incorporated by reference. Other embodiments of the invention are possible. It is to be understood that the above description is intended to be illustrative, and not restrictive. Many other embodiments will be apparent to those of skill in the art upon reviewing the above description. The scope of the invention should, therefore, be determined with reference to the appended claims, along with the full scope of equivalents to which such claims are entitled.
The present application claims the benefit of U.S. Provisional Application Ser. No. 60/636,777 entitled TOTAL NUCLEUS REPLACEMENT (TNR) METHOD filed on Dec. 16, 2004; the present application is also a Continuation-in-Part of U.S. patent application Ser. No. 10/984,493 entitled MULTI-STAGE BIOMATERIAL INJECTOR SYSTEM FOR SPINAL IMPLANTS filed on Nov. 9, 2004 and U.S. patent application Ser. No. 10/984,566 entitled MULTI-STAGE BIOMATERIAL INJECTOR SYSTEM FOR SPINAL IMPLANTS filed on Nov. 9, 2004, both of which claim the benefit of U.S. Provisional Application Ser. No. 60/555,382 entitled MULTI-STAGE BIOMATERIAL INJECTION SYSTEM FOR SPINAL IMPLANTS filed on Mar. 22, 2004, all of which are hereby incorporated by reference.
| Number | Date | Country | |
|---|---|---|---|
| 60636777 | Dec 2004 | US | |
| 60555382 | Mar 2004 | US | |
| 60555382 | Mar 2004 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 10984493 | Nov 2004 | US |
| Child | 11304053 | Dec 2005 | US |
| Parent | 10984566 | Nov 2004 | US |
| Child | 11304053 | Dec 2005 | US |
