CA2208848A1 - Nerve deflecting conduit needle and method - Google Patents
Nerve deflecting conduit needle and methodInfo
- Publication number
- CA2208848A1 CA2208848A1 CA002208848A CA2208848A CA2208848A1 CA 2208848 A1 CA2208848 A1 CA 2208848A1 CA 002208848 A CA002208848 A CA 002208848A CA 2208848 A CA2208848 A CA 2208848A CA 2208848 A1 CA2208848 A1 CA 2208848A1
- Authority
- CA
- Canada
- Prior art keywords
- conduit
- surgical
- disc
- distal
- distal tip
- Prior art date
- Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
- Abandoned
Links
Classifications
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/34—Trocars; Puncturing needles
- A61B17/3417—Details of tips or shafts, e.g. grooves, expandable, bendable; Multiple coaxial sliding cannulas, e.g. for dilating
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/32—Surgical cutting instruments
- A61B17/320016—Endoscopic cutting instruments, e.g. arthroscopes, resectoscopes
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/02—Surgical instruments, devices or methods, e.g. tourniquets for holding wounds open; Tractors
- A61B17/0218—Surgical instruments, devices or methods, e.g. tourniquets for holding wounds open; Tractors for minimally invasive surgery
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/16—Bone cutting, breaking or removal means other than saws, e.g. Osteoclasts; Drills or chisels for bones; Trepans
- A61B17/1662—Bone cutting, breaking or removal means other than saws, e.g. Osteoclasts; Drills or chisels for bones; Trepans for particular parts of the body
- A61B17/1671—Bone cutting, breaking or removal means other than saws, e.g. Osteoclasts; Drills or chisels for bones; Trepans for particular parts of the body for the spine
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/34—Trocars; Puncturing needles
- A61B17/3401—Puncturing needles for the peridural or subarachnoid space or the plexus, e.g. for anaesthesia
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/00234—Surgical instruments, devices or methods, e.g. tourniquets for minimally invasive surgery
- A61B2017/00238—Type of minimally invasive operation
- A61B2017/00261—Discectomy
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/00234—Surgical instruments, devices or methods, e.g. tourniquets for minimally invasive surgery
- A61B2017/00349—Needle-like instruments having hook or barb-like gripping means, e.g. for grasping suture or tissue
Abstract
This invention relates to devices and methods for accessing the spinal epidural space via the neural foramen. In one aspect of this invention, a deflecting conduit needle device (10) is disclosed having an elongated body extending substantially along a first axis. The device has a proximal end and a distal end (12), and a transverse conduit (18), positioned along the distal one-eigth of the device and extending substantially along a second axis, wherein the second axis is positioned at an acute angle relative to the first axis. In another aspect of the invention, a method is disclosed for accessing the spinal epidural space via the neural foramen.
Description
NERVE DEFLECTING CONDUIT NEEDLE AND METHOD
FIELD OF THE INVENTION
This invention relates to surgical tools and methods for back surgery. In particular, this invention relates to methods and devices for a~P7,:-g the neural foramen in patients having a disc herniation or in patients with 5 nerve root pain emanating from a vertebral foramen.
BACKGROUND OF THE INVENTION
There are a variety of pathological conditions which require surgical intervention in and around the spinal epidural space. The most common of these is in~ .lu~,dl disc herniation. Other conditions which require surgical intervention in and around the epidural space include, but are not limited to, foramenal stenosis, tumor excision~0 procedures including excision of neurofibromas, meningiomas, and the like, and procedures involving nerve root blocks.
The neural foramen provides an entry port into the epidural space. The foramen is ~ ,ull.~LHbEd by the pedicles of adjacent vertebral bodies and the floor of the foramen is formed from the annulus of a disc positioned between adjacent vertebra. Disc hell~;d; -s extend from the anterior surface of the epidural space, extending into the space or out of the neural foramen. There are currently three major routes for accessing herniated disc tissue:~5 laminectomy and hemilaminectomy procedures, anterior approaches and F~ ulal-c,dl approaches.
Laminectomy and hemilaminectomy ,..~ du,c~ are some of the more common procedures for treating herniated discs. These procedures allow direct access to the epidural space through the removal of all, or a portion, of the adjacent lamina (i.e. the posterior vertebral surfacel to expose the nerve root and the disc herniation. These procedures are tedious and involve extensive ~;,se.liun and surgical manipulation as~oLiàl~d with the required bone excision. An added complication of these l~.uc6du~cs iS the threat of spinal instability resulting from excess bone removal.
In the p~ ulalcldl approach for accessing herniated disc tissue, exemplified by U.S. Patent 4,573,448 to Kambin, the patient is poC;ti .Pd in a lateral decubitus or in a prone position. In this method, ;Il~Llu,llcllls are illllLd 7r~ into disc tissue at an angle of ~,~ UAillldll,lt 35~ relative to the mid-sagittal plane of the patient (the longitudinal plane running perpendicular to the spine). Here, attempts are made to indirectly access the herniated tissue by entering disc tissue and excavating to the site of the 1~ I,;ali~a. Entry is complete when the surgical tools are positioned within the disc tissue anterior to the spinal epidural space. Once in position, the surgeon -cu~uaYàl-c~
through the disc tissue, at approxi",alu'y a 60~ angle, p~: iurly, to the site of the herniation and removes the herniation from inside the disc, without entering the epidural space.
The Kambin procedure can be ,c~.~u""~d using one or two incision sites and requires steerable tools and angulated scopes. Because the method necessarily involves excdYalia,1 of the disc tissue, there is ~;y"i~i..anl ..Jt;.al to keep the c~uaYalio;l as narrow as possible. The narrow opening requires ~u~ e~;.c entry and removal of . 1L 1~ equipment and e-,uàvdlu,~ thereby i"~, ca~;"g the length of time of the surgical I uCc6J~ c. Normal disc tissue is d : ."ed and removed in this technique with the added complication that the surgeon cannot ~ IlAmPGk;l~
35 view the area to be excised while ~-,LaYali~n is taking place. The suryeon is also unable to see into the epidural CA 02208848 l997-06-26 W O96/21395 . PCTrUS96/00394 space where the actual pathology lies unless a second incision on the opposite side of the spine is used, thereby permitting simultaneous visualization and excision of disc tissue.
U.S. Patent 4,638,799 to Moore details a needle guide apparatus for positioning surgical instruments suitable for disc cher~ ~ via a posterolateral approach. Like Kambin, Moore also contemplates indirect entry 5 disc tissue to correct a disc defect. The needle guide fixes the angle of entry into disc tissue with preferred entry angles ranging from 45~ to 55~. Neither Kambin nor Moore discloses a method for entering the spinal epidural space.
Anterior approaches to correct ;.lt~ S.al disc herniation are generally an improvement over the post~ al approach because the target herniation is in line with the entry port. As a result, the herniation is 10 easier to visualize from within the disc tissue. However, anterior approaches typically require extensive insu~
of the p .i ' space. Where in~uilldliu.. is not employed, entry into the p, - m is complicated by the inherent risk that bowel or ureter tissue could be injured and such injury to the bowel can result in life threatening sequelae.
Like the Kambin approach described above, the anterior approach also requires that the surgeon remove intact, normal disc tissue to get to the area of the herniation while the surgeon works from inside the disc space and the anterior 15 approach does not permit direct visualization of the epidural space where the pathr' ~,y lies. Therefore there remains a need in the medical arts for a surgical method and device which permits direct access and visualization of the epidural space without requiring extensive removal of bone or disc tissue.
In the aforementioned methods, there is the potential for con, ' : resulting from the length surgery, patient recovery time and the risk of complications during the surgical ~...ce' ~. Patient recovery time is further 20 extended when the patient is of an advanced age. Since disc herniation is a degau~dL;~ pathology, it is not .,.. A~.6~,ldd that the majority of hldNid~.31s with disc herniations or other back cr , ' lions requiring access to the IL.~ ..dl space are of advanced age. For elderly patients, increased surgical time, generai ~ne~lh~ and spine destabilization resulting from bone removal can all increase patient recovery time. Thus, there is a need for a surgical method that decreasing the length of surgery and reduces the length of patient recovery.
SUMMARY OF THE INVENTION
The methods and devices of the present invention facilitate access to the epidural space via the neural foramen without disturbing the integrity of the nerve roots and spinal dura while working with and around the anatomical features of the lateral surfaces of the spinal column. Unlike the above described prior art i ' , ~s, 30 the methods and devices of the present invention are designed to gently deflect the neural roots away from the lu. ~' space.
In one aspect of this invention, a deflecting conduit needle device is dicrlose~l The device ~.~le,abl~
embeds in disc tissue adjacent to the neural foramen assûc.~l~d with the spinal defect. The anchored device provides a conduit to connect the ~ ,iloneal space with the spinal epidural space. In one embodiment, the 35 device includes a transverse conduit through which see ' y surgical i~ ull~ aliùn is h~llùdu~.~d at an angle to directly access the anterior surface of the epidural space. In this embodiment the sum of the angle of insertion of CA 02208848 l997-06-26 W O96/21395 PCTrUS96/00394 the d~ Lli"g conduit needle device and the angle of the transverse conduit relative to the longitudinal axis of the device is at least 70~.
In a second embodiment of the deflecting conduit needle device, the device forms a hoilow sleeve along the longitudinal axis of the device allowing secondary surgical instrumentation to be introduced into the hollow sleeve 5 and exiting at the l,a"~ e conduit adjacent the neural foramen.
In another aspect of the invention, the deflecting conduit needle device is modified to function as a radially expanding dilator. This modified device is equipped with a central needle guide and an expandable sleeve. Again, the device may be formed with a transverse conduit andlor as a hollow sleeve exiting at the location of the transverse conduit adjacent the relevant neural foramen.
In yet another aspect of the invention, the device is modified as a "peel away" catheter and includes an outer peelable sleeve.
The invention also relates to a method for directly accessing the epidural space via the neural foramen.
In one embodiment, the method includes arc~Ps~ a the space using one of the disclosed d~ LIi..~, conduit needle devices and in another embodiment, the method provides direct access to the epidural space via the neural foramen.
15 In one preferred method, the il 'ILCI;IIY conduit needle device is positinnPd, based on an anterior fluoroscopic view, lateral to the medial aspect of the pedicle base and is F ~i ' such that it abuts a line defined by the posterior aspect of the vertebral body and the disc based on a lateral fluoroscopic view. The device is embedded into the disc tissue at its distal tip and rotated about 45~ to deflect the nerve root extending from the neural foramen and to align the tlall~,G.~e conduit of the device with the neural foramen. See d y surgical instn.",~ is 20 ;~ udul,ed through the ll~ e conduit to access the epidural space via the neural foramen.
BRIEF DESl.~lrllON OF THE DRAWINGS
Fig. 1 is an anterior view of the distal portion of a preferred embodiment of the ;1~ , conduit needle of the present ;..~,,liun, Fig. 2 is a lateral view of the distal portion of a preferred embodiment of the deflecting conduit needle of 25 the present i.l.~ iu,l;
Fig. 3is a posterior view of the distal portion of a preferred embodiment of the deflecting conduit needle of the present ;..~,~..liull, Fig. 4 is a cross-section of a vertebra illustrating the p~: ~, of the device in a method of using the d~lel,li.l3 conduit needle of Fig. 1;
Fig. 5 is a cross-section of a vertebra illustrating the nerve deflecting step in the method of using the d~ l,lillg conduit needle of Fig. 1;
~ Fig. 6 is a cross-section of a vertebra illustrating the d~ lillg conduit needle of Fig. 1 pc- -ed in disc tissue;
Fig. 7 is a cross-section of a vertebra illustrating the deflecting conduit needle of Fig. 1 F~~ ' to 35 receive surgical ;Il;,llulll~ i to access the posterior surface of the lo~' space;
W O96/21395 PCTnUS96/00394 Fig. 8 is a lateral view of the vertebral column with surgical instrumentation positioned in the transverse conduit of the device of Fig. 1;
Fig. 9 is a cross-section of a patient mid-section with the deflecting conduit needle in place;
Fig. 10 is a lateral view of a du~ y conduit needle dilator embodiment; and Fig. 11 is a flow diagram illustrating a preferred surgical method according to this invention.
DETAILED DESCRIPTIOH OF THE INVENTION
The present invention relates to a method and a deflecting conduit needle device for c), -cting the ,~1,1.,,~. ' space to the spinal foramen, and in particular for accessing the anterior and lateral portions of the spinal epidural space.
The terms "spinal foramen", "neural foramen" and f~ .. ,.. al space" are used interchangeably Ihl. g~1LL
this document.
The term "entering" is used herein to include any surgical technique for accessing an internal body space in a patient through a surgically created opening. Thus, the term "entering" includes the use of incisions, punctures, or the like.
The device and method of the present invention have a variety of surgical applications. Not only is the device suitable for treating disc ~ Idd~ , but it may be used to directly treat foramenal stenosis, excise nerve tumors, or to perform diagnostic nerve blocks. As one embodiment of this invention, a d~.le~ y conduit needle device is employed to gently deflect the nerve root away from the neural foramen formed between adjacent vertebral pedicles while simultaneously i..."~as;"g the angle of entry into the foramenal space to between 70~ and 90~ and 20 more p,~ieldLly between 75~ and 80~ relative to the mid-sagittal plane of the patient while employing a relll pr i a ' approach.
Referring to Fig. 1-3, the preferred deflecting conduit needle device of this invention has a ;,ub~ldllli~lly elongate body 10 which includes a proximal end and a distal end, with the proximal end closest to the surgeon and the distal end positioned adjacent to the neural foramen. The elongate body 10 extends S~h lly along a first 25 axis laxis A). The body of the device may be substantially "y; ' h,dl or it may have a variety of other cross-sectional shapes. Further, the shape of the d ~l~cli"g conduit needle device, while ~ubal~ 'ly elongate, may optionally be provided with a variety of out-pouchings, curves, or the like.
In a preferred embodiment of the invention, the distal portion of the device terminates in a pointed tip 12.
The tip is sufficiently sharp to permit the device to puncture the annulus fibrosis of the disc in question. The device 30 has, at its distal end, an anterior and a posteribr face. Fig.1 diagrams the anterior face of the device. As is readily appreciated from Fig. 1, the pointed tip 12 widens slightly, ~ bly reaching the full circumference of the device within the distal one eighth of the length of the device and more ,.,~e,~ bl~ within the distal three c~lllilllel~r~ of the device.
Referring now to Fig. 2 and to Fig. 3, in a preferred embodiment of the device, the posterior surface of 35 the distal end of the device is bevelled relative to the anterior surface. This bevelled surface 14 is p,e~ldbly a continuous surface with smooth rounded edges, unlike a needle used for ~,. , . lul~. The bevelled surface 14 CA 02208848 l997-06-26 W O 96/21395 PCT~US96/00394 widens from or adjacent to the tip 12 to a heel 16 located at the proximal end of the bevelled surface 14. The preferred contour of the bevelled surface 14 can be readily appreciated from the lateral view of the distal portion of the device, illustrated in Fig. 2.
In this preferred embodiment, the elongate body of the device 10 includes a transverse conduit 18 extending 5 through the device. The conduit traverses the elongate body 10 at substantially a second axis (axis B) relative to the first axis (axis A) of the elongate body, such that an acute angle (~) is formed between the first axis and the second axis. The acute angle is, ~1~. hl~ between 25~ and 55~ and more, ~ ,bl~ between 30~ and 40~ with a preferred angle of about 35~. However, even those of ordinary skill in the art will recognize that the transverse conduit 18 within the elongate body 10 can be F~ e~ at a variety of angles relative to the axis formed by the 10 elongate body and that the ultimate angle of the conduit 18 will depend on the preferred angle of entry of the device relative to the mid-sagittal plane of the patient. Preferably, the sum of the angle of introduction of the device relative to the mid-sagittal plane of the patient and the acute angle formed between the first axis and the second axis is at least 70~.
To continue, the conduit 18 traverses the elongate body within a range of distances as measured from the 15 distal tip of the apparatus. In a preferred embodiment, the conduit is pcl ' within the distal one-eighth of the device and in another embodiment, the conduit is positioned within four centimeters from the tip and is ~ ,dLly positioned proximal to the bevelled surface 14 and adjacent to the heel 16 of the bevelled surface 14 of the device.
In one embodiment of this invention, the ' g l~d body of the device is hollow along its longitudinal axis with the hollow interior cannula 30 portion communicating with the l,dn~ .ae conduit 18 as illustrated in Fig. 10c.
20 In this embodiment, the device forms a hollow sleeve such that the proximal end of the device forms a first opening and extends through the device l~ ly at the conduit 18. Thus, surgical i"~l",."~..ls can be i"ll"d~.ced through the conduit 18 or through the hollowed proximal portion of the device and in both inct~nre~, the ;,,~I,u,,,e,,l~ exit the conduit 18 from the anterior surface of the device.
In a preferred embodiment of this invention the effective length of the elongate body 10 of the device is 1 ~ dbly between 10 cm and 45 cm in length. The d~ y conduit needle device can be held by the surgeon or; ,~ throughout the surgical ~loc6dul~, or the device can be mounted or stabilized on a surgical stand, or the like. Moreover, while a pOSt~lOI~eidl approach is p,~ disclosed in Example 1, those skilled in the art will recognize that the disclosed device could be readily employed in surgical procedures using other surgical ap~JIuabhes.
Therefore, the length of the device will vary depending on how it is employed in a particular surgical procedure.
Where the device is held by the surgeon in a posterolateral procedure, the d~ cli"g conduit needle device is ,dLly between 17 cm and 21 cm"in one embodiment length, and in another preferred embodiment, the defl~LLill3 conduit needle device is between 25 cm and 31 cm in length.
The cross sectional dimensions of the device will also vary, with the overall width of the device depending on whether or not the device forms a hollow sleeve for the ;~lluluclh~ of surgical tools to the disc site or whether the device is solid and lacking an accessible longitudinal sleeve. For deflecting conduit needle devices without a W O96/21395 PCTrUS96100394 central accessible hollow sleeve, the device will, ~, SI) have a cross-sectional dimension of between 4 mm to 10 mm and preferably between 8 mm to 10 mm.
The transverse conduit 18 is positioned to accommodate instrumentation suitable for performing the types of surgical techniques which require access to the anterior and lateral portions of the spinal epidural space. Thus, 5 the l,On~ e conduit 18 will be suitable to accommodate e 1~ lprs, trocars, rongeurs, cannula sleeves, arthroscopic shaver blades, suction devices, cauterizing tools, and the like. In a preferred embodiment, the transverse conduit 18 has a cross-sectional dimension of at least 2.0 mm and p.~ between 5 mm to 9 mm. Where the elongate body 10 is cylindrical, the transverse conduit will preferably have a cross sectional dimension of 0.5 mm to 2.0 mm less than the cross-sectional dimension of the elongate body 10. In this preferred embodiment, the 10 I,d"~ e conduit, like the shape of the elongate body 10, is s ~h~ ; Jly cylindrical; however, the ll~
conduit, like the cross-section of the elongate body, may also have a variety of other shapes. Thus, where the cross sectional shape of the device is circular, an oblong conduit will be useful for maximizing the working space for a~re"i~ g the spinal epidural space via the neural foramen.
The d~ li.lg conduit needle device can be prepared from any number of materials well known in the 15 surgical arts. These include, for example, surgical steel, other suitable surgical alloys, TEFLON~, or related materials, or thermoplastic polymers including pol~ , pQl~ ar!, polyvinylchloride, silastics or the like, including other materials which can be sterilized for surgical use. Those skilled in the art of surgical device C~LII.I~ will be able to select a suitable material.
Fig. 9 depicts a mid-section of a patient with a deflecting conduit needle device 10 in place. In a preferred 20 method of this invention, the patient is pDit-~ed in a lateral position and the p~,i r-u~ is hl~ laled as illustrated in Fig. 9. Minimal bl;~ ldl through an ;..;,ur~i port 46 into the retro p~.iloneal space 48 is p.~rubly used to retract the pe,ito"~.J", 34 containing the bowel 36. Those skilled in the art will recognize that the extent of ~ ~ldi needed to access the spinal foramen will vary between patients. Thus, Fig. 9 is illustrative and is not intended to demonstrate the extent of insuiildlion required to perform the claimed technique.
Once ;"~u~ldlion is completed, puncture or incision is made in the I~Ll~,p.. ilo"~u",. The preferred entry position of the dt il~li"g conduit needle device 10 is illustrated, relative to the patient mid section in Fig. 9. Fig.
4 illustrates the preferred angle of entry and position of the device as it approal.l,ds the spinal column. ~l~ie,dbly, the d~ .,i O conduit needle device 10 is inserted through a ~ p ilol,eal pelcut_ ee- puncture and advanced toward the foramenal space in need of surgical ;.,t~ Using fluoroscopy, and referring to Fig. 4, the distal tip 12 is guided toward the disc space in need of surgical ;"le,~ ,l;Jn. The device tip 12 is p,~e,.,bly pos;li.,1e~
based on an anterior view, lateral to the medial aspect of the pedicle base. Based on a lateral view, the needle tip is pc~ d such that it abuts a line defined by the posterior aspect of the vertebral body and the disc. The posterior surface of the device, as illustrated in Fig. 3, faces rostrally as the device moves into position. Oncé in position, pressure is applied to the distal tip 12 which is su~ sharp such that the device is ~ ' ed('c ' in the disc annulus. Care is taken such that the device impales the disc annulus without damaging adjacent nerve roots as~oc;al~d with the neural foramen. The angle of entry and the angle that the device is e,~ l e~dFd into the disc W O96/21395 PCTrUS96/00394 annulus relative to the mid-sagittal plane C, as shown in Fig. 9, is important to facilitate easy access to the epidural space via the neural foramen. Preferably, for lumbar procedures, the device is positioned at a 35~ to 55~ angle relative to the mid-sagittal plane of the patient.
As illustrated in Fig. 5, once the deflecting conduit needle device 10 is embedded in the disc annulus, the device 10 is gently rotated about 45~ clockwise if treating the right side of the patient and 45~ counterclockwise if treating the left side of the patient. The rotation of the heel 16 of the bevelled surface 14 gently deflects the nerve root 44 away from the foramenal space, permitting easier and safer access to the foramenal space and aligns the transverse conduit 18 with the neural foramen. The position of the device following rotation is provided in Fig.
6. The deflecting conduit needle device 10 is now in place, connecting the loll~, ~' space with the spinal epidural space.
Next, referring to Fig. 7 and 9, secondary surgical instrumentation 20 suitable for performing the di~.,Ecl~..,.~
or other procedures assoL;dll!d with accessing the spinal foramen are introduced either using the same incision or through a second incision site 42 through the l~a.~ a conduit 18 and into the ~ .al space and ~ule~O~l~.bl~ into the anterior and lateral portions of the spinal epidural space. A secondary puncture is, OPo~ introduced into the patient along the flank. First, a fluoroscope grid is positioned on the flank to align the puncture site with the conduit 18. Once the angle of entry is identified, secondary surgical instrumentation, including initially, a needle or canula are introduced through the puncture to the conduit 18. Electrical stimulation is, ~ofol.,bly employed to ensure that the nerve root 44 has been deflected away from the foramen before the secD~' y instrumentation 20 fully engages the transverse conduit 18.
Once the needle is in place, a canula can be dropped over the needle and slidably pe s~d adjacent the foramen. Secondary surgical ;"~II",llo,lldliun required to perform the discectomy or other surgical procedures are advdllldy~ s~ through the canula. The lld,)sl,O,~a conduit serves as a guide for maintaining an angle suitable for a~eC-: y the spinal epidural space via the neural foramen. An OAO~,ulaly detailed surgical method employing the device of this invention is provided in Example 1.
Fig. 8 provides a lateral view of the device 10, in position, with the nerve root deflected with the device 10 receiving secondary surgical instrumentation 20 such as a cannula or P~drscere suitable for use with other surgical instruments such as suction punches, rongeurs, and the like. While this method uses two entry sites, it is also ~ ~u ~ u d that one entry site can be used in some cases. For example, it is possible with the use of fluoroscopy, real time imaging with ultrasound, magnetic ,esonance imaging guidance or computerized axial tomographic guidance to directly access the epidural space through the neural foramen without the deflecting conduit needle device. A single entry site procedure can also be performed using the d 301~ 9 conduit needle device 10.
For a single entry site p~ocEd~.~O the do~l~o~ y conduit needle device is lu~O~O~ hollow from the proximal end to the transverse conduit 18 such that secD~' y surgical ;.,;,II~ HI;~n 20 can be inserted through the hollow p~ P~. . u, and exit through the lldll~lc.~a conduit. In this embodiment, steerable surgical equipment guided through 35 the length of the body 10, out the l,,.~,O.~a conduit 18 and into the epidural space via the neural foramen.
W O96121395 PCTrU~96/00394 An important benefit of the present device, as compared with the prior art, is that the device provides a method of i"c.~a~ , the angle of entry into the foramenal space from what is disclosed to at least 700, without requiring extensive retroperitoneal insufflation. -The angular position of the deflecting conduit needle device 10 relative to the mid sagittal plane of the patient and the angle of the transverse conduit, in combination with nerve 5 deflection, provides a substantially lateral approach for discectomy. The technique is minimally invasive while providing direct visualization of the site in need of surgical intervention.
In another modification of the deflecting conduit needle device, the device includes a blunt distal tip, as shown in Fig. 10c. In this embodiment, the device is not embedded in disc tissue, rather the device is brought into position and held in place by external supports such as the support disclosed in U.S. Patent No. 4r638r799 to Moore.
10 Al~ la~ ly, the device can be held in place by the physician or surgical a::
It is further re: mp'~ted within the scope of this invention that the L~lbrr,li..,J conduit needle device can be modified to function as a dilator. Tools for dilating the access site during a surgical ~JIuLeùu~e are well known in the art. One such tool is a radially expanding dilator (RED). This type of device is disclosed in U.S. Patent Nos.
5~312~360 and 5~275~611 to Behl which are both hereby incu.~ dted by reference. Such devices are suitable for 15 enlarging ~ , OL penetrations in body cavities and include elongate guide members and at least one elongate dilatation member. The central portion of the guide member is removed once the device is p ~inned within a body cavity and a unitized dilator is i.~l,udùced to widen the cross-sectional diameter of the device. This permits surgical in~ ",enl,-~lion to be ;..l~ d through the device to facilitate the surgical procedure while minimizing the inv i~"n is of the I~IUC6r.~UI~.
The d~ "~li"g conduit needle dilator embodiment of this invention can be used in assoc;aliun with the first puncture or all~,l"rJLi~al~, the dilating needle can be employed in the second step to facilitate introduction of surgical i.~sl~l..llouldliun through the conduit 18. Referring to Fig. 10a, in the first dilation embodiment of this device, the device has a proximal end and a distal end and comprises a central needle guide 22r an elongate d~ illg dilator 24 and an ~ -r 1n~l ~1 outer sleeve 26~ The e .r I " outer sleeve 26 may be prepared from a variety of materials 25 known in the art, including but not limited to rubber, heat-stable polymers, or woven sleeves prepared from poiymers or other suitable material. Other suitable materials are disclosed in U.S. Patent Nos. 5r312r360 and 5~275~611 to Behl. The elongate d~ ,.,li"y dilator optionally cu,,,~ as a l, l~.c.~econduit 18, a hollow interior cannula 30 and a r;~ cli..g heel 32 with a bevelled surface 33 po~ d between the distal end and the heel 32. The hollow interior cannula 30 is just wide enough at the distal terminus to accommodate the central needle guide. The 30 ll~n;~vr,~ a conduit 18 traverses the dpp~lolu5 and is pe 9~ along the distal c..c ci~lllll of the device. The hollow interior cannula 30 is - ~e,ably wide enough at the proximal end to 3reGIl ,rnrlOle both the central needle guide 22 and steerable surgical tqu;~"",,"l including ~ I y surgical i.,~"~ r,ls 20r such as endoscopes trocars, ,al II"~s ~ shavers, rongeurs and the like, and the cannula 30 ,,..,, 0,~, ' ly con :-te~ with the ll ,3n~v, ~ ~a conduit 18 such that surgical equipment i..lluduc~d at the proximal end of the device can be passed down the cannula 30 35 and exit at the llau~ a conduit 18.
W O 96/2139~ PCTrUS96/00394 .9.
During use the central needle guide 22 with the expandable sleeve 26, is introduced into the patient using the procedures disclosed in Example 1. The needle 22 impales the disc annulus at a position medial to the exiting nerve root. Once positioned within the disc annulus, the elongate deflecting dilator 24 is pc ,i~ir-~d over the central needle guide 22, within the expandable outer sleeve 26 as illustrated in Fig. 10b. In this embodiment, the elonyate 5 deflecting dilator serves to expand the diameter of the expandable outer sleeve from within. This type of ~ n is safer for the nerve root. Once in place, the device, can be rotated 45~ to deflect the nerve root. The central needle guide 22 is removed, as illustrated in Fig. 10c, and instruments are introduced down the central longitudinal axis of the dilator using a steerable ~ 'a ~pr If it is impossible to access the epidural space by this route, the surgeon can make a second puncture in the flank of the patient and introduce surgical instrumentation through the 10 transverse conduit 18, into the epidural space via the neural foramen.
In a second dilator embodiment, the dilator is introduced through the transverse conduit 18 of the d 'l~ lg conduit needle device 10, as illustrated in Fig.1. In this embodiment, a probe rather than the needle guide 22, is inserted with an L--r ' ' ' sleeve 26 through the second puncture, in line with the l~all~.~r~d conduit and pc~ ned adjacent to the neural foramen. Once in position, the dilator is introduced within the r n~ sleeve and the 15 probe is removed. This serves to gently increase the cross-sectional diameter of the device to provide greater access to the epidural space with minimal inv- .L..~ESS.
The devices of this invention can also be modified as a "peel away" catheter. "Peel away" calhc~l~cls are known in the art such as those described in U.S. Patent No. 4, 581,025 and are available from Cook Group Company (PEEL-AWAY~ catheter, Bloomington Indiana) or from Boston Scientific CGI,~: dliUn (BANANA PEEL~, Medi tech, 20 Boston Scientific Cor~ ~lldGon, Vl~'dlcl lU~ - ' LI:i).
In this embodiment, the secondd,y surgical instrumentation is a "peel away" cannula, iulluduced through lldlls~,c~ae conduit 18. The "peel away" portion of the device is an outer sleeve which can be peeled away. The sleeve forms a cannula. A needle is aligned with the transverse conduit 18 of the de~lel,lillg conduit needle device 10 which is anchored within the disc annulus. Once the needle is in place, the "peel away" sleeve and inner stylet 25 are slidably pc,;li~ ~ed over the needle. The needle is retracted and ~ u~Ostopcs and other surgical illsl~ulu6rlldlion are introduced through the sleeve. If needed, the sleeve can be peeled away as is provided in either the PEEL
AWAY~ or the BANANA PEEL~ sleeves disclosed above.
Methods for preparing these modified embodiments will be readily apparent to those skilled in the art in view of this d;.~.h~3~..C. Thus, it is contemplated that these modifications and others, which include the inventive 30 features of the device, can be prepared without undue EA~ Il;Jn Fig. 11 provides a flow diagram of a surgical method for accessing the epidural space via the neural foramen. The ~lu. ~ g~am indicates that the patient is ,.lc~cl ' 1~ pc ;1i ~Pd in the lateral position with a C arm flu~,r~ .a~e pc ~ ,Fd to facilitate visualization of the ,Ic~l-c~,lilly conduit needle device positioning steps of this invention. The patient is sedated and the ~cll.r ilon2um is gently ;,,~u~ldled, as needed, to displace abdominal 35 viscera out of the way of the needle tracts. The ,clll, -- ' approach, as disclosed in Fig. 11 employs either the d~lc~lill9 conduit needle device or the dc~lc,.lill9 conduit radially expanding dilator device. The pû5;~i - 9 steps W O96/21395 PCTrUS961'~G394 associated with using these devices are discussed above with reference to Figs 4-9. Electrical stimulation is used to ensure that the nerve tissue is deflected away from the foramen and is not blocking that portion of the Ir .~,.ae conduit that is adjacent to the neural foramen. An sndlYr1~e is introduced through the transverse conduit of the device or altL.Ila~i..,5y, in the hollow interior cannula embodiment the instrument is introduced down the proximal 5 length of the device. Other ;~ u~ la are introduced through the device including a drill (to remove a portion of the superior articulating facet) such as provided by Dyonics (Andover, ~ ' tts~ a biter or rongeur ~to remove bony remnant) and a suction punch (to remove ligamentl, as needed, to access the epidural space via the neural foramen. Bone and ligament blocking access to the epidural space are removed so that the dura, the epidural space and the disc with its annulus can be visualized.
Once this region is visualized it is possible to treat extruded, s; r.dlmigrated or contained herniations.
For extruded and s~u~ al~,.dlmigrated' nll;aliulls, a pituitary grasper is used to remove the disc tissue. For contained herniations, the disc space is entered and shavers, curettes and suction punches are used to remove the disc tissue. Using this method it is also possible to perform a diagnostic nerve block test or treat iold",~"al stenosis. During the treatment of the foramenal stenosis bone, ligament and c~tc~rb~l~ are removed. All~ludl;.~ly, 15 this method is suited to laser surgeries. Laser surgery procedures are known to those skilled in the art.
As has been ~i~c~cspd~ the deflecting conduit needle device is useful for directly ~rce~, l, the epidural space, via the neural foramen, without extensive bone d;,c~ The techniques taught herein a d~l 1çe~- ly employ a surgical approach requiring only local a~r,lh~ Moreover, the i -' , P is minimally invasive and can be performed with a single, or p,et~,ably two small ~ull~ a. Further, the t~ '' disclosed in this invention 20 arc~, U!~ nd~l~ the use of a wide range of surgical tools. In contrast to the anterior approach, which requires gross ~lldom~ au~ldliull to avoid penetration or injury of the ~ ' viscus, the present technique uses only minor hlau~ldliun of the r~ll up~ neal space.
In addition, the method of the present invention, unlike the pOa~ , al approach or the anterior approach, employs a straight line of entry to the site of disc he",ià~ion without disc e~Ldlldliun. This straight line of entry 25 makes extensive manipulation with steerable surgical tools unn~ce~sdly and permits visualization of the spinal epidural space where the pathology lies. The present method is less invasive, since disc tissue dissection is not required and the method is safer because the lateral approach combined with i~au~ldliùll reduces the likelihood that the ureter or abdominal viscus will be injured. Moreover, where nerve root cr~, reaa;~,1 is assûc,dled with the ' "id~;un~ the methods of the present invention permit direct visual cor,~i""d~i~" of the extent of the decompression. Direct access 30 and visualizatiûn are not possible in any of the -diur~ n~iù.lcd prior art h ' a further benefit of the present invention over what is currently available in the art is that e~Ldvdlion or removal of intact disc tissue is not required to access the area of the epidural space containing the disc hc.,,idliun.
Other procedures requiring disc excavation or ~x~dblion run the risk that the disc space will settle, resulting in secondary pain. An addii 1n, ' Lo" r!D lion of disc ~ALa~,dlil.n is that the t:ALdvdled disc may become unstable due 35 to the removal of the disc material. Using the present l~,' . access to the epidural space does not depend on disc eALr.-dlio", ~ there is no risk of disc ~IL ' "'~:;tion. In further contrast to standard laminectomy W O96/21395 PCTrUS96/00394 procedures, the present invention does not require di-,erli,Jn of large amounts of bone to access the epidural space.
This has the added benefit of reducing the risk of spinal instability as a result of the surgical procedure.
Importantly, the devices and methods of this invention are minimally invasive. Therefore, as will become apparent from a description of the surgical procedure of Example 1, and Fig. 11, the device of this invention permits 5 the surgeon to correct the spinal defect while the patient is under local anesthesia. Further, the device offers flexibility not available in the aforel"~"i ' methods. The device of this invention and methods that employ direct access to the epidural space via the neural foramen facilitate discectomy procedures, foramenal stenosis correction procedures, tumor LAII__ - or nerve root block procedures can be readily corrected using the procedures and devices disclosed herein on an outpatient basis.
The following example discusses a particular embodiment in detail and Fig. 11 discloses select surgical ~ liai ~ contemplated within the scope of the invention. There are a variety of other instruments and pluL~du.~s which can accompany this technique and which are available to those of skill in the art. Thus, a~
instrumentation and procedures would similarly permit one to successfully perform the intended methods of this invention.
Example 1 Foramenal Approach for Lumbar Discectomy The patient is placed in the lateral position with the ~yul~Jtollldlil, side up. The axilla on the u~Jel~ d of the patient is padded and the patient is affixed in a true lateral position as seen on fll uscu,u~ using 3 C-arm 20 iluv.~ L~i~e (OEC ''-' y~l~llls, Inc. Salt Lake City, Utah). The procedure is carried out preferably under local ~n~ lht~;a with strong sedation or, dll~,l,ali.~'y, with general allei~ll6~;d.
A ~ p~RIonedl incision is made into the flank on the upper side of the back using a 10 to 12 mm incision into the r~llupE,ilon~al space. A d;~sELIilly balloon such as the Origin balloon, or the like, lOrigin Balloon, Origin Medsytems, Inc. Menlo Park, CA) is inflated while endûscou~ is being carried out. The balloon is removed and â
25 trocar is illllud~,.Ld into the incision. hlau~lidliun is carried out with a pressure as small as 5 psi.
At this point, a d~ i,lg conduit needle device, as disclosed in Fig. 1, is inserted via a traditional postoiol~l~ldl approach. The needle is placed into the disc space under ~L,.,..sc r control. The device pierces the annulus lateral to the medial aspect of the ~csaL:~led pedicles and medial to the nerve root which has exited from that Ib~,U~b~ foramen. Once this position is E~i '' ' -d, the needle is rotated 45~ clochw iie or co.,,.l~,Llochw;~e 30 depending on whether the plu~.~.dh~ld iS p~l~U u,ad right or left of the midline. The angle of entry of the deflecting conduit needle device combined with the angle of the conduit within the device provides a nearly full lateral approach relative to the anterior-posterior di- ,~ a so that entry into the foramen will be nearly a full lateral trajectory. In this position, the conduit serves to connect the l~l,upE,ilolleal space with the epidural space of the spinal canal.
Rotation of the needle by 45~ laterally displaces and retracts the nerve root which has exited from the 35 foramen. Using lateral ~LUIUjLIJ~JY~ the conduit is located so that its maximal dimension becomes apparent.
The surgeon makes a lateral puncture (I.r~e,dLly between 8 cm and 10 cm) in the flank in line with this condun as seen on fluGrusct~y"GrQlelahly using a 6.5 mm needle. In this example, the needle is a silastic access W O96/2139S PCTnUS96/00394 trocar. Both the needle and cannula catheter are produced by Cook Instruments (Bloomington, Indiana). Once the access catheter has engaged the lateral aspect of the conduit in the deflecting conduit needle device, the surgeon removes the inner trocar of the access catheter and inserts an e '- r v~ e with working port down the catheter, in effect, cannulating the conduit, through the transverse conduit of the deflecting conduit needle device. This 5 procedure is performed li..~... c r Illy andlor using a laparoscope inserted in the retroperitoneal space.
Once positioned, visualization is possible by the endoscope. The - ' 5 pe can be a rigid rod lens system or a steerable ~ib~r~r - device. Preferably a 4 mm working port endoscope is used with light source and optics.
The scope has suction and irrigation ports at its distal end allowing simultaneous suction and irrigation.
Upon entering the foramen with the endoscope, the surgeon explores the epidural space. The surgeon can 10 drill off a portion of the bony lateral foramen, that is, the lower portion of the superior articular facet, if it is blocking access to the foramenal space. This permits visualization of the lateral aspect of the spinal dura along with the nerve root and epidural space containing blood vessels, fibrous tissue and fat.
The annulus of the disc space with its herniation is also visualized and the surgeon can remove the herniation directly without entering the disc space if the herniation is an extruded fragment. It is now also possible 15 to puncture the annulus to enter the disc space to pursue a ~, ~;un contained within the annulus. Automated shavers, suction punches and rongeurs are used to remove the contained disc herniation. Next, the epidural space is again examined to ensure that the disc h~.l,;dli.,.. has been removed in its entirety.
When the removal pluC6dul~ iS completed, the trocars are removed and the entry site is sutured. Steri-Strips are applied to the skin. The patient is taken to the recovery room for ob~,vdli~n and is dijchd,u~ed two to 20 three hours pDsLope,dliJ~ly.
While particular embodiments of the invention have been described in detail, it will be apparent to those skilled in the art, that these embodiments are exemplary rather than limiting, and the true scope of the invention is that defined in the following claims.
FIELD OF THE INVENTION
This invention relates to surgical tools and methods for back surgery. In particular, this invention relates to methods and devices for a~P7,:-g the neural foramen in patients having a disc herniation or in patients with 5 nerve root pain emanating from a vertebral foramen.
BACKGROUND OF THE INVENTION
There are a variety of pathological conditions which require surgical intervention in and around the spinal epidural space. The most common of these is in~ .lu~,dl disc herniation. Other conditions which require surgical intervention in and around the epidural space include, but are not limited to, foramenal stenosis, tumor excision~0 procedures including excision of neurofibromas, meningiomas, and the like, and procedures involving nerve root blocks.
The neural foramen provides an entry port into the epidural space. The foramen is ~ ,ull.~LHbEd by the pedicles of adjacent vertebral bodies and the floor of the foramen is formed from the annulus of a disc positioned between adjacent vertebra. Disc hell~;d; -s extend from the anterior surface of the epidural space, extending into the space or out of the neural foramen. There are currently three major routes for accessing herniated disc tissue:~5 laminectomy and hemilaminectomy procedures, anterior approaches and F~ ulal-c,dl approaches.
Laminectomy and hemilaminectomy ,..~ du,c~ are some of the more common procedures for treating herniated discs. These procedures allow direct access to the epidural space through the removal of all, or a portion, of the adjacent lamina (i.e. the posterior vertebral surfacel to expose the nerve root and the disc herniation. These procedures are tedious and involve extensive ~;,se.liun and surgical manipulation as~oLiàl~d with the required bone excision. An added complication of these l~.uc6du~cs iS the threat of spinal instability resulting from excess bone removal.
In the p~ ulalcldl approach for accessing herniated disc tissue, exemplified by U.S. Patent 4,573,448 to Kambin, the patient is poC;ti .Pd in a lateral decubitus or in a prone position. In this method, ;Il~Llu,llcllls are illllLd 7r~ into disc tissue at an angle of ~,~ UAillldll,lt 35~ relative to the mid-sagittal plane of the patient (the longitudinal plane running perpendicular to the spine). Here, attempts are made to indirectly access the herniated tissue by entering disc tissue and excavating to the site of the 1~ I,;ali~a. Entry is complete when the surgical tools are positioned within the disc tissue anterior to the spinal epidural space. Once in position, the surgeon -cu~uaYàl-c~
through the disc tissue, at approxi",alu'y a 60~ angle, p~: iurly, to the site of the herniation and removes the herniation from inside the disc, without entering the epidural space.
The Kambin procedure can be ,c~.~u""~d using one or two incision sites and requires steerable tools and angulated scopes. Because the method necessarily involves excdYalia,1 of the disc tissue, there is ~;y"i~i..anl ..Jt;.al to keep the c~uaYalio;l as narrow as possible. The narrow opening requires ~u~ e~;.c entry and removal of . 1L 1~ equipment and e-,uàvdlu,~ thereby i"~, ca~;"g the length of time of the surgical I uCc6J~ c. Normal disc tissue is d : ."ed and removed in this technique with the added complication that the surgeon cannot ~ IlAmPGk;l~
35 view the area to be excised while ~-,LaYali~n is taking place. The suryeon is also unable to see into the epidural CA 02208848 l997-06-26 W O96/21395 . PCTrUS96/00394 space where the actual pathology lies unless a second incision on the opposite side of the spine is used, thereby permitting simultaneous visualization and excision of disc tissue.
U.S. Patent 4,638,799 to Moore details a needle guide apparatus for positioning surgical instruments suitable for disc cher~ ~ via a posterolateral approach. Like Kambin, Moore also contemplates indirect entry 5 disc tissue to correct a disc defect. The needle guide fixes the angle of entry into disc tissue with preferred entry angles ranging from 45~ to 55~. Neither Kambin nor Moore discloses a method for entering the spinal epidural space.
Anterior approaches to correct ;.lt~ S.al disc herniation are generally an improvement over the post~ al approach because the target herniation is in line with the entry port. As a result, the herniation is 10 easier to visualize from within the disc tissue. However, anterior approaches typically require extensive insu~
of the p .i ' space. Where in~uilldliu.. is not employed, entry into the p, - m is complicated by the inherent risk that bowel or ureter tissue could be injured and such injury to the bowel can result in life threatening sequelae.
Like the Kambin approach described above, the anterior approach also requires that the surgeon remove intact, normal disc tissue to get to the area of the herniation while the surgeon works from inside the disc space and the anterior 15 approach does not permit direct visualization of the epidural space where the pathr' ~,y lies. Therefore there remains a need in the medical arts for a surgical method and device which permits direct access and visualization of the epidural space without requiring extensive removal of bone or disc tissue.
In the aforementioned methods, there is the potential for con, ' : resulting from the length surgery, patient recovery time and the risk of complications during the surgical ~...ce' ~. Patient recovery time is further 20 extended when the patient is of an advanced age. Since disc herniation is a degau~dL;~ pathology, it is not .,.. A~.6~,ldd that the majority of hldNid~.31s with disc herniations or other back cr , ' lions requiring access to the IL.~ ..dl space are of advanced age. For elderly patients, increased surgical time, generai ~ne~lh~ and spine destabilization resulting from bone removal can all increase patient recovery time. Thus, there is a need for a surgical method that decreasing the length of surgery and reduces the length of patient recovery.
SUMMARY OF THE INVENTION
The methods and devices of the present invention facilitate access to the epidural space via the neural foramen without disturbing the integrity of the nerve roots and spinal dura while working with and around the anatomical features of the lateral surfaces of the spinal column. Unlike the above described prior art i ' , ~s, 30 the methods and devices of the present invention are designed to gently deflect the neural roots away from the lu. ~' space.
In one aspect of this invention, a deflecting conduit needle device is dicrlose~l The device ~.~le,abl~
embeds in disc tissue adjacent to the neural foramen assûc.~l~d with the spinal defect. The anchored device provides a conduit to connect the ~ ,iloneal space with the spinal epidural space. In one embodiment, the 35 device includes a transverse conduit through which see ' y surgical i~ ull~ aliùn is h~llùdu~.~d at an angle to directly access the anterior surface of the epidural space. In this embodiment the sum of the angle of insertion of CA 02208848 l997-06-26 W O96/21395 PCTrUS96/00394 the d~ Lli"g conduit needle device and the angle of the transverse conduit relative to the longitudinal axis of the device is at least 70~.
In a second embodiment of the deflecting conduit needle device, the device forms a hoilow sleeve along the longitudinal axis of the device allowing secondary surgical instrumentation to be introduced into the hollow sleeve 5 and exiting at the l,a"~ e conduit adjacent the neural foramen.
In another aspect of the invention, the deflecting conduit needle device is modified to function as a radially expanding dilator. This modified device is equipped with a central needle guide and an expandable sleeve. Again, the device may be formed with a transverse conduit andlor as a hollow sleeve exiting at the location of the transverse conduit adjacent the relevant neural foramen.
In yet another aspect of the invention, the device is modified as a "peel away" catheter and includes an outer peelable sleeve.
The invention also relates to a method for directly accessing the epidural space via the neural foramen.
In one embodiment, the method includes arc~Ps~ a the space using one of the disclosed d~ LIi..~, conduit needle devices and in another embodiment, the method provides direct access to the epidural space via the neural foramen.
15 In one preferred method, the il 'ILCI;IIY conduit needle device is positinnPd, based on an anterior fluoroscopic view, lateral to the medial aspect of the pedicle base and is F ~i ' such that it abuts a line defined by the posterior aspect of the vertebral body and the disc based on a lateral fluoroscopic view. The device is embedded into the disc tissue at its distal tip and rotated about 45~ to deflect the nerve root extending from the neural foramen and to align the tlall~,G.~e conduit of the device with the neural foramen. See d y surgical instn.",~ is 20 ;~ udul,ed through the ll~ e conduit to access the epidural space via the neural foramen.
BRIEF DESl.~lrllON OF THE DRAWINGS
Fig. 1 is an anterior view of the distal portion of a preferred embodiment of the ;1~ , conduit needle of the present ;..~,,liun, Fig. 2 is a lateral view of the distal portion of a preferred embodiment of the deflecting conduit needle of 25 the present i.l.~ iu,l;
Fig. 3is a posterior view of the distal portion of a preferred embodiment of the deflecting conduit needle of the present ;..~,~..liull, Fig. 4 is a cross-section of a vertebra illustrating the p~: ~, of the device in a method of using the d~lel,li.l3 conduit needle of Fig. 1;
Fig. 5 is a cross-section of a vertebra illustrating the nerve deflecting step in the method of using the d~ l,lillg conduit needle of Fig. 1;
~ Fig. 6 is a cross-section of a vertebra illustrating the d~ lillg conduit needle of Fig. 1 pc- -ed in disc tissue;
Fig. 7 is a cross-section of a vertebra illustrating the deflecting conduit needle of Fig. 1 F~~ ' to 35 receive surgical ;Il;,llulll~ i to access the posterior surface of the lo~' space;
W O96/21395 PCTnUS96/00394 Fig. 8 is a lateral view of the vertebral column with surgical instrumentation positioned in the transverse conduit of the device of Fig. 1;
Fig. 9 is a cross-section of a patient mid-section with the deflecting conduit needle in place;
Fig. 10 is a lateral view of a du~ y conduit needle dilator embodiment; and Fig. 11 is a flow diagram illustrating a preferred surgical method according to this invention.
DETAILED DESCRIPTIOH OF THE INVENTION
The present invention relates to a method and a deflecting conduit needle device for c), -cting the ,~1,1.,,~. ' space to the spinal foramen, and in particular for accessing the anterior and lateral portions of the spinal epidural space.
The terms "spinal foramen", "neural foramen" and f~ .. ,.. al space" are used interchangeably Ihl. g~1LL
this document.
The term "entering" is used herein to include any surgical technique for accessing an internal body space in a patient through a surgically created opening. Thus, the term "entering" includes the use of incisions, punctures, or the like.
The device and method of the present invention have a variety of surgical applications. Not only is the device suitable for treating disc ~ Idd~ , but it may be used to directly treat foramenal stenosis, excise nerve tumors, or to perform diagnostic nerve blocks. As one embodiment of this invention, a d~.le~ y conduit needle device is employed to gently deflect the nerve root away from the neural foramen formed between adjacent vertebral pedicles while simultaneously i..."~as;"g the angle of entry into the foramenal space to between 70~ and 90~ and 20 more p,~ieldLly between 75~ and 80~ relative to the mid-sagittal plane of the patient while employing a relll pr i a ' approach.
Referring to Fig. 1-3, the preferred deflecting conduit needle device of this invention has a ;,ub~ldllli~lly elongate body 10 which includes a proximal end and a distal end, with the proximal end closest to the surgeon and the distal end positioned adjacent to the neural foramen. The elongate body 10 extends S~h lly along a first 25 axis laxis A). The body of the device may be substantially "y; ' h,dl or it may have a variety of other cross-sectional shapes. Further, the shape of the d ~l~cli"g conduit needle device, while ~ubal~ 'ly elongate, may optionally be provided with a variety of out-pouchings, curves, or the like.
In a preferred embodiment of the invention, the distal portion of the device terminates in a pointed tip 12.
The tip is sufficiently sharp to permit the device to puncture the annulus fibrosis of the disc in question. The device 30 has, at its distal end, an anterior and a posteribr face. Fig.1 diagrams the anterior face of the device. As is readily appreciated from Fig. 1, the pointed tip 12 widens slightly, ~ bly reaching the full circumference of the device within the distal one eighth of the length of the device and more ,.,~e,~ bl~ within the distal three c~lllilllel~r~ of the device.
Referring now to Fig. 2 and to Fig. 3, in a preferred embodiment of the device, the posterior surface of 35 the distal end of the device is bevelled relative to the anterior surface. This bevelled surface 14 is p,e~ldbly a continuous surface with smooth rounded edges, unlike a needle used for ~,. , . lul~. The bevelled surface 14 CA 02208848 l997-06-26 W O 96/21395 PCT~US96/00394 widens from or adjacent to the tip 12 to a heel 16 located at the proximal end of the bevelled surface 14. The preferred contour of the bevelled surface 14 can be readily appreciated from the lateral view of the distal portion of the device, illustrated in Fig. 2.
In this preferred embodiment, the elongate body of the device 10 includes a transverse conduit 18 extending 5 through the device. The conduit traverses the elongate body 10 at substantially a second axis (axis B) relative to the first axis (axis A) of the elongate body, such that an acute angle (~) is formed between the first axis and the second axis. The acute angle is, ~1~. hl~ between 25~ and 55~ and more, ~ ,bl~ between 30~ and 40~ with a preferred angle of about 35~. However, even those of ordinary skill in the art will recognize that the transverse conduit 18 within the elongate body 10 can be F~ e~ at a variety of angles relative to the axis formed by the 10 elongate body and that the ultimate angle of the conduit 18 will depend on the preferred angle of entry of the device relative to the mid-sagittal plane of the patient. Preferably, the sum of the angle of introduction of the device relative to the mid-sagittal plane of the patient and the acute angle formed between the first axis and the second axis is at least 70~.
To continue, the conduit 18 traverses the elongate body within a range of distances as measured from the 15 distal tip of the apparatus. In a preferred embodiment, the conduit is pcl ' within the distal one-eighth of the device and in another embodiment, the conduit is positioned within four centimeters from the tip and is ~ ,dLly positioned proximal to the bevelled surface 14 and adjacent to the heel 16 of the bevelled surface 14 of the device.
In one embodiment of this invention, the ' g l~d body of the device is hollow along its longitudinal axis with the hollow interior cannula 30 portion communicating with the l,dn~ .ae conduit 18 as illustrated in Fig. 10c.
20 In this embodiment, the device forms a hollow sleeve such that the proximal end of the device forms a first opening and extends through the device l~ ly at the conduit 18. Thus, surgical i"~l",."~..ls can be i"ll"d~.ced through the conduit 18 or through the hollowed proximal portion of the device and in both inct~nre~, the ;,,~I,u,,,e,,l~ exit the conduit 18 from the anterior surface of the device.
In a preferred embodiment of this invention the effective length of the elongate body 10 of the device is 1 ~ dbly between 10 cm and 45 cm in length. The d~ y conduit needle device can be held by the surgeon or; ,~ throughout the surgical ~loc6dul~, or the device can be mounted or stabilized on a surgical stand, or the like. Moreover, while a pOSt~lOI~eidl approach is p,~ disclosed in Example 1, those skilled in the art will recognize that the disclosed device could be readily employed in surgical procedures using other surgical ap~JIuabhes.
Therefore, the length of the device will vary depending on how it is employed in a particular surgical procedure.
Where the device is held by the surgeon in a posterolateral procedure, the d~ cli"g conduit needle device is ,dLly between 17 cm and 21 cm"in one embodiment length, and in another preferred embodiment, the defl~LLill3 conduit needle device is between 25 cm and 31 cm in length.
The cross sectional dimensions of the device will also vary, with the overall width of the device depending on whether or not the device forms a hollow sleeve for the ;~lluluclh~ of surgical tools to the disc site or whether the device is solid and lacking an accessible longitudinal sleeve. For deflecting conduit needle devices without a W O96/21395 PCTrUS96100394 central accessible hollow sleeve, the device will, ~, SI) have a cross-sectional dimension of between 4 mm to 10 mm and preferably between 8 mm to 10 mm.
The transverse conduit 18 is positioned to accommodate instrumentation suitable for performing the types of surgical techniques which require access to the anterior and lateral portions of the spinal epidural space. Thus, 5 the l,On~ e conduit 18 will be suitable to accommodate e 1~ lprs, trocars, rongeurs, cannula sleeves, arthroscopic shaver blades, suction devices, cauterizing tools, and the like. In a preferred embodiment, the transverse conduit 18 has a cross-sectional dimension of at least 2.0 mm and p.~ between 5 mm to 9 mm. Where the elongate body 10 is cylindrical, the transverse conduit will preferably have a cross sectional dimension of 0.5 mm to 2.0 mm less than the cross-sectional dimension of the elongate body 10. In this preferred embodiment, the 10 I,d"~ e conduit, like the shape of the elongate body 10, is s ~h~ ; Jly cylindrical; however, the ll~
conduit, like the cross-section of the elongate body, may also have a variety of other shapes. Thus, where the cross sectional shape of the device is circular, an oblong conduit will be useful for maximizing the working space for a~re"i~ g the spinal epidural space via the neural foramen.
The d~ li.lg conduit needle device can be prepared from any number of materials well known in the 15 surgical arts. These include, for example, surgical steel, other suitable surgical alloys, TEFLON~, or related materials, or thermoplastic polymers including pol~ , pQl~ ar!, polyvinylchloride, silastics or the like, including other materials which can be sterilized for surgical use. Those skilled in the art of surgical device C~LII.I~ will be able to select a suitable material.
Fig. 9 depicts a mid-section of a patient with a deflecting conduit needle device 10 in place. In a preferred 20 method of this invention, the patient is pDit-~ed in a lateral position and the p~,i r-u~ is hl~ laled as illustrated in Fig. 9. Minimal bl;~ ldl through an ;..;,ur~i port 46 into the retro p~.iloneal space 48 is p.~rubly used to retract the pe,ito"~.J", 34 containing the bowel 36. Those skilled in the art will recognize that the extent of ~ ~ldi needed to access the spinal foramen will vary between patients. Thus, Fig. 9 is illustrative and is not intended to demonstrate the extent of insuiildlion required to perform the claimed technique.
Once ;"~u~ldlion is completed, puncture or incision is made in the I~Ll~,p.. ilo"~u",. The preferred entry position of the dt il~li"g conduit needle device 10 is illustrated, relative to the patient mid section in Fig. 9. Fig.
4 illustrates the preferred angle of entry and position of the device as it approal.l,ds the spinal column. ~l~ie,dbly, the d~ .,i O conduit needle device 10 is inserted through a ~ p ilol,eal pelcut_ ee- puncture and advanced toward the foramenal space in need of surgical ;.,t~ Using fluoroscopy, and referring to Fig. 4, the distal tip 12 is guided toward the disc space in need of surgical ;"le,~ ,l;Jn. The device tip 12 is p,~e,.,bly pos;li.,1e~
based on an anterior view, lateral to the medial aspect of the pedicle base. Based on a lateral view, the needle tip is pc~ d such that it abuts a line defined by the posterior aspect of the vertebral body and the disc. The posterior surface of the device, as illustrated in Fig. 3, faces rostrally as the device moves into position. Oncé in position, pressure is applied to the distal tip 12 which is su~ sharp such that the device is ~ ' ed('c ' in the disc annulus. Care is taken such that the device impales the disc annulus without damaging adjacent nerve roots as~oc;al~d with the neural foramen. The angle of entry and the angle that the device is e,~ l e~dFd into the disc W O96/21395 PCTrUS96/00394 annulus relative to the mid-sagittal plane C, as shown in Fig. 9, is important to facilitate easy access to the epidural space via the neural foramen. Preferably, for lumbar procedures, the device is positioned at a 35~ to 55~ angle relative to the mid-sagittal plane of the patient.
As illustrated in Fig. 5, once the deflecting conduit needle device 10 is embedded in the disc annulus, the device 10 is gently rotated about 45~ clockwise if treating the right side of the patient and 45~ counterclockwise if treating the left side of the patient. The rotation of the heel 16 of the bevelled surface 14 gently deflects the nerve root 44 away from the foramenal space, permitting easier and safer access to the foramenal space and aligns the transverse conduit 18 with the neural foramen. The position of the device following rotation is provided in Fig.
6. The deflecting conduit needle device 10 is now in place, connecting the loll~, ~' space with the spinal epidural space.
Next, referring to Fig. 7 and 9, secondary surgical instrumentation 20 suitable for performing the di~.,Ecl~..,.~
or other procedures assoL;dll!d with accessing the spinal foramen are introduced either using the same incision or through a second incision site 42 through the l~a.~ a conduit 18 and into the ~ .al space and ~ule~O~l~.bl~ into the anterior and lateral portions of the spinal epidural space. A secondary puncture is, OPo~ introduced into the patient along the flank. First, a fluoroscope grid is positioned on the flank to align the puncture site with the conduit 18. Once the angle of entry is identified, secondary surgical instrumentation, including initially, a needle or canula are introduced through the puncture to the conduit 18. Electrical stimulation is, ~ofol.,bly employed to ensure that the nerve root 44 has been deflected away from the foramen before the secD~' y instrumentation 20 fully engages the transverse conduit 18.
Once the needle is in place, a canula can be dropped over the needle and slidably pe s~d adjacent the foramen. Secondary surgical ;"~II",llo,lldliun required to perform the discectomy or other surgical procedures are advdllldy~ s~ through the canula. The lld,)sl,O,~a conduit serves as a guide for maintaining an angle suitable for a~eC-: y the spinal epidural space via the neural foramen. An OAO~,ulaly detailed surgical method employing the device of this invention is provided in Example 1.
Fig. 8 provides a lateral view of the device 10, in position, with the nerve root deflected with the device 10 receiving secondary surgical instrumentation 20 such as a cannula or P~drscere suitable for use with other surgical instruments such as suction punches, rongeurs, and the like. While this method uses two entry sites, it is also ~ ~u ~ u d that one entry site can be used in some cases. For example, it is possible with the use of fluoroscopy, real time imaging with ultrasound, magnetic ,esonance imaging guidance or computerized axial tomographic guidance to directly access the epidural space through the neural foramen without the deflecting conduit needle device. A single entry site procedure can also be performed using the d 301~ 9 conduit needle device 10.
For a single entry site p~ocEd~.~O the do~l~o~ y conduit needle device is lu~O~O~ hollow from the proximal end to the transverse conduit 18 such that secD~' y surgical ;.,;,II~ HI;~n 20 can be inserted through the hollow p~ P~. . u, and exit through the lldll~lc.~a conduit. In this embodiment, steerable surgical equipment guided through 35 the length of the body 10, out the l,,.~,O.~a conduit 18 and into the epidural space via the neural foramen.
W O96121395 PCTrU~96/00394 An important benefit of the present device, as compared with the prior art, is that the device provides a method of i"c.~a~ , the angle of entry into the foramenal space from what is disclosed to at least 700, without requiring extensive retroperitoneal insufflation. -The angular position of the deflecting conduit needle device 10 relative to the mid sagittal plane of the patient and the angle of the transverse conduit, in combination with nerve 5 deflection, provides a substantially lateral approach for discectomy. The technique is minimally invasive while providing direct visualization of the site in need of surgical intervention.
In another modification of the deflecting conduit needle device, the device includes a blunt distal tip, as shown in Fig. 10c. In this embodiment, the device is not embedded in disc tissue, rather the device is brought into position and held in place by external supports such as the support disclosed in U.S. Patent No. 4r638r799 to Moore.
10 Al~ la~ ly, the device can be held in place by the physician or surgical a::
It is further re: mp'~ted within the scope of this invention that the L~lbrr,li..,J conduit needle device can be modified to function as a dilator. Tools for dilating the access site during a surgical ~JIuLeùu~e are well known in the art. One such tool is a radially expanding dilator (RED). This type of device is disclosed in U.S. Patent Nos.
5~312~360 and 5~275~611 to Behl which are both hereby incu.~ dted by reference. Such devices are suitable for 15 enlarging ~ , OL penetrations in body cavities and include elongate guide members and at least one elongate dilatation member. The central portion of the guide member is removed once the device is p ~inned within a body cavity and a unitized dilator is i.~l,udùced to widen the cross-sectional diameter of the device. This permits surgical in~ ",enl,-~lion to be ;..l~ d through the device to facilitate the surgical procedure while minimizing the inv i~"n is of the I~IUC6r.~UI~.
The d~ "~li"g conduit needle dilator embodiment of this invention can be used in assoc;aliun with the first puncture or all~,l"rJLi~al~, the dilating needle can be employed in the second step to facilitate introduction of surgical i.~sl~l..llouldliun through the conduit 18. Referring to Fig. 10a, in the first dilation embodiment of this device, the device has a proximal end and a distal end and comprises a central needle guide 22r an elongate d~ illg dilator 24 and an ~ -r 1n~l ~1 outer sleeve 26~ The e .r I " outer sleeve 26 may be prepared from a variety of materials 25 known in the art, including but not limited to rubber, heat-stable polymers, or woven sleeves prepared from poiymers or other suitable material. Other suitable materials are disclosed in U.S. Patent Nos. 5r312r360 and 5~275~611 to Behl. The elongate d~ ,.,li"y dilator optionally cu,,,~ as a l, l~.c.~econduit 18, a hollow interior cannula 30 and a r;~ cli..g heel 32 with a bevelled surface 33 po~ d between the distal end and the heel 32. The hollow interior cannula 30 is just wide enough at the distal terminus to accommodate the central needle guide. The 30 ll~n;~vr,~ a conduit 18 traverses the dpp~lolu5 and is pe 9~ along the distal c..c ci~lllll of the device. The hollow interior cannula 30 is - ~e,ably wide enough at the proximal end to 3reGIl ,rnrlOle both the central needle guide 22 and steerable surgical tqu;~"",,"l including ~ I y surgical i.,~"~ r,ls 20r such as endoscopes trocars, ,al II"~s ~ shavers, rongeurs and the like, and the cannula 30 ,,..,, 0,~, ' ly con :-te~ with the ll ,3n~v, ~ ~a conduit 18 such that surgical equipment i..lluduc~d at the proximal end of the device can be passed down the cannula 30 35 and exit at the llau~ a conduit 18.
W O 96/2139~ PCTrUS96/00394 .9.
During use the central needle guide 22 with the expandable sleeve 26, is introduced into the patient using the procedures disclosed in Example 1. The needle 22 impales the disc annulus at a position medial to the exiting nerve root. Once positioned within the disc annulus, the elongate deflecting dilator 24 is pc ,i~ir-~d over the central needle guide 22, within the expandable outer sleeve 26 as illustrated in Fig. 10b. In this embodiment, the elonyate 5 deflecting dilator serves to expand the diameter of the expandable outer sleeve from within. This type of ~ n is safer for the nerve root. Once in place, the device, can be rotated 45~ to deflect the nerve root. The central needle guide 22 is removed, as illustrated in Fig. 10c, and instruments are introduced down the central longitudinal axis of the dilator using a steerable ~ 'a ~pr If it is impossible to access the epidural space by this route, the surgeon can make a second puncture in the flank of the patient and introduce surgical instrumentation through the 10 transverse conduit 18, into the epidural space via the neural foramen.
In a second dilator embodiment, the dilator is introduced through the transverse conduit 18 of the d 'l~ lg conduit needle device 10, as illustrated in Fig.1. In this embodiment, a probe rather than the needle guide 22, is inserted with an L--r ' ' ' sleeve 26 through the second puncture, in line with the l~all~.~r~d conduit and pc~ ned adjacent to the neural foramen. Once in position, the dilator is introduced within the r n~ sleeve and the 15 probe is removed. This serves to gently increase the cross-sectional diameter of the device to provide greater access to the epidural space with minimal inv- .L..~ESS.
The devices of this invention can also be modified as a "peel away" catheter. "Peel away" calhc~l~cls are known in the art such as those described in U.S. Patent No. 4, 581,025 and are available from Cook Group Company (PEEL-AWAY~ catheter, Bloomington Indiana) or from Boston Scientific CGI,~: dliUn (BANANA PEEL~, Medi tech, 20 Boston Scientific Cor~ ~lldGon, Vl~'dlcl lU~ - ' LI:i).
In this embodiment, the secondd,y surgical instrumentation is a "peel away" cannula, iulluduced through lldlls~,c~ae conduit 18. The "peel away" portion of the device is an outer sleeve which can be peeled away. The sleeve forms a cannula. A needle is aligned with the transverse conduit 18 of the de~lel,lillg conduit needle device 10 which is anchored within the disc annulus. Once the needle is in place, the "peel away" sleeve and inner stylet 25 are slidably pc,;li~ ~ed over the needle. The needle is retracted and ~ u~Ostopcs and other surgical illsl~ulu6rlldlion are introduced through the sleeve. If needed, the sleeve can be peeled away as is provided in either the PEEL
AWAY~ or the BANANA PEEL~ sleeves disclosed above.
Methods for preparing these modified embodiments will be readily apparent to those skilled in the art in view of this d;.~.h~3~..C. Thus, it is contemplated that these modifications and others, which include the inventive 30 features of the device, can be prepared without undue EA~ Il;Jn Fig. 11 provides a flow diagram of a surgical method for accessing the epidural space via the neural foramen. The ~lu. ~ g~am indicates that the patient is ,.lc~cl ' 1~ pc ;1i ~Pd in the lateral position with a C arm flu~,r~ .a~e pc ~ ,Fd to facilitate visualization of the ,Ic~l-c~,lilly conduit needle device positioning steps of this invention. The patient is sedated and the ~cll.r ilon2um is gently ;,,~u~ldled, as needed, to displace abdominal 35 viscera out of the way of the needle tracts. The ,clll, -- ' approach, as disclosed in Fig. 11 employs either the d~lc~lill9 conduit needle device or the dc~lc,.lill9 conduit radially expanding dilator device. The pû5;~i - 9 steps W O96/21395 PCTrUS961'~G394 associated with using these devices are discussed above with reference to Figs 4-9. Electrical stimulation is used to ensure that the nerve tissue is deflected away from the foramen and is not blocking that portion of the Ir .~,.ae conduit that is adjacent to the neural foramen. An sndlYr1~e is introduced through the transverse conduit of the device or altL.Ila~i..,5y, in the hollow interior cannula embodiment the instrument is introduced down the proximal 5 length of the device. Other ;~ u~ la are introduced through the device including a drill (to remove a portion of the superior articulating facet) such as provided by Dyonics (Andover, ~ ' tts~ a biter or rongeur ~to remove bony remnant) and a suction punch (to remove ligamentl, as needed, to access the epidural space via the neural foramen. Bone and ligament blocking access to the epidural space are removed so that the dura, the epidural space and the disc with its annulus can be visualized.
Once this region is visualized it is possible to treat extruded, s; r.dlmigrated or contained herniations.
For extruded and s~u~ al~,.dlmigrated' nll;aliulls, a pituitary grasper is used to remove the disc tissue. For contained herniations, the disc space is entered and shavers, curettes and suction punches are used to remove the disc tissue. Using this method it is also possible to perform a diagnostic nerve block test or treat iold",~"al stenosis. During the treatment of the foramenal stenosis bone, ligament and c~tc~rb~l~ are removed. All~ludl;.~ly, 15 this method is suited to laser surgeries. Laser surgery procedures are known to those skilled in the art.
As has been ~i~c~cspd~ the deflecting conduit needle device is useful for directly ~rce~, l, the epidural space, via the neural foramen, without extensive bone d;,c~ The techniques taught herein a d~l 1çe~- ly employ a surgical approach requiring only local a~r,lh~ Moreover, the i -' , P is minimally invasive and can be performed with a single, or p,et~,ably two small ~ull~ a. Further, the t~ '' disclosed in this invention 20 arc~, U!~ nd~l~ the use of a wide range of surgical tools. In contrast to the anterior approach, which requires gross ~lldom~ au~ldliull to avoid penetration or injury of the ~ ' viscus, the present technique uses only minor hlau~ldliun of the r~ll up~ neal space.
In addition, the method of the present invention, unlike the pOa~ , al approach or the anterior approach, employs a straight line of entry to the site of disc he",ià~ion without disc e~Ldlldliun. This straight line of entry 25 makes extensive manipulation with steerable surgical tools unn~ce~sdly and permits visualization of the spinal epidural space where the pathology lies. The present method is less invasive, since disc tissue dissection is not required and the method is safer because the lateral approach combined with i~au~ldliùll reduces the likelihood that the ureter or abdominal viscus will be injured. Moreover, where nerve root cr~, reaa;~,1 is assûc,dled with the ' "id~;un~ the methods of the present invention permit direct visual cor,~i""d~i~" of the extent of the decompression. Direct access 30 and visualizatiûn are not possible in any of the -diur~ n~iù.lcd prior art h ' a further benefit of the present invention over what is currently available in the art is that e~Ldvdlion or removal of intact disc tissue is not required to access the area of the epidural space containing the disc hc.,,idliun.
Other procedures requiring disc excavation or ~x~dblion run the risk that the disc space will settle, resulting in secondary pain. An addii 1n, ' Lo" r!D lion of disc ~ALa~,dlil.n is that the t:ALdvdled disc may become unstable due 35 to the removal of the disc material. Using the present l~,' . access to the epidural space does not depend on disc eALr.-dlio", ~ there is no risk of disc ~IL ' "'~:;tion. In further contrast to standard laminectomy W O96/21395 PCTrUS96/00394 procedures, the present invention does not require di-,erli,Jn of large amounts of bone to access the epidural space.
This has the added benefit of reducing the risk of spinal instability as a result of the surgical procedure.
Importantly, the devices and methods of this invention are minimally invasive. Therefore, as will become apparent from a description of the surgical procedure of Example 1, and Fig. 11, the device of this invention permits 5 the surgeon to correct the spinal defect while the patient is under local anesthesia. Further, the device offers flexibility not available in the aforel"~"i ' methods. The device of this invention and methods that employ direct access to the epidural space via the neural foramen facilitate discectomy procedures, foramenal stenosis correction procedures, tumor LAII__ - or nerve root block procedures can be readily corrected using the procedures and devices disclosed herein on an outpatient basis.
The following example discusses a particular embodiment in detail and Fig. 11 discloses select surgical ~ liai ~ contemplated within the scope of the invention. There are a variety of other instruments and pluL~du.~s which can accompany this technique and which are available to those of skill in the art. Thus, a~
instrumentation and procedures would similarly permit one to successfully perform the intended methods of this invention.
Example 1 Foramenal Approach for Lumbar Discectomy The patient is placed in the lateral position with the ~yul~Jtollldlil, side up. The axilla on the u~Jel~ d of the patient is padded and the patient is affixed in a true lateral position as seen on fll uscu,u~ using 3 C-arm 20 iluv.~ L~i~e (OEC ''-' y~l~llls, Inc. Salt Lake City, Utah). The procedure is carried out preferably under local ~n~ lht~;a with strong sedation or, dll~,l,ali.~'y, with general allei~ll6~;d.
A ~ p~RIonedl incision is made into the flank on the upper side of the back using a 10 to 12 mm incision into the r~llupE,ilon~al space. A d;~sELIilly balloon such as the Origin balloon, or the like, lOrigin Balloon, Origin Medsytems, Inc. Menlo Park, CA) is inflated while endûscou~ is being carried out. The balloon is removed and â
25 trocar is illllud~,.Ld into the incision. hlau~lidliun is carried out with a pressure as small as 5 psi.
At this point, a d~ i,lg conduit needle device, as disclosed in Fig. 1, is inserted via a traditional postoiol~l~ldl approach. The needle is placed into the disc space under ~L,.,..sc r control. The device pierces the annulus lateral to the medial aspect of the ~csaL:~led pedicles and medial to the nerve root which has exited from that Ib~,U~b~ foramen. Once this position is E~i '' ' -d, the needle is rotated 45~ clochw iie or co.,,.l~,Llochw;~e 30 depending on whether the plu~.~.dh~ld iS p~l~U u,ad right or left of the midline. The angle of entry of the deflecting conduit needle device combined with the angle of the conduit within the device provides a nearly full lateral approach relative to the anterior-posterior di- ,~ a so that entry into the foramen will be nearly a full lateral trajectory. In this position, the conduit serves to connect the l~l,upE,ilolleal space with the epidural space of the spinal canal.
Rotation of the needle by 45~ laterally displaces and retracts the nerve root which has exited from the 35 foramen. Using lateral ~LUIUjLIJ~JY~ the conduit is located so that its maximal dimension becomes apparent.
The surgeon makes a lateral puncture (I.r~e,dLly between 8 cm and 10 cm) in the flank in line with this condun as seen on fluGrusct~y"GrQlelahly using a 6.5 mm needle. In this example, the needle is a silastic access W O96/2139S PCTnUS96/00394 trocar. Both the needle and cannula catheter are produced by Cook Instruments (Bloomington, Indiana). Once the access catheter has engaged the lateral aspect of the conduit in the deflecting conduit needle device, the surgeon removes the inner trocar of the access catheter and inserts an e '- r v~ e with working port down the catheter, in effect, cannulating the conduit, through the transverse conduit of the deflecting conduit needle device. This 5 procedure is performed li..~... c r Illy andlor using a laparoscope inserted in the retroperitoneal space.
Once positioned, visualization is possible by the endoscope. The - ' 5 pe can be a rigid rod lens system or a steerable ~ib~r~r - device. Preferably a 4 mm working port endoscope is used with light source and optics.
The scope has suction and irrigation ports at its distal end allowing simultaneous suction and irrigation.
Upon entering the foramen with the endoscope, the surgeon explores the epidural space. The surgeon can 10 drill off a portion of the bony lateral foramen, that is, the lower portion of the superior articular facet, if it is blocking access to the foramenal space. This permits visualization of the lateral aspect of the spinal dura along with the nerve root and epidural space containing blood vessels, fibrous tissue and fat.
The annulus of the disc space with its herniation is also visualized and the surgeon can remove the herniation directly without entering the disc space if the herniation is an extruded fragment. It is now also possible 15 to puncture the annulus to enter the disc space to pursue a ~, ~;un contained within the annulus. Automated shavers, suction punches and rongeurs are used to remove the contained disc herniation. Next, the epidural space is again examined to ensure that the disc h~.l,;dli.,.. has been removed in its entirety.
When the removal pluC6dul~ iS completed, the trocars are removed and the entry site is sutured. Steri-Strips are applied to the skin. The patient is taken to the recovery room for ob~,vdli~n and is dijchd,u~ed two to 20 three hours pDsLope,dliJ~ly.
While particular embodiments of the invention have been described in detail, it will be apparent to those skilled in the art, that these embodiments are exemplary rather than limiting, and the true scope of the invention is that defined in the following claims.
Claims (26)
1. A surgical apparatus for accessing the spinal foramen comprising:
an elongate body extending substantially along a first axis with a cross-sectional diameter of at least 3.0 mm, said body having a proximal end and a distal end, said distal end comprising a tip that is sufficiently sharp to puncture disc tissue thereby anchoring said apparatus in said tissue, and a conduit having a cross-sectional diameter of at least 2.0 mm positioned along the distal one-eighth of said body, said conduit extending substantially along a second axis and traversing said apparatus, said second axis positioned at an acute angle relative to said first axis.
an elongate body extending substantially along a first axis with a cross-sectional diameter of at least 3.0 mm, said body having a proximal end and a distal end, said distal end comprising a tip that is sufficiently sharp to puncture disc tissue thereby anchoring said apparatus in said tissue, and a conduit having a cross-sectional diameter of at least 2.0 mm positioned along the distal one-eighth of said body, said conduit extending substantially along a second axis and traversing said apparatus, said second axis positioned at an acute angle relative to said first axis.
2. The apparatus of Claim 1, wherein said elongate body is hollow, forming a working diameter in said device and wherein the distal tip is solid.
3. The apparatus of Claim 1, wherein the body of said apparatus comprises an elongated hollow sleeve exiting at said conduit, wherein the hollow sleeve extends from said proximal end of the apparatus to said conduit said hollow sleeve serving as a guide for the introduction and removal of one or more surgical tools through the proximal end of said apparatus through said transverse conduit.
4. The apparatus of Claim 2, wherein said tip comprises the end of a guide needle extending through said elongate hollow body.
5. The apparatus of Claim 4, wherein said guide needle is removable from said elongate hollow body.
6. The apparatus of Claims 2, 3, 4 or 5, wherein said distal end further comprises at least one bevelled surface, said distal tip forming the most distal portion of said bevelled surface.
7. The apparatus of Claim 6. wherein said bevelled surface terminates at its widest point as a heel located between said distal tip and said transverse conduit.
8. The apparatus of Claims 2, 3, 4 or 5. wherein said elongate body is substantially cylindrical.
9. The apparatus of Claims 2, 3, 4 or 5, wherein the cross-sectional diameter is between 4.0 mm - 10.0mm.
10. The apparatus of Claims 2, 3, 4 or 5, wherein said acute angle is at least 25°.
11. The apparatus of Claims 2, 3, 4 or 5, wherein said body comprises surgical grade steel.
12. The apparatus of Claims 2, 3, 4 or 5, wherein said body comprises a heat-stable polymer.
13. The apparatus of Claims 2, 3, 4 or 5, wherein the apparatus additionally comprises an outer sleeve extending along the exterior surface of said elongate body.
14. The apparatus of Claim 13, wherein the sleeve is expandable and said sleeve, when expanded, increases the working diameter of said apparatus.
15. The apparatus of Claim 13, wherein said sleeve forms a cannula which can be peeled away.
16. The apparatus of Claims 6 or 7, wherein said elongate body has an anterior face and a posterior face, and wherein said conduit traverses said apparatus from said posterior face to said anterior face.
17. The apparatus of Claim 16, wherein said bevelled surface extends along said posterior face from the distal tip to a position beneath said transverse conduit.
18. A method for accessing the epidural space of the spinal canal comprising the steps of;
introducing a surgical apparatus of Claim 1 posterolaterally toward a vertebral disc;
positioning said apparatus lateral to the medial aspect of the pedicles of adjacent vertebra based on an anterior fluoroscopic view and abutting a line defined by the posterial aspect of the vertebral body and the disc based on a lateral fluoroscopic view; and entering the epidural space through the spinal foramen.
introducing a surgical apparatus of Claim 1 posterolaterally toward a vertebral disc;
positioning said apparatus lateral to the medial aspect of the pedicles of adjacent vertebra based on an anterior fluoroscopic view and abutting a line defined by the posterial aspect of the vertebral body and the disc based on a lateral fluoroscopic view; and entering the epidural space through the spinal foramen.
19. The method of Claim 18, wherein the distal end of the apparatus additionally comprises a distal tip and a bevelled surface, said bevelled surface extending along said posterior face from the distal tip to a position beneath said transverse conduit, said distal tip being sufficiently sharp to puncture the annulus of a vertebral disc, wherein the positioning step additionally comprising the steps of:
piercing said vertebral disc tissue with said distal tip and urging said tip into said disc tissue until said distal tip is embedded sufficiently within saidtissue to be rotatably anchored at said distal tip;
rotating said apparatus thereby deflecting said intravertebral nerve away from the spinal column and directing said conduit toward said spinal foramen;
and introducing one or more surgical tools through said conduit and into said:
spinal foramen to access said epidural space.
piercing said vertebral disc tissue with said distal tip and urging said tip into said disc tissue until said distal tip is embedded sufficiently within saidtissue to be rotatably anchored at said distal tip;
rotating said apparatus thereby deflecting said intravertebral nerve away from the spinal column and directing said conduit toward said spinal foramen;
and introducing one or more surgical tools through said conduit and into said:
spinal foramen to access said epidural space.
20. The method of Claim 19, wherein the body of said apparatus comprises an elongated hollow sleeve exiting at said conduit, wherein the hollow sleeve extends from said proximal end of the apparatus to said conduit, said hollow sleeve serving as a guide for the introduction, and removal of one or more surgical tools through the proximal end of said apparatus, through said transverse conduit.
21. The method of Claim 19, wherein said tool is a catheter.
22. The method of Claim 19, wherein said tool is an endoscope.
23. The method of Claim 19, wherein said tool is a rongeur.
24. The method of Claim 19, wherein said tool is an automated arthroscopic shaver blade.
25. The method of Claim 19, wherein the tool is a bipolar cauterizer.
26. A method of Claim 18, further comprising the steps:
placing a patient in a lateral position;
entering said patient retroperitoneally;
positioning a first apparatus adjacent to the lamina of a first vertebra between the superior articulating process of a first vertebra and the inferior articulating process of a second vertebra at an approximate angle of between 35°
and 50° relative to the spinous process, wherein said first apparatus comprises said surgical apparatus of Claim 1; and inserting a second apparatus through said conduit of said first apparatus wherein the angle formed between the longitudinal axis of said first apparatus and the longitudinal axis of said second apparatus is an acute angle, thereby accessing the spinal foramen.
placing a patient in a lateral position;
entering said patient retroperitoneally;
positioning a first apparatus adjacent to the lamina of a first vertebra between the superior articulating process of a first vertebra and the inferior articulating process of a second vertebra at an approximate angle of between 35°
and 50° relative to the spinous process, wherein said first apparatus comprises said surgical apparatus of Claim 1; and inserting a second apparatus through said conduit of said first apparatus wherein the angle formed between the longitudinal axis of said first apparatus and the longitudinal axis of said second apparatus is an acute angle, thereby accessing the spinal foramen.
Applications Claiming Priority (2)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| US08/370,989 | 1995-01-10 | ||
| US08/370,989 US5562695A (en) | 1995-01-10 | 1995-01-10 | Nerve deflecting conduit needle and method |
Publications (1)
| Publication Number | Publication Date |
|---|---|
| CA2208848A1 true CA2208848A1 (en) | 1996-07-18 |
Family
ID=23462034
Family Applications (1)
| Application Number | Title | Priority Date | Filing Date |
|---|---|---|---|
| CA002208848A Abandoned CA2208848A1 (en) | 1995-01-10 | 1996-01-11 | Nerve deflecting conduit needle and method |
Country Status (6)
| Country | Link |
|---|---|
| US (2) | US5562695A (en) |
| EP (1) | EP0957787A1 (en) |
| JP (1) | JPH10512169A (en) |
| AU (1) | AU692677B2 (en) |
| CA (1) | CA2208848A1 (en) |
| WO (1) | WO1996021395A1 (en) |
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-
1995
- 1995-01-10 US US08/370,989 patent/US5562695A/en not_active Expired - Fee Related
-
1996
- 1996-01-11 AU AU47535/96A patent/AU692677B2/en not_active Ceased
- 1996-01-11 WO PCT/US1996/000394 patent/WO1996021395A1/en not_active Application Discontinuation
- 1996-01-11 CA CA002208848A patent/CA2208848A1/en not_active Abandoned
- 1996-01-11 JP JP8521817A patent/JPH10512169A/en active Pending
- 1996-01-11 EP EP96903447A patent/EP0957787A1/en not_active Withdrawn
- 1996-06-27 US US08/669,720 patent/US5730754A/en not_active Expired - Fee Related
Also Published As
| Publication number | Publication date |
|---|---|
| EP0957787A4 (en) | 1999-12-22 |
| JPH10512169A (en) | 1998-11-24 |
| AU4753596A (en) | 1996-07-31 |
| US5562695A (en) | 1996-10-08 |
| US5730754A (en) | 1998-03-24 |
| WO1996021395A1 (en) | 1996-07-18 |
| AU692677B2 (en) | 1998-06-11 |
| EP0957787A1 (en) | 1999-11-24 |
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Legal Events
| Date | Code | Title | Description |
|---|---|---|---|
| FZDE | Discontinued |