Devices and methods for percutaneous surgery

• US 5,954,635 A
• Filed: 08/29/1997
• Issued: 09/21/1999
• Est. Priority Date: 03/22/1996
• Status: Expired due to Term

• Current Assignee: SDGI Holdings Incorporated (Medtronic Plc)
• Original Assignee: SDGI Holdings Incorporated (Medtronic Plc)
• Inventors: Clayton, John B., Smith, Maurice Mell, Moctezuma, Joseph, Foley, Kevin Thomas
• Primary Examiner(s): FLANAGAN, BEVERLY MEINDL
• Application Number:
  US08/920,990
• Time in Patent Office: 753 Days
• Field of Search: 600/102, 600/114, 600/171, 604/264, 604/164, 604/167, 604/169
• US Class Current: 600/114
• CPC Class Codes: A61B 17/02 for holding wounds open; Tractors specula A61B1/32 ; drainage appliances for wounds A61M27/00
• CPC Class Codes: A61B 17/1671 for the spine
• CPC Class Codes: A61B 17/3417 Details of tips or shafts, e.g. grooves, expandable, bendable; Multiple coaxial sliding cannulas, e.g. for dilating syringe needles A61M5/32; dilators A61M29/00
• CPC Class Codes: A61B 17/3421 Cannulas
• CPC Class Codes: A61B 2017/00261 Discectomy
• CPC Class Codes: A61B 2017/00296 mounted on an endoscope
• CPC Class Codes: A61B 2017/0046 with a releasable handle; with handle and operating part separable for prosthetic joint-implanting tools A61F2/4603
• CPC Class Codes: A61B 2017/00469 for insertion of instruments, e.g. guide wire, optical fibre
• CPC Class Codes: A61B 2017/0262 with a provision for protecting nerves
• CPC Class Codes: A61B 2017/3445 used as instrument channel for multiple instruments catheters A61B2017/22072
• CPC Class Codes: A61B 2017/347 Locking means, e.g. for locking instrument in cannula
• CPC Class Codes: A61B 2090/306 using optical fibres
• CPC Class Codes: A61B 2090/3614 using optical fibre
• CPC Class Codes: A61B 2090/373 using light, e.g. by using optical scanners
• CPC Class Codes: A61B 90/50 Supports for surgical instruments, e.g. articulated arms
• CPC Class Codes: A61M 29/00 Dilators with or without means for introducing media, e.g. remedies instruments for performing visual medical inspections of cavities or tubes of the body A61B1/00
• CPC Class Codes: A61M 29/02 Dilators made of swellable material balloon catheters for angioplasty A61M25/104

Abstract

Devices and methods for performing percutaneous spinal surgery under direct visualization and through a single cannula are shown. A device (10) is provided which includes an elongated cannula (20) having a first inner diameter (D_I) and an outer diameter (D_O) sized for percutaneous introduction into a patient. The cannula (20) defines a working channel (25) between its ends (21, 22) which has a second diameter (D₂) equal to the diameter (D_I) of the cannula sized for receiving a tool therethrough. An elongated viewing element (50) is engageable to the cannula (20) adjacent the working channel (25), preferably by a fixture (30). The fixture (30) includes a housing (31) attachable to the proximal end (22) of the cannula (20) that defines a working channel opening (35) which is in communication with the working channel (25). The housing (31) also defines an optics bore (60) adjacent the working channel opening (35). In certain embodiments, the fixture (30) supports the viewing element (50) for translation and/or rotation within the optics bore (60) along the longitudinal axis of the bore, and for rotation of the housing (31) relative to the cannula (20) so that the longitudinal axis of the optics bore (60) will rotate about the longitudinal axis of the working channel (25). Methods are also provided for performing spinal surgeries percutaneously with direct visualization and without the requirement for a fluid-maintained workspace.

Claims

1. The method for performing a surgical procedure at a location in a patient'"'"'s body, comprising the steps of:

creating a working channel through the skin and tissue of a patient;

creating a working space in communication with the working channel and adjacent the location in the patient'"'"'s body;

inserting optics through the working channel to the working space;

extending a first tool through the working channel to the working space with the optics in the working channel; and

manipulating the first tool through the working channel to perform a surgical procedure on the location in the working space under direct vision from the optics and without directing irrigation fluid to the location.

2. The method of claim 1 wherein the tool is a power drill and the surgical procedure is drilling through bone or tissue at the location.

3. The method of claim 1, further comprising the steps of:

extending the optics through the working channel beyond the end of the working channel adjacent the working space for direct visualization of the working space and manipulating the tool.

4. The method of claim 1, further comprising the steps of:

removably inserting a second tool through the working channel simultaneous with the first tool; and

manipulating the second tool to perform a function at the location.

5. The method of claim 4 further comprising the steps of:

inserting a guidewire into a patient through skin and tissue to the location;

inserting a cannulated dilator over the guidewire and through the skin and tissue to the location;

inserting a cannula over the dilator;

removing the guidewire after inserting the dilator; and

removing the dilator after inserting the cannula.

6. The method for performing a surgical procedure of claim 1, wherein the step of creating a working channel includes:

inserting a first dilator through the skin and tissue of the patient;

sequentially inserting at least one more dilator over the first dilator;

inserting a cannula over the last inserted dilator; and

then removing the dilators so that the cannula defines the working channel.

7. A method for performing a surgical procedure at a location on the spine, comprising the steps of:

creating a working channel through the skin and tissue of a patient;

creating a working space in communication with the working channel and adjacent the location on the spine;

extending a tool through the working channel beyond the end of the working channel and manipulating the tool in the working space; and

placing optics through the working channel with the tool in the working channel, the optics extending beyond the end of the working channel adjacent the working space to directly visualize the working space and manipulation of the tool.

8. The method for performing a surgical procedure of claim 7 wherein the step of creating a working channel includes:

inserting a first dilator through the skin and tissue of the patient;

sequentially inserting at least one more dilator over the first dilator;

inserting a cannula over the last inserted dilator; and

then removing the dilators so that the cannula defines the working channel.

9. A method for performing a surgical procedure at a location on the spine, comprising the step of:

creating a working channel through the skin and tissue of a patient;

creating a working space in communication with the working channel and adjacent the location on the spine;

removably inserting a first tool through the working channel;

manipulating the first tool to perform a function at the location;

removably inserting a second tool through the working channel simultaneous with the first tool; and

manipulating the second tool to perform a function at the location.

10. A method for performing a surgical procedure at a location on the spine, comprising the steps of:

creating a working channel through the skin and tissue of a patient;

creating a working space in communication with the working channel and adjacent the location on the spine;

removably inserting a first tool through the working channel wherein the first tool is a tissue retractor;

manipulating the tissue retractor to retract tissue to maintain the working space;

removably inserting a second tool through the working channel simultaneous with the first tool; and

manipulating the second tool to perform a function at the location.

11. A method for performing a discectomy at a subject vertebral level on the spine, comprising the steps of:

creating an incision in the skin substantially directly posterior to the subject vertebral level;

creating a bore through the lamina at a posterior medial position on the spine;

mounting a cannula through the incision at the bore in the lamina to create a working channel;

inserting optics through the cannula to directly visualize the location on the spine beyond the end of the cannula;

extending a retractor through the working channel to retract tissue to create a path to the spinal disc;

extending the optics through the working channel and path to the spinal disc; and

extending and manipulating discectomy instruments through the working channel to the disc to perform a discectomy under direct vision by the optics.

12. The method of claim 11 wherein the step of creating a bore includes conducting a laminectomy comprising the steps of:

inserting a cannula into the incision and through tissue to the lamina to define a working channel;

extending optics through the working channel to directly visualize the lamina; and

extending a bone cutting tool through the working channel and manipulating the tool to perform a laminectomy under direct vision from the optics.

13. A method for performing a laminectomy, comprising the steps of:

creating an incision in the skin substantially directly posterior to the subject vertebral level;

inserting a cannula into the incision and through tissue to the lamina to define a working channel;

extending optics through the working channel to directly visualize the lamina; and

extending a bone cutting tool through the working channel simultaneous with the optics and manipulating the tool to perform a laminectomy under direct vision from the optics.

14. The method for performing a laminectomy of claim 13, wherein the step of inserting a cannula includes:

inserting a first dilator into the incision and through tissue to the lamina;

sequentially inserting at least one more dilator over the first dilator;

inserting the cannula over the last inserted dilator; and

then removing the dilators.

15. A method for implanting a vertebral fixation element, comprising the steps of:

making an incision in the skin to provide access to the location on the vertebra at which the fixation element is to be implanted;

inserting a cannula into the incision and through tissue to the location to define a working channel;

inserting optics through the cannula to directly visualize the location;

extending an insertion tool supporting the vertebral fixation element through the working channel to the location under direct vision; and

manipulating the insertion tool to implant the fixation element at the location under direct vision from the optics.

16. The method of claim 15, wherein the vertebral fixation element is a bone screw.

17. A method for performing a surgical procedure at a location in a patient'"'"'s body, comprising the steps of:

creating a working channel through the skin and tissue of a patient;

creating a working space in communication with the working channel and adjacent the location in the patient'"'"'s body;

inserting optics through the working channel to the working space;

extending a first tool through the working channel to the working space wherein the first tool is a power tool;

manipulating the first tool through the working channel to perform a surgical procedure on the location in the working space under direct vision from the optics and without directing irrigation fluid to the location; and

providing aspiration at the working space to remove smoke generated by operation of the power tool.

18. A method for performing a surgical procedure at a location in a patient'"'"'s body, comprising the steps of:

creating a working channel through the skin and tissue of a patient by inserting a cannula into the patient, the cannula having an inner dimension defining the working channel;

creating a working space in communication with the working channel and adjacent the location in the patient'"'"'s body;

inserting optics through the working channel to the working space;

extending a first tool through the working channel to the working space; and

manipulating the first tool through the working channel to perform a surgical procedure on the location in the working space under direct vision from the optics and without directing irrigation fluid to the location.

19. A method for performing a surgical procedure at a location on the spine, comprising the steps of:

creating a working channel through the skin and tissue of a patient by inserting a cannula into the patient, the cannula having an inner dimension defining the working channel;

creating a working space in communication with the working channel and adjacent the location on the spine;

extending a tool through the working channel beyond the end of the working channel and manipulating the tool in the working space; and

extending optics through the working channel beyond the end of the working channel adjacent the working space to directly visualize the working space and manipulation of the tool.

20. A method for performing a surgical procedure at a location on the spine, comprising the steps of:

creating a working channel through the skin and tissue of a patient by inserting a cannula into the patient, the cannula having an inner dimension defining the working channel;

creating a working space in communication with the working channel and adjacent the location on the spine;

removably inserting a first tool through the working channel;

manipulating the first tool to perform a function at the location;

removably inserting a second tool through the working channel simultaneous with the first tool; and

manipulating the second tool to perform a function at the location.

21. A method for performing a surgical procedure at a location in a patient'"'"'s body, comprising the steps of:

creating a working channel through the skin and tissue of a patient;

creating a working space in communication with the working channel and adjacent the location in the patiant'"'"'s body;

extending a first tool through the working channel to the working space; and

manipulating the first tool through the working channel to perform a surgical procedure on the location in the working space without directing irrigation fluid to the location.

22. The method of claim 21, wherein the tool is a power drill and the surgical procedure is drilling through bone or tissue at the location.

23. The method of claim 21, further comprising the steps of:

removably inserting a second tool through the working channel simultaneous with the first tool; and

manipulating the second tool to perform a function at the location.

24. The method of claim 21, wherein said step of creating a working channel includes inserting a cannula into the patient, the cannula having an inner dimension defining the working channel.

25. The method for performing a surgical procedure of claim 21, wherein the step of creating a working channel includes:

inserting a first dilator into the incision and through tissue to the lamina;

sequentially inserting at least one more dilator over the first dilator;

inserting a cannula over the last inserted dilator; and

then removing the dilators so that the cannula defines a working channel.

26. A method for preparing a working channel adjacent the spine, comprising the steps of:

inserting a guidewire through an incision in the skin and into the lamina of a vertebra;

inserting a first dilator over the guidewire and through the incision into contact with the lamina;

removing the guidewire;

sequentially inserting dilators of increasing diameter over the first and subsequent dilators, each of the dilators having a tapered working end configured to atraumatically displace tissue;

advancing a cannula over the last inserted dilator, the cannula having a distal end adjacent the lamina and an opposite proximal end; and

then removing the dilators so that the cannula defines a working channel.

27. The method of claim 26, further comprising the step of affixing to the cannula a mounting bracket having a flexible arm support.

28. The method of claim 27, wherein the flexible arm support is contoured.

29. The method of claim 26, further comprising the step of advancing a fixture over the proximal end of the cannula for supporting a viewing element adjacent the working channel.

30. A method for implantation of at least one fusion device in a disc space between adjacent vertebrae, comprising the steps of:

making an incision in the skin to provide access to the disc space where the fusion device is to be implanted,;

inserting a cannula into the incision and through the tissue to the location to define a working channel to the disc space;

inserting optics through the cannula to directly visualize the disc space;

preparing the disc space through the working channel under direct vision from the optics for implantation of at least one fusion device; and

advancing the fusion device through the working channel into the prepared disc space under direct vision from the optics.

31. The method of claim 30, wherein the fusion device is a bone dowel.

32. The method of claim 30, wherein the fusion device is a push-in implant.

33. The method of claim 30, wherein the fusion device is a threaded implant.

34. The method of claim 30, wherein the fusion device is graft material.