阅读说明：本技术 患者安装的外科支撑件 (Patient mounted surgical support ) 是由 Z.布特瓦拉 A.梅代罗斯 N.米勒 R.洛美丽 于 2018-09-24 设计创作，主要内容包括：本文描述了外科支撑器械,该外科支撑器械可联接到例如植入的锚定件并且提供用于将其他外科器具联接到其上的平台。在一个实施方案中,器械可包括细长主体,该细长主体具有从其远侧部分横向延伸的相对的突起部,该相对的突起部可至少部分地围绕可植入锚定件的柄部,使得细长主体的纵向轴线从锚定件的纵向轴线横向偏移。器械还可包括被构造成在锚定件的头部上施加拖曳力以控制器械相对于锚定件的多轴移动的锁。此外,细长主体的近侧部分可被构造成用于接纳包括多个组织操纵器具的牵开器组件并且选择性地将牵开器组件锁定在沿着细长主体的长度的多个位置中的任一处。(Described herein are surgical buttress instruments that can be coupled to, for example, an implanted anchor and provide a platform for coupling other surgical instruments thereto. In one embodiment, an instrument can include an elongate body having opposing projections extending laterally from a distal portion thereof, the opposing projections can at least partially surround a handle of an implantable anchor such that a longitudinal axis of the elongate body is laterally offset from a longitudinal axis of the anchor. The instrument may further include a lock configured to exert a drag force on the head of the anchor to control polyaxial movement of the instrument relative to the anchor. Further, the proximal portion of the elongate body can be configured for receiving a retractor assembly comprising a plurality of tissue manipulation instruments and selectively locking the retractor assembly at any of a plurality of positions along the length of the elongate body.)

1. A surgical instrument, comprising:

an elongated body;

opposing projections extending laterally from a distal portion of the elongate body, the opposing projections configured to at least partially surround a handle of an implantable anchor at a location distal to a proximal head of the anchor such that a longitudinal axis of the elongate body is laterally offset from a longitudinal axis of the anchor; and

a lock configured to exert a drag force on the head of the anchor to control polyaxial movement of the instrument relative to the anchor;

wherein a proximal portion of the elongate body is configured for receiving a retractor assembly comprising a plurality of tissue manipulation instruments and selectively locking the retractor assembly at any of a plurality of positions along a length of the proximal portion of the elongate body.

2. The instrument of claim 1, wherein the lock is configured to translate relative to the elongate body and contact an upper portion of the proximal head of the anchor.

3. The instrument of claim 2, further comprising a biasing element disposed within the lumen of the elongate body and configured to urge the lock into contact with an anchor head to apply the drag force to the anchor.

4. The instrument of claim 2, further comprising a locking screw disposed within a lumen of the elongate body and configured to adjust the drag force exerted on the head of the anchor.

5. The instrument of claim 2, wherein the lock includes a laterally extending annular protrusion at a distal end thereof that contacts the anchor head while remaining proximate to a drive feature formed on a proximal end of the anchor head.

6. The instrument of claim 5, wherein the lock further comprises an annular drive guide pivotally coupled thereto.

7. The instrument of claim 1, wherein the proximal portion of the elongated body includes a plurality of holes formed therein configured to receive locking pins of the retractor assembly to selectively lock the retractor assembly at any of a plurality of positions along the length of the proximal portion of the elongated body.

8. The instrument of claim 1, wherein the proximal portion of the elongate body comprises a ratchet configured to engage a pawl coupled to the retractor assembly to selectively lock the retractor assembly at a plurality of positions along the proximal portion of the elongate body.

9. The instrument of claim 1, wherein the plurality of tissue manipulating implements are laterally translatable relative to the longitudinal axis of the elongate body.

10. The instrument of claim 9, wherein the plurality of tissue manipulating implements are pivotable about an axis transverse to the longitudinal axis of the elongate body.

11. A surgical method, comprising:

positioning opposing protrusions of a handle extension instrument at least partially around a handle of an implantable anchor at a location distal to a proximal head of the anchor such that a longitudinal axis of an elongate body is laterally offset from a longitudinal axis of the anchor;

applying a drag force on the head of the anchor to control multi-axial movement of the handle extension instrument relative to the anchor;

coupling a retractor assembly comprising a plurality of tissue manipulation instruments to a proximal portion of the handle extension instrument; and

retracting soft tissue by moving the plurality of tissue manipulating instruments of the retractor assembly.

12. The method of claim 11, wherein applying a drag force on the head of the anchor comprises translating a lock relative to the elongate body to contact an upper portion of the proximal head of the anchor.

13. The method of claim 11, further comprising:

adjusting a position of the retractor assembly relative to the elongate body to position the plurality of tissue manipulating instruments relative to tissue; and

locking the position of the retractor assembly relative to the elongate body.

14. The method of claim 11, wherein retracting soft tissue by moving the plurality of tissue manipulating instruments of the retractor assembly comprises translating opposing instruments in a medial-lateral direction.

15. The method of claim 14, wherein retracting soft tissue by moving the plurality of tissue manipulating instruments of the retractor assembly further comprises moving the opposing instruments diagonally to bring their distal ends closer to or farther away from each other.

16. The method of claim 11, further comprising coupling a light source to the retractor assembly to illuminate a working space between the plurality of tissue manipulating instruments.

17. The method of claim 11, further comprising coupling the retractor assembly to an external rigid structure.

18. The method of claim 11, wherein the retractor assembly is anchored only to the anchor.

19. The method of claim 11, further comprising implanting the anchor within bone prior to positioning the opposing projections of the handle extension instrument at least partially around the handle of the anchor.

20. The method of claim 11, further comprising implanting the anchor within bone after positioning the opposing projections of the handle extension instrument at least partially around the handle of the anchor.

21. The method of claim 11, further comprising coupling a multi-axial receiver head to the proximal head of the anchor.

22. A surgical instrument assembly comprising:

an implantable anchor having a proximal head and a distally extending stem having a diameter less than a diameter of the proximal head;

an anchor extension comprising

An elongated body;

opposing projections extending laterally from a distal portion of the elongate body, the opposing projections at least partially surrounding the handle of the anchor at a location distal to a proximal head of the anchor such that a longitudinal axis of the elongate body is laterally offset from a longitudinal axis of the anchor;

a lock that exerts a drag force on the head of the anchor to control multi-axial movement of the extension relative to the anchor;

a tissue retractor coupled to a proximal portion of the anchor extension, the tissue retractor comprising a plurality of instruments that move laterally relative to the longitudinal axis of the elongate body of the anchor extension to retract tissue.

Technical Field

The present disclosure relates generally to surgical instruments, systems, and methods, and more particularly to instruments, systems, and methods for providing access to a surgical site using patient-mounted components. Such instruments, systems, and methods may be used in various procedures, such as orthopedic or neurosurgical procedures, such as spinal fusion procedures.

Background

Surgery is used to treat and treat various diseases, conditions, and injuries. Surgical access to internal tissue is often required through open or minimally invasive surgery. The term "minimally invasive" refers to all types of minimally invasive surgical procedures, including endoscopic, laparoscopic, arthroscopic, natural orifice intraluminal, and natural orifice endoscopic procedures. Minimally invasive surgery may have many advantages over traditional open surgery, including reduced trauma, faster recovery, reduced risk of infection, and reduced scarring.

Whether minimally invasive or not, there are a variety of surgical procedures in which it may be desirable to form a working channel within a patient to provide access to a surgical site within the patient. One such example is orthopedic or neurosurgical procedures, including, for example, spinal fusion procedures, in which it may be desirable to form a working channel through tissue of a patient to access its vertebrae and/or an intervertebral disc disposed between adjacent vertebrae.

Various methods for providing such working channels are known, including various devices that anchor to an operating table on which a patient is disposed, penetrate tissue without anchoring to any other structure, or couple with multiple anchors implanted in a bone of a patient. In such arrangements, the device may not be properly supported, may undesirably move relative to the patient in the event the patient moves relative to the operating table or some other external structure, or may interfere with certain aspects of the surgery performed by the surgeon or other user.

For example, in spinal surgery involving surgery on an intervertebral disc between adjacent vertebrae of a patient, access to the disc space may be difficult. Previous methods may involve performing procedures on the intervertebral disc prior to implanting pedicle screws into adjacent vertebrae. However, surgical procedures on intervertebral discs may involve removing portions of bone from adjacent vertebrae, which may make subsequent pedicle screw implantation more difficult. Thus, it may be desirable to implant the screws prior to removing the vertebrae, but the surgeon cannot implant the pedicle screws with the receptacle heads prior to performing the intervertebral disc procedure because the receptacle heads (and the extension posts typically coupled thereto) may obstruct access to the intervertebral disc space. Thus, surgeons typically rely on inserting a guide wire for the pedicle screw, bending the guide wire away from the intervertebral space to perform an intervertebral disc procedure around the guide wire, and then implanting the pedicle screw.

The presence of modular pedicle screws may allow for the implantation of pedicle anchors prior to performing an intervertebral disc procedure. This is because modular pedicle screws may include flat type implantable anchors that can be implanted without obstructing access to, for example, the intervertebral disc. The spinal fixation element receiver may be coupled to the anchor after implantation and completion of any intervertebral disc manipulation. Such anchors may also provide a rigid access point to the patient's anatomy.

Accordingly, there is a need for improved access devices, systems, and methods that can simplify the instruments and methods of various surgical procedures. For example, there is a need for improved access devices, systems, and methods that can utilize anchors implanted in a patient's anatomy to support surgical instruments.

Disclosure of Invention

In some embodiments, a patient-mounted surgical buttress is provided that is coupleable to an implanted anchor and provides an adjustable and selectively lockable platform for securing other surgical instruments and/or assemblies. For example, a surgical buttress may be provided that may be coupled to a single implanted pedicle screw or other anchor and provide selective or lockable polyaxial adjustment relative thereto. In addition, the surgical support may be configured to be coupled to another instrument or assembly, such as a tissue retractor, which may manipulate tissue to provide a working channel to a surgical site, such as an intervertebral disc space of a patient. Such support instruments may advantageously be introduced to the patient via coupling with the implanted anchor, and may minimize the space required to support the retractor or other instruments. While the instruments, devices, systems, and methods described herein may be used in a variety of surgical procedures, they may have particular use in various orthopedic or neurosurgical procedures, such as spinal procedures.

In one aspect, a surgical instrument is provided and can include an elongate body and opposing projections extending laterally from a distal portion of the elongate body, the opposing projections can be configured to at least partially surround a handle of an implantable anchor at a location distal to a proximal head of the anchor such that a longitudinal axis of the elongate body is laterally offset from a longitudinal axis of the anchor. The instrument may further include a lock configured to exert a drag force on the anchor head to control polyaxial movement of the instrument relative to the anchor. Further, the proximal portion of the elongate body can be configured to receive a retractor assembly including a plurality of tissue manipulation blades and selectively lock the retractor assembly at any of a plurality of positions along the length of the proximal portion of the elongate body.

The instruments and methods described herein may have a variety of additional features and/or variations, all of which are within the scope of the present invention. In some embodiments, for example, the lock can be configured to translate relative to the elongate body and contact an upper portion of the proximal head of the anchor. In some embodiments, the instrument can further include a biasing element disposed within the lumen of the elongate body, the biasing element can be configured to urge the lock into contact with the anchor head to exert a drag force on the anchor. In certain embodiments, the instrument can further include a locking screw disposed within the lumen of the elongate body and configured to adjust a drag force exerted on the head of the anchor. Still further, the lock may include a laterally extending annular protrusion at a distal end thereof that may contact the anchor head while maintaining access to a drive feature formed on a proximal end of the anchor head. In some embodiments, the lock may further comprise an endless drive guide pivotally coupled thereto.

In certain embodiments, the proximal portion of the elongate body can include a plurality of holes formed therein, which can be configured to receive locking pins of a retractor assembly to selectively lock the retractor assembly at any of a plurality of positions along the length of the proximal portion of the elongate body. In other embodiments, the proximal portion of the elongate body can include a ratchet configured to engage a pawl coupled to the retractor assembly to selectively lock the retractor assembly at a plurality of positions along the proximal portion of the elongate body.

In some embodiments, the plurality of tissue manipulating blades may be laterally translatable relative to the longitudinal axis of the elongate body. For example, in some embodiments, the blades may be translated toward or away from each other in the medial-lateral direction. Further, in some embodiments, the plurality of tissue manipulating blades may be pivotable about an axis transverse to the longitudinal axis of the elongate body. Such movement may include a diagonal movement in which the distal ends of the plurality of tissue manipulating instruments are moved toward or away from each other while the distance between the proximal ends of the plurality of tissue manipulating instruments remains constant.

In another aspect, a surgical method is provided that includes positioning opposing projections of a handle extension instrument at least partially around a handle of an implantable anchor at a location distal to a proximal head of the anchor, thereby laterally offsetting a longitudinal axis of an elongate body from the longitudinal axis of the anchor, and exerting a drag force on the head of the anchor to control polyaxial movement of the handle extension instrument relative to the anchor. The method may further include coupling a retractor assembly including a plurality of tissue manipulation instruments to the proximal portion of the handle extension instrument, and retracting the soft tissue by moving the plurality of tissue manipulation instruments of the retractor assembly.

As with the system described above, many variations and additional features are possible. For example, in some embodiments, applying the drag force on the head of the anchor can include translating the lock relative to the elongate body to contact an upper portion of the proximal head of the anchor. As another example, in some embodiments, the method can further include adjusting a position of the retractor assembly relative to the elongate body to position the plurality of tissue manipulating instruments relative to the tissue, and locking the position of the retractor assembly relative to the elongate body.

In some embodiments, retracting the soft tissue by moving the plurality of tissue manipulation instruments of the retractor assembly may comprise translating the opposing instruments in the medial-lateral direction. In certain embodiments, retracting soft tissue by moving a plurality of tissue manipulating instruments of the retractor assembly may also and/or alternatively comprise moving opposing instruments diagonally to bring their distal ends closer to or farther away from each other.

In some embodiments, the method can further include coupling a light source to the retractor assembly to illuminate a working space between the plurality of tissue manipulating blades. Further, in some embodiments, the method can further include coupling the retractor assembly to an external rigid structure, such as an operating table or the like. However, in certain other embodiments, the retractor assembly may be anchored only to the anchor.

In some embodiments, the method can further include implanting the anchor within the bone prior to positioning the opposing projections of the stem extension instrument at least partially around the stem of the anchor. In other embodiments, the method may include implanting the anchor within the bone after positioning the opposing projections of the stem extension instrument at least partially around the stem of the anchor. Further, in some embodiments, the method can include coupling the multi-axial receiver head to the proximal head of the anchor.

In another aspect, a surgical instrument assembly is provided that includes an implantable anchor having a proximal head and a distally extending stem having a diameter that is less than a diameter of the proximal head, and an anchor extension. The anchor extension may include an elongate body and opposing projections extending laterally from a distal portion of the elongate body, the opposing projections at least partially surrounding the handle of the anchor at a location distal to the proximal head of the anchor such that the longitudinal axis of the elongate body is laterally offset from the longitudinal axis of the anchor. The anchor extension may also include a lock that exerts a drag force on the anchor head to control polyaxial movement of the extension relative to the anchor. The assembly can also include a tissue retractor coupled to the proximal portion of the anchor extension, the tissue retractor including a plurality of implements that move laterally relative to the longitudinal axis of the elongate body of the anchor extension to retract tissue.

Any of the above features or variations can be applied to any particular aspect or embodiment of the present disclosure in a variety of different combinations. Any particular combination is not explicitly recited only to avoid redundancy in the context of the present invention.

Drawings

FIG. 1 is a diagrammatic view of one embodiment of a surgical instrument according to the teachings provided herein;

FIG. 2A is a front perspective view of the lock of the instrument of FIG. 1;

FIG. 2B is a rear perspective view of the lock of FIG. 2A;

FIG. 3A is a front perspective view of the elongated body of the instrument of FIG. 1;

FIG. 3B is a rear perspective view of the elongated body of FIG. 3A;

FIG. 4 is a partially transparent side view of the instrument of FIG. 1 coupled to an implantable anchor;

FIG. 5 is an exploded view of the instrument of FIG. 1;

FIG. 6A is a rear perspective view of another embodiment of an instrument according to the teachings provided herein;

FIG. 6B is a rear perspective cutaway view of the instrument of FIG. 6A;

FIG. 7 is a front perspective view of another embodiment of a surgical instrument coupled to an implantable anchor;

fig. 8A is a side view of another embodiment of a surgical instrument coupled to an implantable anchor;

FIG. 8B is a front perspective view of the instrument of FIG. 8A;

FIG. 8C is a partially transparent side view of the instrument of FIG. 8A;

FIG. 9A is a front perspective view of another embodiment of a surgical instrument according to the teachings provided herein;

FIG. 9B is a cross-sectional view of the instrument of FIG. 9A;

FIG. 10A is a front perspective view of another embodiment of a surgical instrument according to the teachings provided herein;

FIG. 10B is a cross-sectional view of the instrument of FIG. 10A;

FIG. 10C is a rear perspective view of the instrument of FIG. 10A;

FIG. 11 is a front perspective view of another embodiment of a surgical instrument according to the teachings provided herein;

FIG. 12 is a front perspective view of one embodiment of a retractor assembly;

fig. 13A is a front perspective view of an embodiment of a surgical instrument assembly including the extension of fig. 9A and 9B, the retractor assembly of fig. 12, and a driver;

FIG. 13B is a rear perspective view of the assembly of FIG. 13A;

fig. 14 is a front perspective view of an embodiment of a surgical instrument assembly including the extension of fig. 9A and 9B and the retractor assembly of fig. 12;

FIG. 15 is a front perspective view of the surgical instrument assembly of FIG. 14 implanted in a patient's spine;

FIG. 16 is a top view of the assembly of FIG. 14 implanted in a patient's spine along with other instruments for performing medial and lateral tissue retraction;

fig. 17A is a front perspective view of another embodiment of a retractor assembly according to the teachings provided herein;

fig. 17B is a front perspective view of a tissue manipulation instrument of the retractor assembly of fig. 17A;

FIG. 18A is a side view of an embodiment of a surgical instrument including a tissue manipulating implement coupled thereto;

FIG. 18B is a front perspective view of the instrument of FIG. 18A;

FIG. 18C is a top view of the instrument of FIG. 18A;

FIG. 19 is a front perspective view of one of the tissue manipulating implements of the instrument of FIG. 18A;

FIG. 20 is a front perspective view of another embodiment of a surgical instrument including a tissue manipulating implement coupled thereto;

FIG. 21 is a perspective view of an anchor extension of the instrument of FIG. 20;

FIG. 22 is a perspective view of a tissue manipulating instrument of the instrument of FIG. 20;

FIG. 23 is a front perspective view of an anchor extension and a tissue manipulation tool coupled to the instrument of FIG. 20;

FIG. 24A is an alternative front perspective view of the instrument of FIG. 20, illustrating a first type of relative movement between tissue manipulating instruments;

FIG. 24B is an alternative top view of the instrument of FIG. 20 illustrating a first type of relative movement between the tissue manipulating instruments;

FIG. 25 is an alternative front perspective view of the instrument of FIG. 20, illustrating a second type of relative movement between tissue manipulating implements;

FIG. 26 is a side perspective view of one embodiment of a spinal traction device in accordance with the teachings provided herein;

FIG. 27A is a side perspective view of the traction instrument of FIG. 26 coupled with other surgical instruments described herein;

FIG. 27B is a detail view of the distal end of the traction instrument of FIG. 26 approaching the other surgical instrument illustrated in FIG. 27A;

FIG. 28 is a side perspective view of the spinal traction device of FIG. 26 applying traction to the other surgical instrument illustrated in FIG. 27A;

FIG. 29 is a side perspective view of another embodiment of a spinal traction device in accordance with the teachings provided herein;

FIG. 30 is a side perspective view of the traction instrument of FIG. 29 coupled with other surgical instruments described herein;

FIG. 31A is a side perspective view of the traction device of FIG. 29 being actuated; and is

FIG. 31B is a side perspective view of the traction device of FIG. 29 applying traction to the other surgical instrument illustrated in FIG. 30;

FIG. 32 is a perspective view of an embodiment of a surgical instrument assembly;

FIG. 33 is an exploded view of components of the surgical instrument assembly of FIG. 32;

FIG. 34 is a perspective view of various sizes of surgical instruments;

FIG. 35A is a first perspective view of the reference bar;

FIG. 35B is a second perspective view of the reference bar;

FIG. 36A is a perspective view of a first step in a method of using a surgical instrument component removal tool;

FIG. 36B is a perspective view of a second step in the method of using the surgical instrument component removal tool of FIG. 36A;

FIG. 36C is a perspective view of a third step in the method of using the surgical instrument component removal tool of FIG. 36A; and is

Fig. 36D is a perspective view of a fourth step in the method of using the surgical instrument component removal tool of fig. 36A.

Detailed Description

Certain exemplary embodiments will now be described to provide an overall understanding of the principles of the structure, function, manufacture, and use of the devices, systems, and methods disclosed herein. One or more examples of these embodiments are illustrated in the accompanying drawings. Those skilled in the art will understand that the devices, systems, and methods specifically described herein and illustrated in the accompanying drawings are non-limiting exemplary embodiments. Features illustrated or described in connection with one exemplary embodiment may be combined with features of other embodiments. Such modifications and variations are intended to be included within the scope of the present disclosure.

In addition, to the extent that linear or circular dimensions are used in the description of the disclosed devices and methods, such dimensions are not intended to limit the types of shapes that may be used in connection with such devices and methods. Those skilled in the art will recognize that the equivalent dimensions of such linear and circular dimensions can be readily determined for any geometric shape. Additionally, in the present disclosure, similarly numbered components of the embodiments generally have similar features. Still further, the size and shape of the device and its components may depend at least on the anatomy of the subject in which the device will be used, the size and shape of the components with which the device will be used, and the method and procedure in which the device will be used.

Fig. 1-5 illustrate an exemplary surgical instrument 100 according to the teachings provided herein. The instrument 100 may be used in a variety of surgical procedures, including spinal procedures, such as microsurgical osteotomies, spinal decompressions, spinal fusions, and the like. In general, instrument 100 may include an elongated body 102, a lock body 104, and a locking actuator 106. The instrument 100 can be configured to couple to an implantable anchor 108, such as a pedicle screw or other bone screw. Instrument 100 may include or be coupled with other components not shown herein. Such components may include, for example, any of the various retractor assemblies described herein, as well as other components, such as a camera or visualization system, as well as any of the other various surgical instruments.

An exemplary method of using the instrument 100 of fig. 1-5 may include any one or more of the following steps, performed in any of a variety of sequences: a) forming an incision in the skin of a patient; b) percutaneously inserting an implantable anchor, such as a pedicle screw or other bone screw, through the incision; c) coupling the instrument 100 to an implanted anchor (e.g., a pedicle anchor); d) coupling a tissue retractor to an instrument; e) providing medial and lateral retraction of tissue surrounding the incision; f) coupling an optical visualization instrument to the tissue retractor and/or instrument; g) resecting a portion of the superior articular process, and/or performing microsurgical decompression surgery; h) extracting intervertebral disc material, including removing cartilage material from vertebral endplates; i) inserting an interbody device; and j) deploying a stabilization mechanism to stabilize the intervertebral section.

Returning to fig. 1-5, the elongate body 102 of the instrument 100 can include a prong 110 formed at a distal end thereof that can engage the narrowed neck 402 of the anchor 108, the prong 110 can include opposing projections 302a, 302b that can be transverse or oblique to the longitudinal axis L of the elongate body₃The projections 302a, 302b may define an open-ended U-shaped or other recess 304 sized to receive a portion of the implantable ANCHOR 108. for example, the projections 302a, 302b may be configured to fit around a proximal portion of a BONE ANCHOR, which may be part of a modular monoaxial or polyaxial pedicle screw.

Upon disposing the protrusions 302a, 302b of the prongs 110 about the neck 402 of the anchor 108, friction between the elongated body and the anchor can create a drag force either against or preventing movement of the elongated body relative to the anchor. In certain embodiments, the drag force is sufficient to prevent movement of the elongate body 102 relative to the anchor 108 in the absence of an intentional manipulation force being applied, such as by a user grasping the elongate body and polyaxially adjusting its position relative to the anchor. Such a drag force may be applied in a variety of ways. For example, in some embodiments, the tissue forming the walls of the incision around the anchor 108 can exert sufficient force on the prongs 110 to prevent relative movement between the prongs and the anchor. Such force may be an inward or compressive force exerted by tissue surrounding the anchor 108, or the prongs 110 may be pulled upward such that the patient's skin surface is disposed below the prongs and exerts an upward force on the prongs. As another example, the anchor 108 can be tightened to compress the prongs 110 between the head portion 404 of the anchor and the bone surface.

Additionally or alternatively, the instrument may include a lock configured to exert a drag force on the anchor head to control polyaxial movement of the instrument 100 relative to the anchor 108, as shown in fig. 1-5, such a lock may include a lock body 104 coupled to the elongate body 102 and configured along the elongate body's longitudinal axis L₃The lock body 104 may also include a transversely extending annular projection 114 at a distal end thereof that may be configured to contact and apply a drag force to the proximal head 404 of the anchor 108. the lumen 202 defined by the annular projection 114 may maintain access to a drive feature 502 formed on the proximal end of the head 404 of the anchor 108. the inner lumen, in combination with the projection 114 and the transverse extension of the prong 110, may orient the instrument 100 such that the longitudinal axis L of the instrument₁To the longitudinal axis L of the anchor 108₂Laterally offset or not coaxial. Such a configuration can allow a driver or other instrument to access the drive feature 502 of the anchor 108 even if the instrument 100 is coupled thereto. This can be done upon coupling the instrument 100 to the anchor 108The anchor is flexibly implanted in either of the anterior and posterior cases.

The lock body 104 may also include any of a variety of features to facilitate a sliding coupling with the elongated body 102. For example, the lock body 104 may include guide tabs 204, 206 that may be configured to be received within longitudinally extending slots 306 formed on the elongated body. The protrusions 204, 206 and slots 306 may have any of a variety of complementary shapes, and in some embodiments, may include one or more angled surfaces, such as dovetails or the like, that may allow longitudinal or axial translation while preventing lateral or radial separation of the components. The slot 306 may also include one or more widened portions 308, 310 such that the lock body 104 may be translated to a position that allows lateral or radial separation of the lock body from the elongate body 102.

The lock body 104 may also include a slot 208 formed therein that may receive a second lock 504. The second lock 504 may be configured to prevent the lock body 104 from translating relative to the elongated body 102 to the aforementioned position that allows the lock body to laterally or radially separate from the elongated body. For example, the second lock 504 may include a protrusion 506 that, when assembled, may extend through the passage 210 formed in the lock body 104 and into the aperture 312 formed in the elongated body 102. Thus, proximal translation of the lock body 104 may be limited by the interaction of the protrusions 506 with the proximal wall of the aperture 312 at a location where the protrusions 204, 206 of the lock body 104 are not aligned with the widened portions 308, 310 of the slot 306 in the elongated body. However, removal of the second lock 504 may allow the lock body 104 to translate proximally relative to the elongated body 104 without restriction to a position where the protrusions 204, 206 are aligned with the widened portions 308, 310 of the slot 306, and separation of the two components is possible.

As described above, the lock body 104 can exert a drag force on the proximal head 404 of the anchor 108 to control (e.g., selectively allow or prevent) polyaxial movement of the instrument 100 relative to the anchor 108 using different magnitudes of manipulation force as necessary for the purpose. The amount of force applied by the lock body 104 may be controlled by a locking actuator 106, such as a locking screw in the illustrated embodiment. The locking screw 106 may be disposed within the inner lumen 314 of the elongate body 102, for example, threads 406 formed on the locking screw 106 may engage complementary threads 316 formed on an inner surface of the lumen 314. Distal advancement of the screw 106 may apply a distal force to the lock body 104 via the protrusion 210 extending into the hole 318 formed in the elongate body 102. In some embodiments, the distal portion of the locking screw or other actuator 106 may directly contact the protrusion 210. In other embodiments and as shown, for example, in fig. 4, a biasing element 408 may be disposed between the screw 106 and the protrusion 210. The biasing element 408 may be, for example, a coil or other compression spring that can apply a desired drag force capable of semi-rigidly maintaining the position of the instrument 100 relative to the anchor 108 while continuing to allow multi-axial movement of the instrument, for example, if the user overcomes the drag force. When desired, complete locking of all relative movement between the instrument and anchor can be achieved by distal advancement of a locking screw or other actuator 106.

In some embodiments, the instrument 100 can be configured to allow attachment of the modular receiver head to the proximal head 404 of the anchor 108 without decoupling the anchor and instrument 100. For example, in the illustrated embodiment, the locking actuator 106 may be at least partially retracted proximally and may be completely removed to eliminate the drag force exerted by the lock body 104 on the anchor 108. Further, the second lock 504 may be removed to allow the lock body 104 to translate proximally and then decouple from the elongate body 102. An instrument for assisting in the removal of the lock body 104 is shown in figures 36A to 36D. A modular receiver head (not shown) may then be coupled to the proximal head 404 of the anchor 108. The elongated body 102 may be left in place because it is offset from the anchor 108 by the laterally extending projections 302a, 302b of the prongs 110, and because the projections 302a, 302b disposed below the proximal head 404 will not interfere with coupling the receiver head to the proximal head of the anchor 108. Additionally and as described above, in some embodiments, the relative position of the elongated body 102 with respect to the anchor 108 may continue to remain even after the lock body 104 is removed by forces applied, for example, by the anchor and tissue surrounding the elongated body. Still further, in some embodiments, the elongate body 102 or other components coupled thereto can be coupled to an external rigid structure, such as a surgical table or the like. Such external rigid structures may help maintain the position of the elongated body 102 even after the lock body 104 is removed.

In some embodiments, the retractor assembly may be coupled to a proximal portion of the elongate body 102 and may be selectively lockable at any of a plurality of positions along the length of the proximal portion of the elongate body.for example, and as shown in fig. 3B and 4, the elongate body 102 may include a plurality of notches 320 formed along the length of a proximal portion thereof.a series of notches 320 may be used as ratchets that may be engaged with pawl-like features of the retractor assembly (such as protrusions or other portions of the assembly) to secure the assembly from following the longitudinal axis L of the elongate body 102₃And (4) moving.

Thus, the support instrument 100 described above can provide a platform for mounting a retractor assembly that is anchored to a single implanted bone screw or other anchor. This may provide a number of advantages. For example, it is advantageous to utilize a support that is anchored to the patient's body, as opposed to an external structure (such as a surgical table or the like). For example, anchoring relative to the patient's body may provide advantages by maintaining the relative position between the access device and the patient even if the patient moves during surgery. Moreover, anchoring to a single bone screw or other anchor (e.g., as opposed to a structure spanning multiple implanted anchors) may be advantageous because it may reduce the footprint of the instrument and may allow more working space for other instruments used in the procedure. However, in some embodiments, it is possible to also anchor the instruments and assemblies described herein to an external structure, such as a surgical table or the like. In some embodiments employing external fixation, locking against movement relative to the implanted anchor can be avoided, such that some adjustment can be made relative to the implanted anchor, in the event of patient movement, etc.

Various alternative embodiments of the bracing instrument are within the scope of the present disclosure. For example, fig. 6A-11 illustrate various exemplary alternative embodiments of a surgical buttress instrument similar to instrument 100. For example, the instrument 600 of fig. 6A and 6B is coupled to the anchor 108 and includes an alternative configuration of an elongate body 602 and a lock body 604. For example, the lock body 604 may include a hooked protrusion 608 that may be disposed within a slot 610 formed on the elongated body 602. The protrusions 608 and slots 610 are alternative geometries that may serve similar purposes to the protrusions 204, 206 and slots 306 described above. An alternative geometry of the locking screw 606 can also be seen in figures 6A and 6B, which passes through a proximal portion 612 of the elongate body 602 and directly contacts a proximal end 614 of the lock body 604. Further, the elongate body 602 includes a post 616 extending toward the proximal end, which can be used to couple the instrument 600 to, for example, a retractor assembly or an external fixation structure, as described herein.

Fig. 7 illustrates another embodiment of an instrument 700 coupled to the anchor 108. Instrument 700 includes an elongated body 702, a lock body 704, and a locking actuator 706 for selectively controlling polyaxial movement of the instrument relative to the anchor. The elongate body 702 includes an extended proximal portion 708 that increases the height of the elongate body to provide additional mounting options for coupling a retractor assembly thereto. Any desired length of the elongate body 702 and its proximal portion 708 is possible, and the length of the locking actuator 706 can be adjusted accordingly to maintain the maneuverability of the instrument. In addition, the proximal portion 708 can include a plurality of holes 710 formed therein that can be used to lock the position of the retractor assembly relative thereto. For example, one or more of the holes 710 may receive one or more locking pins coupled to the retractor assembly to achieve locking between the components, similar to the ratchet and pawl configuration described above. Alternatively, the retractor assembly or other instrument can be coupled to the elongate body proximal portion 708 in another manner, such as by clamping around the cylindrical proximal portion of the elongate body with sufficient force to prevent relative movement between the two components.

Fig. 8A-8C illustrate another embodiment of an instrument 800 that can be coupled to the anchor 108 and includes an alternative configuration of an elongate body 802 and a lock body 804. For example, the lock body 804 may include a hook-shaped protrusion 808 disposed within a slot formed on the elongated body 802, similar to the instrument 600 described above. Further, the proximal surface of the hook protrusion 808 may be used to control the drag force exerted by the lock body 804 on the anchor 108 via the locking actuator 806. In the illustrated embodiment, the locking actuator includes a screw 806 threaded into a proximal portion of the elongate body 802, as well as a biasing element 810 and an intermediate member 812 extending between the protrusion 808 and the biasing element 810.

The proximal portion of the elongate body 802 may include one or more holes 815 formed therein, which may, for example, receive locking pins from a retractor assembly or other instrument to couple to the instrument 800, similar to the holes 710 described above. The proximal portion of the elongate body may also include one or more tool interfacing surfaces 814, such as one or more pairs of opposing flat surfaces, which may be used to prevent rotation of the elongate body 802 when torque is applied to the locking screw 806. For example, a wrench or other tool may be used to secure or apply a counter torque to the elongated body 802 when rotating the locking screw 806 to engage or disengage the lock of the instrument 800 relative to the anchor 108.

Still further, the lock body 804 of the instrument 800 may include a driver guide 816 coupled thereto. In the illustrated embodiment, the driver guide 816 is a ring-shaped member that is pivotably coupled to the proximal end of the lock body 804. The driver guide 816 can pivot or rotate between a first configuration, as shown in fig. 8A and 8B, and a second configuration, as shown in fig. 8C. In the first configuration, the driver guide extends laterally from the elongated body 802 and the lock body 804 such that an inner lumen 818 defined by the guide is aligned with an inner lumen of the annular protrusion 820 of the lock body 804. In the second configuration, the driver guide 816 is aligned with the lock body 804 and rests flush against the elongated body 802, thereby clearing the space above the anchor 108 and annular protrusion 820. In some embodiments, driver guide 816 can include one or more retention features, such as protrusions 822a, 822B that can engage with complementary features (such as recesses 824, 824B formed on elongate body 802) to retain driver guide 816 in the second configuration of fig. 8C and prevent it from accidentally falling into the first configuration of fig. 8A and 8B.

Fig. 9A and 9B illustrate a similar instrument 900 that includes an elongated proximal portion 918 having a plurality of holes 915a, 915B formed therein about its circumference and along its length. The hole 915 may be configured to receive one or more locking pins that may be coupled to a retractor assembly of the instrument 900 or other surgical instrument to lock any of the rotational and longitudinal positions of the instrument relative to the instrument. The instrument 900 also includes an alternative locking actuator including a screw 906 having a distal post 922 that can extend into the inner lumen of the compression spring biasing element 910 and can directly contact the intermediate element 912 when advanced distally to a sufficient extent, as shown in fig. 9B. The posts may help prevent buckling of the compression spring 910 when not in contact with the intermediate member 912 to directly apply a force thereto.

Fig. 10A-10C illustrate yet another embodiment of an instrument 1000 that includes an elongated body 1002, two-part lock bodies 1004, 1005, and a locking actuator 1006. The elongate body 1002 is similar in construction to the embodiments described above, including a proximal portion 1018 having a plurality of sets of apertures 1015a, 1015b distributed along its length that can be used to lock a retractor assembly or other implement at particular locations along the length of the elongate body 1002. The elongate body 1002 also includes a slot 1020 formed on a distal portion thereof. Portions of the distal lock 1004 and the proximal lock 1005 are disposed within the slot 1020, and a biasing member 1010 (such as a compression spring) may be disposed therebetween to urge the proximal lock proximally and the distal lock distally. Movement of the locks 1004, 1005 may be limited by the proximal and distal ends of the slot 1020, and the biasing element may act to exert at least a minimal drag force on the anchor 108 via the distal lock 1004. Additional drag force may be achieved by rotating the screw 1006 to advance it distally relative to the elongate body 1002 and the proximal lock 1005 distally toward the distal lock 1004, up to and including full locking to prevent relative movement between the instrument 1000 and the anchor 108.

The proximal and distal lock bodies 1004, 1005 may include one or more complementary slots 1022 and protrusions (not visible) to engage the lock bodiesTogether and prevented from moving apart from along the longitudinal axis L of the instrument₁Undesired separation or movement in addition to translation relative to each other. Further, the proximal lock body 1005 may include a pivoting driver guide 1016, similar to driver guide 816 described above. However, in the exemplified embodiment, another retention feature in the form of a slot 1024 is formed on the distal end of the driver guide and can be configured to engage a projection 1026 formed on elongate body 1002 as the driver guide is retracted toward the elongate body to prevent it from inadvertently moving away from the elongate body. The retention features 1024, 1026 may be in addition to or in place of tab features 1028 formed at opposite ends of the driver guide and configured to engage a ridge 1030 formed on the elongate body. Further, in the exemplified embodiment, the ridge 1030 extends a distance along the elongate body to allow the tab feature 1028 to translate with the proximal lock body 1005 relative to the elongate body.

Fig. 11 illustrates yet another embodiment of a buttressing instrument 1100 configured for coupling to an anchor 108. The device 1100 comprises first and second opposite elongate bodies 1102,1103 pivotably coupled to each other at a hinge 1104, thus enclosing an axis P₁Rotate relative to each other. The instrument 1100 further includes a lock 1106 including a first lumen 1108a and a second lumen 1108b configured to receive a proximal portion of each elongate body 1102, 1103. The lumens 1108a, 1108b may have fixed sizes and positions relative to each other such that when fitted over the proximal ends of the elongate bodies 1102,1103, the lock 1106 may maintain the positions of the elongate bodies relative to each other.

The distal portion of each elongate body 1102,1103 can include laterally extending protrusions 1110a, 1110b, which can form a semi-circle such that the two elongate bodies 1102,1103 define a circular recess 1112 between the protrusions when positioned adjacent to each other. Thus, the instrument 1100 may be used by separating the lock 1106 from the elongate bodies 1102,1103 and bringing the proximal ends 1114a,1114b toward each other. This motion may cause the elongate bodies 1102,1103 to rotate about the pivot 1104, moving the distal tabs 1110a, 1110b away from each other. The instrument 1100 may then be passed down over the proximal head 404 of the anchor 108, or laterally over the handle 112 or neck 402 below the proximal head 404. The proximal ends 1114a,1114b of the elongate bodies 1102,1103 can be moved away from each other to cause the distal projections 1110a, 1110b to move toward each other and abut the anchor 108. Applying sufficient force toward the proximal end (pushing them away from each other) can grip the anchor 108 with sufficient force to prevent relative movement between the instrument 1100 and the anchor 108.

The position of instrument 1100 relative to anchor 108 may be locked by passing lock 1106 distally over proximal ends 1114a,1114b of elongate bodies 1102,1103 such that elongate body 1102 is received within lumen 1108a and elongate body 1103 is received within lumen 1108 b. Because the dimensions of the elongated body and the lumen of the lock are complementary, and because the lumens are fixed relative to each other on the lock 1106, the lock can maintain the relative position of the elongated bodies 1102,1103 and prevent separation of the distal tabs 1110a, 1110 b.

In addition, the lock 1106 may include one or more detents, tabs, or other features (not visible) that may interact with a series of notches, teeth, shelves, or other recesses 1116a,1116b formed on each elongated body 1102,1103 to secure and maintain a desired height of the lock 1106 relative to the elongated body. The retractor assembly or other implement can then be coupled to the lock 1106, or the lock can be eliminated, and the assembly can include lumens properly spaced and sized to directly engage the elongate bodies 1102, 1103.

In some embodiments, adjusting the position of the lock 1106 along the length of the elongated body 1102,1103 may not affect the clamping force at which the lock is retained. For example, if sufficient grip is achieved when the proximal portions 1114a,1114b of the elongate bodies 1102,1103 are parallel, the lock 1106 can apply and maintain the same gripping force at any location along the series of recesses 1116a,1116 b. Adjusting the positioning of the lock 1106 (or a retractor assembly including a lumen similar to the lock 1106) along the elongate body 1102,1103 can be used to fix the height of any retractor assembly or other implement coupled to the lock 1106.

In one embodiment, the user may place the distal projections 1110a, 1110b of the instrument 1100 around the cylindrical handle or neck of the anchor 108 and push the proximal ends of the elongate bodies 1102,1103 away from each other to secure the instrument to the anchor. The user can then couple the retractor assembly to the elongate body 1102,1103 by passing the elongate body through a lumen formed in the retractor assembly (or coupling the retractor assembly to the lock 1106 and the lock to the elongate body). The user can then push the retractor down towards the tissue of the patient, sliding it distally along the elongate bodies 1102,1103 until the retractor abuts the tissue of the patient. At such points, the rigid positioning of the lumens receiving the elongate bodies 1102,1103 may maintain their relative positioning, and an upward or proximal force applied to the elongate bodies by the retractor assembly in contact with the patient tissue may secure the distal protrusion against, for example, the underside of the proximal head 404 of the anchor 108, thereby stabilizing the position of the instrument.

12-17B illustrate various embodiments of RETRACTOR assemblies that may be used in conjunction with the support instruments described herein, more details regarding the RETRACTOR assemblies can be found in U.S. application _____ and U.S. patent 7,491,168, entitled "PATIENT-MOUNTED SURGICA L RETRACTOR," filed concurrently herewith, the entire contents of which are incorporated herein by reference.

Fig. 12-16 illustrate a first embodiment of a retractor assembly 1200 that may be coupled to a surgical support instrument 100 such as described above. Retractor 1200 can include a plurality of tissue manipulation instruments, such as tissue manipulation blades 1202, 1204. The tissue manipulation instruments or blades 1202,1204 can have any of a variety of shapes and sizes. For example, the tissue manipulation blades 1202,1204 can have various heights to extend to various depths below the surface of the patient's skin and to various heights above the surface of the skin. Further, in some embodiments, the height of either of the blades 1202,1204 is adjustable, for example, in embodiments where the blades include an inner component and an outer component that are configured to translate relative to each other to change the amount of overlap thereof and the overall length of the two components together. The blades 1202,1204 can also have any of a variety of widths, shapes, and curves. For example, in some embodiments, the blade may be planar, while in other embodiments, such as the illustrated embodiment, the blade may have a semi-circular curve extending along its length.

The tissue manipulating instruments or blades 1202,1204 can each be coupled to a housing 1206,1208 that can be coupled to the rack 1210. Instruments 1202,1204 may be disposed relative to each other such that they may be translated either toward and away from each other to perform tissue retraction. In addition, other forms of movement of implement 1202,1204 are possible. For example, in some embodiments, the implements 1202,1204 can be moved diagonally toward or away from each other. The oblique movement may comprise pivoting the instrument such that its distal ends move either towards and away from each other, while the distance between the proximal ends of the instrument remains constant.

Various movements of the instruments or blades 1202,1204 may be controlled by any of a variety of actuators. For example, the thumbwheel actuators 1212, 1214 can be rotated to control translation of the implements 1202,1204 toward or away from each other by moving the housings along the rack 1210, e.g., via cogs or gears coupled to each actuator 1212, 1214 within each respective housing 1206,1208. Further, in embodiments that enable the opposing instruments 1202,1204 to move obliquely relative to one another, screw actuators 1216, 1218 may be included in the housing to control the instruments or blades 1202,1204, respectively, about axis P₂、P₃Is pivoted. Retractor assembly 1200 can also include features to facilitate repositioning of instruments 1202,1204, such as releases 1220, 1222 that can disengage actuators 1212, 1214 from rack 1210 and allow housings 1206,1208 to slide quickly along the rack, e.g., from a position at one end of the rack to a centered or home position, as shown in fig. 12.

The central portion of the rack 1210 can include a full or partial through-hole or recess 1224 formed therein, which can be configured to be disposed about a proximal portion of a support instrument, such as the proximal portion 918 of the instrument 900 described above and shown in fig. 13A-16. Using any of a variety of locking mechanisms, such as those described herein (e.g., a movable pawl or locking pin), retractor 1200 can be selectively locked to a supporting instrument at any particular location along the length of the supporting instrument and in a rotational orientation relative thereto.

Fig. 13A and 13B illustrate the retractor assembly 1200 coupled to the holding instrument 900 and the anchor 108. In addition, the driver 1302 is inserted through the driver guide 916 and the lumen defined by the annular protrusion 920 of the lock body 904 to engage the drive feature 502 of the anchoring element 108. The driver 1302 may include a proximal end 1304 configured to be rotated by hand or using a tool to assist in implanting or adjusting the position of the anchor 108.

Fig. 13B also illustrates a lock release 1306 that can retract, for example, one or more locking pins inserted into one or more holes 915 formed on the proximal portion 918 of the buttressing instrument 900. Similarly, when a user first couples instrument 900 and retractor 1200, lock release 1306 can be depressed to allow the retractor to slide along the length of elongate body proximal portion 918 without interference. At a desired position along the elongate body, the lock release 1306 can be released, thereby advancing one or more locking pins into one or more holes formed in the elongate body to lock the relative position and/or orientation of the retractor and the elongate body. Any of a plurality of positions along the length of the elongate body may be selected. For example, in the embodiment shown in fig. 13A and 13B, only the distal end 914 of the instrument 900 can be seen above the upper surface of the retractor assembly 1200. Conversely, in fig. 14, the retractor 1200 is shown in a more distal position along the length of the instrument 900 or its elongate body 902. In addition to distal end 914, several layers of holes 915 can be seen above the upper surface of retractor 1200.

Fig. 15 and 16 illustrate a retractor assembly 1200 coupled to a support instrument 900 and an anchor 108 implanted in a patient's vertebra 1502. As described above, a surgical procedure according to the teachings provided herein can include forming an incision 1602 in the patient's skin and tissue over an implantation site. The anchor 108 can then be implanted into the patient's vertebra 1502. The anchors can be implanted individually, and the support instrument 900 and retractor assembly 1200 can be coupled thereto together or after sequential implantation. Alternatively, the entire assembly of anchor 108, instrument 900 and retractor 1200 can be implanted together using a driver, as shown in fig. 13A and 13B.

After coupling to the anchor, the instrument 900 and retractor 1200 can be positioned relative to the anchor 108, as shown. This may be accomplished, for example, by manually manipulating the instrument 900 and retractor 1200 to cause them to move polyaxially relative to the anchor 108. When a desired position is reached, for example, as shown in fig. 15 and 16, in which opposing tissue-manipulating instruments 1202,1204 are configured to retract tissue in medial and lateral directions relative to the patient, the position of instrument 900 may be locked using actuator 906.

If necessary, the position of retractor 1200 along instrument 900 can be adjusted to achieve a desired height of tissue manipulation instruments 1202, 1204. Alternatively, if so equipped, the length of each tissue manipulation instrument may be adjusted to a desired height. For example, the tissue manipulation instruments can be adjusted such that they extend into the incision 1602 and abut against the tissue on the inside and outside of the incision.

To enable better access to, for example, the intervertebral disc 1604 of the adjacent vertebra 1502, the tissue manipulation instruments 1202,1204 may be moved either translationally away from each other or obliquely away from each other in both medial and lateral directions relative to the patient. Fig. 15 illustrates one possible combination of such movements, where tissue manipulating instruments 1202,1204 have been translated along rack 1210 away from each other on the medial and lateral sides (see, e.g., separation of housings 1206,1208 from central portion 1504 of the rack). Furthermore, because its distal end 1506 is at an angle to the distal end 1508 of the instrument 1204, the tissue manipulation instrument 1202 is shown moving obliquely away from the instrument 1204. The distance between the proximal ends 1510, 1512 of the implements 1202,1204 remains constant.

In some embodiments, the working channel may extend to an adjacent implantable ANCHOR 1606 implanted in an adjacent vertebra 1608. the adjacent implant ANCHOR 1606 may be any of a variety of ANCHORs and/or extension components known in the art.

Fig. 16 also illustrates that other surgical instruments can be introduced into the working channel defined by the tissue manipulation instruments 1202,1204, and in some embodiments, one or more instruments can be coupled to one or more tissue manipulation instruments. For example, a light or illumination source 1610 may be coupled to one of the tissue manipulating instruments to illuminate the working channel. Alternatively or additionally, a visualization system 1612 (such as a camera) can be coupled to one of the implements 1202,1204 to provide a magnified view of the working channel on an external monitor or the like.

Once the tissue of the incision wall is retracted to form the working channel, any of a variety of surgical procedures can be performed by introducing one or more instruments through the working channel defined by the tissue manipulation instruments of the retractor assembly. For example, procedures on the disc space, such as disc replacement, discectomy, endplate preparation, fusion cage insertion, bone graft delivery, and the like, may be performed by passing an instrument or implant through the working channel.

Many variations and alternative embodiments of the above-described instruments and assemblies are also possible. For example, in fig. 17A and 17B, the retractor 1700 is shown providing only translation of its tissue manipulation instruments 1702, 1704 toward or away from each other along their racks 1710. As shown in FIG. 17B, the implements 1702, 1704 do not include any mechanism for moving diagonally relative to each other. However, in some embodiments, this may allow these appliances to be smaller and thinner than the appliances described above.

Fig. 18A-25 illustrate other embodiments in which the tissue manipulation instrument is more directly incorporated into a buttressing instrument coupled to the anchor and providing selective polyaxial movement relative thereto. Such embodiments may eliminate the need for a separate retractor assembly. For example, in the embodiment shown in fig. 18A-19, opposing tissue manipulation instruments or blades 1802, 1804 are pivotally coupled to an elongate body 1806 of the instrument 1800. Accordingly, instrument 1800 may be introduced into the incision in the configuration of fig. 18B, where the tissue manipulation instruments are in contact with each other and may easily enter the incision. The instruments can then be pivoted away from each other in the direction of arrows 1808, 1810 to retract the tissue forming the walls of the incision and provide the surgeon with a larger working channel, as shown in fig. 18C.

In addition, each tissue manipulation instrument 1802, 1804 can include a distal portion 1812 that is pivotably coupled to the remainder of the instrument. As shown in fig. 19, distal portion 1812 may be configured such that the distal end of instrument 1802 or 1804 may be pivoted away from the rest of the instrument to approximate the diagonal movement of the instrument to facilitate tissue retraction. In some embodiments, pivot axis 1904 of distal portion 1812 may be transverse to pivot axis 1906 of tool 1802.

Fig. 20-25 illustrate another embodiment of an instrument 2000 in which each tissue manipulating implement 2002, 2004 is selectively coupleable to opposite sides of an elongate body 2006 of the instrument. For example, as shown in fig. 21, the instrument 2000 can include an elongate body 2006 configured to couple to the anchor 108 and provide selective polyaxial movement relative thereto. The elongated body 2006 can include mating features 2008 formed on opposing sides thereof. The mating features may be, for example, slots or protrusions formed along the length of the elongated body.

The tissue manipulation instrument 2002 can be coupled to the elongate body 2006 by sliding a complementary mating feature of the instrument over the mating feature 2008 on the elongate body, as shown in fig. 23. The height of the instrument along the elongated body 2006 can be set using any of a variety of mechanisms, such as the detents or locking pins described above. In addition and as shown in fig. 22, blades 2202 can be modular relative to a base 2204 of tissue manipulating implement 2002, such that in some embodiments, the height of implement 2002 relative to elongate body 2006 need not be adjustable, as blades 2202 having a desired height can be selected. However, in some embodiments, two adjustment mechanisms may be included.

Fig. 24A-25 illustrate various degrees of freedom of the tissue manipulation instruments 2002, 2004 after coupling to the elongate body 2006. For example, rotation of the first actuators 2402, 2404 on each base 2204, 2206 can cause the tissue manipulating instruments 2002, 2004 to pivot away from each other, as indicated by arrows 2406, 2408. The pivot axis of each implement 2002, 2004 can be parallel to the longitudinal axis of the elongate body 2006.

Further, rotation of the second actuator 2502, 2504 on each base 2204, 2206 can pivot the implement 2002, 2004 about an axis transverse to the longitudinal axis of the elongate body 2006 to produce a diagonal movement, as shown by arrows 2506, 2508 in fig. 25. This angled movement may involve the distal ends of tissue manipulation instruments 2002, 2004 moving away from each other while the distance between their proximal ends remains constant.

Fig. 26-31B illustrate various embodiments of instruments for separating adjacent vertebrae and their use with the support instruments and retractor assemblies described herein. For example, fig. 26 illustrates one embodiment of distractor 2600 comprising a rack 2602 and two interfaces 2604, 2606 for coupling with either an anchor or an instrument coupled to the anchor. The interface 2604 may be anchored to one end of the rack 2602, and the interface 2606 may be coupled to the rack 2602 via a pawl, cog, gear, or other feature that may engage a series of teeth, recesses, or other features formed along the length of the rack. The thumbwheel 2608 may be coupled to cogs or gears to control movement of the interface 2606 along the rack 2602.

As shown in fig. 27A-28, the interfaces 2604, 2606 can be coupled to anchors implanted in adjacent vertebrae and the thumbwheels 2608 can be rotated to distract the vertebrae by moving the interfaces away from each other along the rack 2602. In an exemplified embodiment, the interface can be coupled to an anchor implanted in an adjacent vertebra via an extension tower and/or bracing instrument described herein, which can be coupled to the implanted anchor and locked against movement relative thereto. Thus, as shown in fig. 27B and 28, the interface 2604 can be coupled to a proximal end of an extension tower 2702 that is coupled to an anchor 2704 implanted in a first vertebra, and the interface 2606 can be coupled to a proximal end of a bracing instrument 2706 that is coupled to a second anchor 2708 implanted in a second vertebra. As shown in fig. 27B, the interfaces 2604, 2606 can include distal ends configured to couple with features formed on the proximal ends of the extension tower 2702 and the support instrument 2706 (e.g., the opposing flat surfaces 814 of the instrument 800 described above). It should also be noted that retractor assembly 2710 is coupled to support instrument 2706 to provide retraction of, for example, medial and lateral tissue during surgery.

Once the distraction device 2600 is coupled to the anchors 2704, 2708 implanted in the adjacent vertebrae via the extension tower 2702 and the distraction device 2706, and the tower and distraction device are locked against movement relative to the anchors, the thumbwheel 2608 or other distraction actuator can be rotated as shown by arrow 2802 in fig. 28. This can cause the interface 2606 to move away from the interface 2604 along the rack 2602, resulting in a corresponding distraction of the anchors 2704, 2708 and the adjacent vertebrae into which they are implanted, as indicated by arrows 2804, 2806.

In an alternative embodiment shown in fig. 29-31B, a clip-like distractor 2902 may be used in place of distractor 2600 described above. Further, distractor 2902 may include interfaces 3002, 3004 that may be configured to laterally abut extension tower 2702 and bracing instrument 2706 at one location along its length, rather than interfacing with its proximal end as described above. The method of operation may be similar to that described above, wherein the extension tower 2702 and the bracing apparatus 2706 may be locked against movement relative to the implanted anchors 2704, 2708. The interfaces 3002, 3004 can then be inserted into the working channel disposed between the opposing tissue manipulating instruments of the retractor assembly 2710, and the opposing handles 3102, 3104 of the distractor 2902 can be pushed toward one another, as shown by arrows 3106, 3108 of fig. 31A. This can cause the interfaces 3002, 3004 to move away from each other, contact the tower 2702 and the support apparatus 2706, and urge the two components away from each other, as shown by arrows 3110, 3112 in fig. 31B. Given the rigid implantation of the anchors 2704, 2708 into adjacent vertebrae (not shown), the vertebrae can be pulled apart from one another in the same manner.

Fig. 32 and 33 illustrate one embodiment of a surgical retractor system 3200 according to the teachings provided herein. The system can be used to facilitate retraction of skin, muscle, and other soft tissue to access various portions of a patient's spine, for example. Further, the system can include a retractor and other components that are interfaced to the patient's body via, for example, vertebrae by the surgical instruments described herein, and thus the system can be used to perform various procedures, including vertebrae distractions, and the like.

As shown in the assembled system of fig. 32 and the exploded view of fig. 33, the system 3200 may comprise: one or more surgical buttress instruments 3202 coupled to screws implanted in vertebrae of a patient; retractor 3204 coupled to a support instrument; one or more tissue manipulation instruments 3206 coupled to the retractor; a stabilizing handle 3208 with a light source 3210 coupled to retractor 3204; a distraction module 3212 coupled to the other support instrument 3202 from retractor 3204; and a distraction rack 3214 coupled to retractor 3204 and distraction module 3212, e.g., to perform distraction between adjacent vertebrae. Also shown in fig. 33 is an actuating instrument 3302 that can be used to couple tissue manipulating instruments 3206 to retractor 3204 and control the positioning/locking thereof, as well as a tissue manipulating instrument adjuster 3304 that can be used to adjust the position, depth, etc. of deployable tissue manipulating instruments coupled to retractor 3204. Fig. 33 also illustrates several different sizes of surgical buttress instruments 3202, such as a larger instrument 3202a, a medium size instrument 3202b, and a smaller instrument 3202 c. Finally, fig. 33 also illustrates a reference bar 3306 that may be used to determine the appropriate dimensions of the buttress instrument 3202 and a surgical instrument component removal tool 3308 that may be used to separate a two-part surgical buttress instrument, as described herein.

Fig. 34 shows in detail various sizes of surgical support instrument 3202, although any of the various sizes are possible, the illustrated embodiment includes a larger instrument 3202a, a medium sized instrument 3202B, and a smaller instrument 3202c the differences between the different sizes may be embodied only as the length extending over the screws to which they are coupled, such that different sized instruments may be selected based on the depth of the surgical site below the skin surface of the patient and the desired amount of extension of the instrument above the skin surface in some embodiments reference rod 3306 shown in fig. 35A and 35B may be used to determine the appropriate size of the surgical support instrument 3202 for any particular patient, for example, reference rod 3306 may be inserted into an incision formed on the skin and soft tissue of the patient and then advanced until it abuts a desired anatomical feature (e.g., pedicle of the patient.) viewing "S, M, L" indicia 3502 on one side of the reference rod (as shown in fig. 35A), and noting that the first indicia displayed above the skin of the patient shows the appropriate size of the surgical support instrument 3202 coupled to the medium sized instrument 3202B, the length of the instrument 3202B may also be reflected on the relative retractor indicia 3306 of the surgical support instrument 3202a, as shown in fig. 3B, a retractor marker 3306, a retractor, and a retractor, and a retractor.

Fig. 36A-36D illustrate one embodiment of a surgical instrument component removal tool 3308 that may be used to remove components of, for example, a two-part surgical buttress instrument such as instrument 100 described above. As described above, the lock body or cap 3602 of the surgical buttress instrument 3202, for example, may be removed using the tool 3308, which may be desirable to provide access to a proximal portion of a bone anchor to connect a modular receiver head (not shown) thereto. As described above in connection with the lock 104 of the instrument 100, removal of the lock may allow the modular receiver head to be coupled to the proximal head 404 of the anchor 108. The elongated body 102 may be left in place because it is offset from the anchor 108 by the laterally extending projections 302a, 302b of the prongs 110, and because the projections 302a, 302b disposed below the proximal head 404 will not interfere with coupling the receiver head to the proximal head of the anchor 108. Returning to fig. 36A-36D, utilizing the removal tool 3308 may include sliding the tool down onto the cap 3602 of the surgical buttress instrument 3202 in the direction of arrow 3603 until the spring button 3604 engages the cap, as shown in fig. 36A and 36B. The removal tool 3308 may then be utilized to disengage the cap 3602 from the handle extension 3606 by withdrawing the tool and attached cap in the direction of arrow 3605 in fig. 36C. To disengage the cap 3602 from the tool 3308 after disengagement from the handle extension 3606, the user may press the button 3604 in the direction of arrow 3607 in fig. 36D.

In conjunction with the distraction described above, any of a variety of surgical procedures can be performed using, for example, the working channel provided by the support instrument 2706 and the retractor assembly 2710. For example, a user can perform a spinal fusion cage insertion procedure via a working channel between opposing tissue manipulation instruments of retractor assembly 2710. Other exemplary procedures may include disc replacement, discectomy, endplate preparation, bone graft delivery, and the like.

It should be noted that any order of method steps expressed or implied in the above description or figures should not be construed as limiting the disclosed method to performing the steps in that order. Rather, the various steps of each method disclosed herein may be performed in any of a variety of orders. Moreover, since the methods described are merely exemplary embodiments, various other methods including more steps or including fewer steps are also encompassed within the scope of the present disclosure.

The instruments disclosed herein may be constructed from any of a variety of known materials. Exemplary materials include materials suitable for use in surgical applications including metals (such as stainless steel, titanium, nickel, cobalt-chromium, or alloys and combinations thereof), polymers (such as PEEK, ceramics, carbon fiber), and the like. The various components of the instruments disclosed herein may have varying degrees of rigidity or flexibility, suitable for their use. The size of the device may also vary widely depending on the intended use and the anatomy of the surgical site. Further, certain components may be formed of different materials than other components. One or more components or portions of the instrument may be formed of radiopaque materials to facilitate visualization under fluoroscopy and other imaging techniques, or of radiolucent materials so as not to interfere with visualization of other structures. Exemplary radiolucent materials include carbon fibers and high strength polymers.

The devices and methods disclosed herein may be used in minimally invasive surgery and/or open surgery. Although the devices and methods disclosed herein are generally described in the context of spinal surgery on a human patient, it should be understood that the methods and devices disclosed herein may be used in any of a variety of surgical procedures on any human or animal subject, or in non-surgical procedures.

The device disclosed herein may be designed to be disposed of after a single use, or it may be designed to be used multiple times. In either case, however, the device may be reconditioned for reuse after at least one use. Reconditioning can include any combination of the steps of disassembly of the device, followed by cleaning or replacement of particular pieces, and subsequent reassembly. In particular, the device may be disassembled, and any number of the particular pieces or parts of the device may be selectively replaced or removed in any combination. After cleaning and/or replacement of particular components, the device may be reassembled for subsequent use either at a reconditioning facility, or by a surgical team immediately prior to a surgical procedure. Those skilled in the art will appreciate that the finishing assembly may be disassembled, cleaned/replaced, and reassembled using a variety of techniques. The use of such techniques and the resulting prosthetic devices are within the scope of the present application.

The devices described herein may be processed prior to use in surgery, first, new or used instruments may be obtained and cleaned as needed, then the instruments may be sterilized.

Based on the above embodiments, one skilled in the art will appreciate further features and advantages. Accordingly, the disclosure is not limited by what has been particularly shown and described. All publications and references cited herein are expressly incorporated herein by reference in their entirety.