Apparatus for use in inserting spinal implants

• US 6,770,074 B2
• Filed: 11/17/2001
• Issued: 08/03/2004
• Est. Priority Date: 06/13/1988
• Status: Expired due to Fees

• Current Assignee: Warsaw Orthopedic Incorporated (Medtronic Plc)
• Original Assignee: Gary K. Michelson
• Inventors: Michelson, Gary Karlin
• Primary Examiner(s): Brown, Michael A.
• Application Number:
  US09/991,579
• Publication Number:
  US 20020077641A1
• Time in Patent Office: 990 Days
• Field of Search: 606/60, 606/61, 623/16.1, 623/17.1
• US Class Current: 623/17.11
• CPC Class Codes: A61B 17/025 Joint distractors
• CPC Class Codes: A61B 17/1655 for tapping
• CPC Class Codes: A61B 17/1671 for the spine
• CPC Class Codes: A61B 17/1757 for the spine
• CPC Class Codes: A61B 17/32 Surgical cutting instruments A61B18/042 takes precedence; suture cutters A61B17/0467; instruments for ligaturing or cutting A61B17/128; instruments for rupturing the amniotic membrane A61B17/4208; specially adapted knives for eye surgery A61F9/0133
• CPC Class Codes: A61B 17/3468 for implanting or removing devices, e.g. prostheses, implants, seeds, wires devices for implanting seeds A61M37/0069
• CPC Class Codes: A61B 17/8877 characterised by the cross-section of the driver bit
• CPC Class Codes: A61B 17/8888 at its central region
• CPC Class Codes: A61B 2017/0256 for the spine
• CPC Class Codes: A61B 2017/922 Devices for impaction, impact element
• CPC Class Codes: A61B 2090/036 abutting on tissue or skin
• CPC Class Codes: A61F 2/30744 End caps, e.g. for closing an endoprosthetic cavity
• CPC Class Codes: A61F 2/442 Intervertebral or spinal discs, e.g. resilient non-disc-shaped intervertebral inflatable pockets A61F2/441; non-disc-shaped intervertebral fusion implants A61F2/4455
• CPC Class Codes: A61F 2/446 having a circular or elliptical cross-section substantially parallel to the axis of the spine, e.g. cylinders or frustocones
• CPC Class Codes: A61F 2/4603 for insertion or extraction of endoprosthetic joints or of accessories thereof
• CPC Class Codes: A61F 2/4611 of spinal prostheses
• CPC Class Codes: A61F 2002/2835 Bone graft implants for filling a bony defect or an endoprosthesis cavity, e.g. by synthetic material or biological material
• CPC Class Codes: A61F 2002/30143 hexagonal
• CPC Class Codes: A61F 2002/30224 cylindrical
• CPC Class Codes: A61F 2002/30235 tubular, e.g. sleeves
• CPC Class Codes: A61F 2002/30405 : made by screwing complementary threads machined on the parts themselves
• CPC Class Codes: A61F 2002/30426 : Bayonet coupling
• CPC Class Codes: A61F 2002/30593 : hollow
• CPC Class Codes: A61F 2002/30774 : internally-threaded
• CPC Class Codes: A61F 2002/30785 : parallel
• CPC Class Codes: A61F 2002/30787 : inclined obliquely with respect to each other
• CPC Class Codes: A61F 2002/30797 : internally-threaded
• CPC Class Codes: A61F 2002/30836 : knurled
• CPC Class Codes: A61F 2002/3085 : with a threaded, e.g. self-tapping, bone-engaging surface, e.g. external surface
• CPC Class Codes: A61F 2002/30904 : serrated profile, i.e. saw-toothed
• CPC Class Codes: A61F 2002/448 : comprising multiple adjacent spinal implants within the same intervertebral space or within the same vertebra, e.g. comprising two adjacent spinal implants
• CPC Class Codes: A61F 2002/4619 : for extraction
• CPC Class Codes: A61F 2002/4627 : with linear motion along or rotating motion about the instrument axis or the implantation direction, e.g. telescopic, along a guiding rod, screwing inside the instrument
• CPC Class Codes: A61F 2002/4629 : connected to the endoprosthesis or implant via a threaded connection
• CPC Class Codes: A61F 2002/4649 : Bone graft or bone dowel harvest sites
• CPC Class Codes: A61F 2002/4681 : by applying mechanical shocks, e.g. by hammering
• CPC Class Codes: A61F 2002/4687 : Mechanical guides for implantation instruments
• CPC Class Codes: A61F 2220/0025 : Connections or couplings between prosthetic parts, e.g. between modular parts; Connecting elements
• CPC Class Codes: A61F 2230/0017 : Angular shapes
• CPC Class Codes: A61F 2230/0069 : cylindrical

Abstract

Apparatus and a method of inserting spinal implants is disclosed in which an intervertebral space is first distracted, a hollow sleeve having teeth at one end is then driven into the vertebrae adjacent that disc space. A drill is then passed through the hollow sleeve removing disc and bone in preparation for receiving the spinal implant which is then inserted through the sleeve. Apparatus and a method of inserting spinal implants is disclosed in which an intervertebral space is first distracted to restore the normal angular relationship of the vertebrae adjacent to that disc space. An extended outer sleeve having extended portions capable of maintaining the vertebrae distracted in their normal angular relationship is then driven into the vertebrae adjacent that disc space. A drill is then passed through the hollow sleeve removing disc and bone in preparation for receiving the spinal implant which is then inserted through the sleeve.

Claims

1. An apparatus for use in human spinal surgery across at least a portion of the height of a surgically corrected disc space between two adjacent vertebral bodies of a human spine, said apparatus comprising:

a guard having a passage for providing access to the disc space and the adjacent vertebral bodies, said passage having a maximum height as measured along the longitudinal axis of the human spine, said guard having a proximal end and an opposite distal end and at least one side therebetween, said guard having at least two openings in said side in communication with said passage, said openings being opposite one another; and

at least one extension extending from said distal end of said guard adapted to be inserted into the disc space between the adjacent vertebral bodies, said extension having a portion adapted to bear against each of the adjacent endplates of the adjacent vertebral bodies from within the disc space, said portion of said extension having an upper surface adapted to contact one of the adjacent endplates of the adjacent vertebral bodies and a lower surface adapted to contact the other of the adjacent endplates of the adjacent vertebral bodies, said portion of said extension having a height between said upper and lower surfaces and a length sufficient to align and distance apart the adjacent vertebral bodies.

2. The apparatus of claim 1, wherein at least one of said openings is at least one of a slot and a key-hole.

3. The apparatus of claim 1, wherein said openings are parallel to one another.

4. The apparatus of claim 1, wherein said openings are at least two slots.

5. The apparatus of claim 1, wherein said openings in said side divide at least a portion of said guard into an upper portion and a lower portion.

6. The apparatus of claim 5, wherein said upper portion and said lower portion of said guard are adapted to move apart from one another to facilitate the insertion of an implant through said passage and into the disc space.

7. The apparatus of claim 1, wherein said guard is a hollow tubular sleeve.

8. The apparatus of claim 1, wherein said guard has a circular cross section.

9. The apparatus of claim 1, wherein said passage has a circular cross section.

10. The apparatus of claim 1, wherein said proximal end of said guard has an increased outer dimension.

11. The apparatus of claim 1, wherein said distal end of said guard is contoured to the curvature of the adjacent vertebral bodies against which said guard is adapted to be placed.

12. The apparatus of claim 1, wherein said guard has a footplate.

13. The apparatus of claim 1, wherein said proximal end of said guard is configured to cooperatively engage an impaction member for receiving an impaction force for driving said guard into the spine.

14. The apparatus of claim 1, further comprising a cap adapted to engage said proximal end of said guard.

15. The apparatus of claim 1, further comprising a removable inner guard.

16. The apparatus of claim 15, wherein said removable inner guard is a hollow tubular sleeve.

17. The apparatus of claim 15, wherein said removable inner guard is adapted to be inserted into said guard.

18. The apparatus of claim 15, wherein said inner guard has a collar at one end larger than said passage of said guard.

19. The apparatus of claim 1, further comprising a second extension extending from said guard adapted to be inserted into the disc space and to bear against the endplates of the adjacent vertebral bodies.

20. The apparatus of claim 19, wherein said extensions are diametrically opposed to each other and spaced apart from one another to provide access to the adjacent vertebral bodies from within the disc space.

21. The apparatus of claim 19, wherein said extensions have the same height.

22. The apparatus of claim 1, wherein the height of said extension has at least a portion that approximates the surgically corrected height of the disc space between the adjacent vertebral bodies.

23. The apparatus of claim 1, wherein said upper and lower surfaces adapted to contact the adjacent end plates of the adjacent vertebral bodies diverge away from said guard along at least a portion of their length.

24. The apparatus of claim 1, wherein said upper and lower surfaces adapted to contact the end plates of the adjacent vertebral bodies converge away from said guard member along at least a portion of their length.

25. The apparatus of claim 1, further comprising a second passage in said guard for providing access to the disc space and the adjacent vertebral bodies.

26. The apparatus of claim 25, wherein said passage and said second passage are parallel to each other along at least a portion of their length.

27. The apparatus of claim 25, wherein said passage and said second passage converge along at least a portion of their length.

28. The apparatus of claim 25, wherein said passage and said second passage overlap at least in part.

29. The apparatus of claim 25, wherein said passage and said second passage are spaced apart.

30. The apparatus of claim 1, wherein said extension has a tapered leading end to facilitate placement of said extension into the disc space.

31. The apparatus of claim 1, wherein said guard comprises spine engaging portions at said distal end of said guard for holding said guard to the spine.

32. The apparatus of claim 31, wherein said spine engaging portions are selected from at least one of teeth and pins.

33. The apparatus of claim 31, wherein said spine engaging portions are adapted to penetrate the adjacent vertebral bodies.

34. The apparatus of claim 31, wherein at least one of said spine engaging portions has a tapered leading end to facilitate placement of at least one of said spine engaging portions into the spine.

35. The apparatus of claim 31, wherein at least one of said spine engaging portions has upper and lower surfaces that are parallel to each other.

36. The apparatus of claim 31, wherein said spine engaging portions are substantially in line with said side of said guard so that said spine engaging portions do not substantially increase the outer cross-sectional dimension of said guard near the distal end of said guard.

37. The apparatus of claim 1, wherein said extension is substantially in line with said side of said guard.

38. The apparatus of claim 1, in combination with a spinal implant.

39. The apparatus of claim 38, wherein said implant has opposed upper and lower surfaces including at least one opening to permit bone growth from adjacent vertebral body to adjacent vertebral body through said implant.

40. The apparatus of claim 39, wherein said spinal implant is in combination with a fusion promoting material.

41. The apparatus of claim 40, wherein said fusion promoting material is selected from at least one of harvested bone, hydroxyapatite, hydroxyapatite tricalcium phosphate, and bone morphogenetic protein.

42. The apparatus of claim 1, in combination with a bone removal device having a portion sized for movement through said passage for forming through said guard an implantation space at least in part across the surgically corrected height of the disc space.

43. The combination of claim 42, wherein said bone removal device is one of a drill, a trephine, a reamer, an end mill, a chisel, and a burr.

44. The combination of claim 42, further in combination with a spinal insert adapted for insertion into the implantation space formed by said bone removal device.

45. The combination of claim 44, wherein said spinal insert is one of a dowel, an interbody spinal implant, and an interbody spinal fusion implant.

46. The combination of claim 44, wherein said spinal insert comprises at least in part bone.

47. The combination of claim 44, wherein said spinal insert is a bone graft.

48. The combination of claim 44, further in combination with a fusion promoting substance.

49. The combination of claim 48, wherein said fusion promoting substance is bone.

50. The combination of claim 48, further in combination with a press for compressing said fusion promoting substance into said spinal insert.

51. The combination of claim 44, further in combination with an implant driver configured to insert said spinal insert into the implantation space formed by said bone removal device.

52. The combination of claim 42, further in combination with an instrument for removing from the spine the bone cut by said bone removal device.

53. The apparatus of claim 1, in combination with a tap for insertion through said guard for tapping the two adjacent vertebral bodies.

54. The apparatus of claim 1, in combination with a distractor adapted to urge apart the adjacent vertebral bodies.

55. The combination of claim 54, wherein said distractor is an interbody distractor.

56. The combination of claim 54, further in combination with at least a second distractor, said at least second distractor being differently sized relative to said distractor to form a set of distractors of graduated sizes.

57. An apparatus for use in human spinal surgery across at least a portion of the height of a surgically corrected disc space between two adjacent vertebral bodies of a human spine, said apparatus comprising:

a guard having a passage for providing access to the disc space and the adjacent vertebral bodies, said passage having a maximum height as measured along the longitudinal axis of the human spine, said guard having a proximal end and an opposite distal end and at least one side therebetween, said guard having at least two openings in said side in communication with said passage, said openings being parallel to one another; and

at least one extension extending from said distal end of said guard adapted to be inserted into the disc space between the adjacent vertebral bodies, said extension having a portion adapted to bear against each of the adjacent endplates of the adjacent vertebral bodies from within the disc space, said portion of said extension having an upper surface adapted to contact one of the adjacent endplates of the adjacent vertebral bodies and a lower surface adapted to contact the other of the adjacent end plates of the adjacent vertebral bodies, said portion of said extension having a height between said upper and lower surfaces and a length sufficient to align and distance apart the adjacent vertebral bodies.

58. The apparatus of claim 57, wherein at least one of said openings is at least one of a slot and a key hole.

59. The apparatus of claim 57, wherein said openings are at least two slots.

60. The apparatus of claim 57, wherein said openings in said side divide at least a portion of said guard into an upper portion and a lower portion.

61. The apparatus of claim 60, wherein said upper portion and said lower portion of said guard are adapted to move apart from one another to facilitate the insertion of an implant through said passage and into the disc space.

62. The apparatus of claim 57, wherein said guard is a hollow tubular sleeve.

63. The apparatus of claim 57, wherein said guard has a circular cross section.

64. The apparatus of claim 57, wherein said passage has a circular cross section.

65. The apparatus of claim 57, wherein said proximal end of said guard has an increased outer dimension.

66. The apparatus of claim 57, wherein said distal end of said guard is contoured to the curvature of the adjacent vertebral bodies against which said guard is adapted to be placed.

67. The apparatus of claim 57, wherein said guard has a footplate.

68. The apparatus of claim 57, wherein said proximal end of said guard is configured to cooperatively engage an impaction member for receiving an impaction force for driving said guard into the spine.

69. The apparatus of claim 57, further comprising a cap adapted to engage said proximal end of said guard.

70. The apparatus of claim 57, further comprising a removable inner guard.

71. The apparatus of claim 70, wherein said removable inner guard is a hollow tubular sleeve.

72. The apparatus of claim 70, wherein said removable inner guard is adapted to be inserted into said guard.

73. The apparatus of claim 70, wherein said inner guard has a collar at one end larger than said passage of said guard.

74. The apparatus of claim 57, further comprising a second extension extending from said guard adapted to be inserted into the disc space and to bear against the endplates of the adjacent vertebral bodies.

75. The apparatus of claim 74, wherein said extensions are diametrically opposed to each other and spaced apart from one another to provide access to the adjacent vertebral bodies from thin the disc space.

76. The apparatus of claim 74, wherein said extensions have the same height.

77. The apparatus of claim 57, wherein the height of said extension has at least a portion that approximates the surgically corrected height of the disc space between the adjacent vertebral bodies.

78. The apparatus of claim 57, wherein said upper and lower surfaces adapted to contact the adjacent endplates of the adjacent vertebral bodies diverge away from said guard along at least a portion of their length.

79. The apparatus of claim 57, wherein said upper and lower surfaces adapted to contact the endplates of the adjacent vertebral bodies converge away from said guard member along at least a portion of their length.

80. The apparatus of claim 57, further comprising a second passage in said guard for providing access to the disc space and the adjacent vertebral bodies.

81. The apparatus of claim 80, wherein said passage and said second passage are parallel to each other along at least a portion of their length.

82. The apparatus of claim 80, wherein said passage and said second passage converge along at least a portion of their length.

83. The apparatus of claim 80, wherein said passage and said second passage overlap at least in part.

84. The apparatus of claim 80, wherein said passage and said second passage are spaced apart.

85. The apparatus of claim 57, wherein said extension has a tapered leading end to facilitate placement of said extension into the disc space.

86. The apparatus of claim 57, wherein said guard comprises spine engaging portions at said distal end of said guard for holding said guard to the spine.

87. The apparatus of claim 86, wherein said spine engaging portions are selected from at least one of teeth and pins.

88. The apparatus of claim 86, wherein said spine engaging portions are adapted to penetrate the adjacent vertebral bodies.

89. The apparatus of claim 86, wherein at least one of said spine engaging portions has a tapered leading end to facilitate placement of at least one of said spine engaging portions into the spine.

90. The apparatus of claim 86, wherein at least one of said spine engaging portions has upper and lower surfaces that are parallel to each other.

91. The apparatus of claim 86, wherein said spine engaging portions are substantially in line with said side of said guard so that said spine engaging portions do not substantially increase the outer cross-sectional dimension of said guard near the distal end of said guard.

92. The apparatus of claim 57, wherein said extension is substantially in line with said side of said guard.

93. The apparatus of claim 57, in combination with a spinal implant.

94. The apparatus of claim 93, wherein said implant has opposed upper and lower surfaces including at least one opening to permit bone growth from adjacent vertebral body to adjacent vertebral body through said implant.

95. The apparatus of claim 94, wherein said spinal implant is in combination with a fusion promoting material.

96. The apparatus of claim 95, wherein said fusion promoting material is selected from at least one of harvested bone, hydroxyapatite, hydroxyapatite tricalcium phosphate, and bone morphogenetic protein.

97. The apparatus of claim 57, in combination with a bone removal device having a portion sized for movement through said passage for forming through said guard an implantation space at least in part across the surgically corrected height of the disc space.

98. The combination of claim 57, wherein said bone removal device is one of a drill, a trephine, a reamer, an end mill, a chisel, and a burr.

99. The combination of claim 57, further in combination with a spinal insert adapted for insertion into the implantation space formed by said bone removal device.

100. The combination of claim 99, wherein said spinal insert is one of a dowel, an interbody spinal implant, and an interbody spinal fusion implant.

101. The combination of claim 99, wherein said spinal insert comprises at least in part bone.

102. The combination of claim 99, wherein said spinal insert is a bone graft.

103. The combination of claim 99, further in combination with a fusion promoting substance.

104. The combination of claim 103, wherein said fusion promoting substance is bone.

105. The combination of claim 103, further in combination with a press for compressing said fusion promoting substance into said spinal insert.

106. The combination of claim 99, further in combination with an implant driver configured to insert said spinal insert into the implantation space formed by said bone removal device.

107. The combination of claim 97, further in combination with an instrument for removing from the spine the bone cut by said bone removal device.

108. The apparatus of claim 57, in combination with a tap for insertion through said guard for tapping the two adjacent vertebral bodies.

109. The apparatus of claim 57, in combination with a distractor adapted to urge apart the adjacent vertebral bodies.

110. The combination of claim 109, wherein said distractor is an interbody distractor.

111. The combination of claim 109, further in combination with at least a second distractor, said at least second distractor being differently sized relative to said distractor to form a set of distractors of graduated sizes.

112. An apparatus for use in human spinal surgery across at least a portion of the height of a surgically corrected disc space between two adjacent vertebral bodies of a human spine, said apparatus comprising:

a guard having a passage for providing access to the disc space and the adjacent vertebral bodies, said passage having a maximum height as measured along the longitudinal axis of the human spine, said guard having a proximal end and an opposite distal end and at least one side therebetween, said guard having at least two openings in said side in communication with said passage, said openings including at least two slots; and

at least one extension extending from said distal end of said guard adapted to be inserted into the disc space between the adjacent vertebral bodies, said extension having a portion adapted to bear against each of the adjacent endplates of the adjacent vertebral bodies from within the disc space, said portion of said extension having an upper surface adapted to contact one of the adjacent endplates of the adjacent vertebral bodies and a lower surface adapted to contact the other of the adjacent endplates of the adjacent vertebral bodies, said portion of said extension having a height between said upper and lower surfaces and a length sufficient to align and distance apart the adjacent vertebral bodies.

113. The apparatus of claim 112, wherein said openings in said side divide at least a portion of said guard into an upper portion and a lower portion.

114. The apparatus of claim 113, wherein said upper portion and said lower portion of said guard are adapted to move apart from one another to facilitate the insertion of an implant through said passage and into the disc space.

115. The apparatus of claim 112, wherein said guard is a hollow tubular sleeve.

116. The apparatus of claim 112, wherein said guard has a circular cross section.

117. The apparatus of claim 112, wherein said passage has a circular cross section.

118. The apparatus of claim 112, wherein said proximal end of said guard has an increased outer dimension.

119. The apparatus of claim 112, wherein said distal end of said guard is contoured to the curvature of the adjacent vertebral bodies against which said guard is adapted to be placed.

120. The apparatus of claim 112, wherein said guard has a footplate.

121. The apparatus of claim 112, wherein said proximal end of said guard is configured to cooperatively engage an impaction member for receiving an impaction force for driving said guard into the spine.

122. The apparatus of claim 112, further comprising a cap adapted to engage said proximal end of said guard.

123. The apparatus of claim 112, further comprising a removable inner guard.

124. The apparatus of claim 123, wherein said removable inner guard is a hollow tubular sleeve.

125. The apparatus of claim 123, wherein said removable inner guard is adapted to be inserted into said guard.

126. The apparatus of claim 123, wherein said inner guard has a collar at one end larger than said passage of said guard.

127. The apparatus of claim 112, further comprising a second extension extending from said guard adapted to be inserted into the disc space and to bear against the endplates of the adjacent vertebral bodies.

128. The apparatus of claim 127, wherein said extensions are diametrically opposed to each other and spaced apart from one another to provide access to the adjacent vertebral bodies from within the disc space.

129. The apparatus of claim 127, wherein said extensions have the same height.

130. The apparatus of claim 112, wherein the height of said extension has at least a portion that approximates the surgically corrected height of the disc space between the adjacent vertebral bodies.

131. The apparatus of claim 112, wherein said upper and lower surfaces adapted to contact the adjacent end plates of the adjacent vertebral bodies diverge away from said guard along at least a portion of their length.

132. The apparatus of claim 112, wherein said upper and lower surfaces adapted to contact the endplates of the adjacent vertebral bodies converge away from said guard member along at least a portion of their length.

133. The apparatus of claim 112, further comprising a second passage in said guard for providing access to the disc space and the adjacent vertebral bodies.

134. The apparatus of claim 133, wherein said passage and said second passage are parallel to each other along at least a portion of their length.

135. The apparatus of claim 133, wherein said passage and said second passage converge along at least a portion of their length.

136. The apparatus of claim 133, wherein said passage and said second passage overlap at least in part.

137. The apparatus of claim 133, wherein said passage and said second passage are spaced apart.

138. The apparatus of claim 112, wherein said extension has a tapered leading end to facilitate placement of said extension into the disc space.

139. The apparatus of claim 112, wherein said guard comprises spine engaging portions at said distal end of said guard for holding said guard to the spine.

140. The apparatus of claim 139, wherein said spine engaging portions are selected from at least one of teeth and pins.

141. The apparatus of claim 139, wherein said spine engaging portions are adapted to penetrate the adjacent vertebral bodies.

142. The apparatus of claim 139, wherein at least one of said spine engaging portions has a tapered leading end to facilitate placement of at least one of said spine engaging portions into the spine.

143. The apparatus of claim 139, wherein at least one of said spine engaging portions has upper and lower surfaces that are parallel to each other.

144. The apparatus of claim 139, wherein said spine engaging portions are substantially in line with said side of said guard so that said spine engaging portions do not substantially increase the outer cross-sectional dimension of said guard near the distal end of said guard.

145. The apparatus of claim 112, wherein said extension is substantially in line with said side of said guard.

146. The apparatus of claim 112, in combination with a spinal implant.

147. The apparatus of claim 146, wherein said implant has opposed upper and lower surfaces including at least one opening to permit bone growth from adjacent vertebral body to adjacent vertebral body through said implant.

148. The apparatus of claim 146, wherein said spinal implant is in combination with a fusion promoting material.

149. The apparatus of claim 148, wherein said fusion promoting material is selected from at least one of harvested bone, hydroxyapatite, hydroxyapatite tricalcium phosphate, and bone morphogenetic protein.

150. The apparatus of claim 112, in combination with a bone removal device having a portion sized for movement through said passage for forming through said guard an implantation space at least in part across the surgically corrected height of the disc space.

151. The combination of claim 150, wherein said bone removal device is one of a drill, a trephine, a reamer, an end mill, a chisel, and a burr.

152. The combination of claim 150, further in combination with a spinal insert adapted for insertion into the implantation space formed by said bone removal device.

153. The combination of claim 152, wherein said spinal insert is one of a dowel, an interbody spinal implant, and an interbody spinal fusion implant.

154. The combination of claim 152, wherein said spinal insert comprises at least in part bone.

155. The combination of claim 152, wherein said spinal insert is a bone graft.

156. The combination of claim 152, further in combination with a fusion promoting substance.

157. The combination of claim 156, wherein said fusion promoting substance is bone.

158. The combination of claim 156, further in combination with a press for compressing said fusion promoting substance into said spinal insert.

159. The combination of claim 152, further in combination with an implant driver configured to insert said spinal insert into the implantation space formed by said bone removal device.

160. The combination of claim 150, further in combination with an instrument for removing from the spine the bone cut by said bone removal device.

161. The apparatus of claim 112, in combination with a tap for insertion through said guard for tapping the two adjacent vertebral bodies.

162. The apparatus of claim 112, in combination with a distractor adapted to urge apart the adjacent vertebral bodies.

163. The combination of claim 162, wherein said distractor is an interbody distractor.

164. The combination of claim 162, further in combination with at least a second distractor, said at least second distractor being differently sized relative to said distractor to form a set of distractors of graduated sizes.

165. An apparatus for use in human spinal surgery across at least a portion of the height of a surgically corrected disc space between two adjacent vertebral bodies of a human spine, said apparatus comprising:

a guard having a passage for providing access to the disc space and the adjacent vertebral bodies, said passage having a maximum height as measured along the longitudinal axis of the human spine, said guard having a proximal end and an opposite distal end and at least one side therebetween, said guard having at least two openings in said side in communication with said passage, said openings dividing at least a portion of said guard into an upper portion and a lower portion; and

at least one extension extending from said distal end of said guard adapted to be inserted into the disc space between the adjacent vertebral bodies, said extension having a portion adapted to bear against each of the adjacent endplates of the adjacent vertebral bodies from within the disc space, said portion of said extension having an upper surface adapted to contact one of the adjacent end plates of the adjacent vertebral bodies and a lower surface adapted to contact the other of the adjacent end plates of the adjacent vertebral bodies, said portion of said extension having a height between said upper and lower surfaces and a length sufficient to align and distance apart the adjacent vertebral bodies.

166. The apparatus of claim 165, wherein at least one of said openings is at least one of a slot and a key-hole.

167. The apparatus of claim 165, wherein said upper portion and said lower portion of said guard are adapted to move apart from one another to facilitate the insertion of an implant through said passage and into the disc space.

168. The apparatus of claim 165, wherein said guard is a hollow tubular sleeve.

169. The apparatus of claim 165, wherein said guard has a circular cross section.

170. The apparatus of claim 165, wherein said passage has a circular cross section.

171. The apparatus of claim 165, wherein said proximal end of said guard has an increased outer dimension.

172. The apparatus of claim 165, wherein said distal end of said guard is contoured to the curvature of the adjacent vertebral bodies against which said guard is adapted to be placed.

173. The apparatus of claim 165, wherein said guard has a footplate.

174. The apparatus of claim 165, wherein said proximal end of said guard is configured to cooperatively engage an impaction member for receiving an impaction force for driving said guard into the spine.

175. The apparatus of claim 165, further comprising a cap adapted to engage said proximal end of said guard.

176. The apparatus of claim 165, further comprising a removable inner guard.

177. The apparatus of claim 176, wherein said removable inner guard is a hollow tubular sleeve.

178. The apparatus of claim 176, wherein said removable inner guard is adapted to be inserted into said guard.

179. The apparatus of claim 176, wherein said inner guard has a collar at one end larger than said passage of said guard.

180. The apparatus of claim 165, further comprising a second extension extending from said guard adapted to be inserted into the disc space and to bear against the endplates of the adjacent vertebral bodies.

181. The apparatus of claim 180, wherein said extensions are diametrically opposed to each other and spaced apart from one another to provide access to the adjacent vertebral bodies from within the disc space.

182. The apparatus of claim 180, wherein said extensions have the same height.

183. The apparatus of claim 165, wherein the height of said extension has at least a portion that approximates the surgically corrected height of the disc space between the adjacent vertebral bodies.

184. The apparatus of claim 165, wherein said upper and lower surfaces adapted to contact the adjacent endplates of the adjacent vertebral bodies diverge away from said guard along at least a portion of their length.

185. The apparatus of claim 165, wherein said upper and lower surfaces adapted to contact the endplates of the adjacent vertebral bodies converge away from said guard member along at least a portion of their length.

186. The apparatus of claim 165, further comprising a second passage in said guard for providing access to the disc space and the adjacent vertebral bodies.

187. The apparatus of claim 186, wherein said passage and said second passage are parallel to each other along at least a portion of their length.

188. The apparatus of claim 186, wherein said passage and said second passage converge along at least a portion of their length.

189. The apparatus of claim 186, wherein said passage and said second passage overlap at least in part.

190. The apparatus of claim 186, wherein said passage and said second passage are spaced apart.

191. The apparatus of claim 165, wherein said extension has a tapered leading end to facilitate placement of said extension into the disc space.

192. The apparatus of claim 165, wherein said guard comprises spine engaging portions at said distal end of said guard for holding said guard to the spine.

193. The apparatus of claim 192, wherein said spine engaging portions are selected from at least one of teeth and pins.

194. The apparatus of claim 192, wherein said spine engaging portions are adapted to penetrate the adjacent vertebral bodies.

195. The apparatus of claim 192, wherein at least one of said spine engaging portions has a tapered leading end to facilitate placement of at least one of said spine engaging portions into the spine.

196. The apparatus of claim 192, wherein at least one of said spine engaging portions has upper and lower surfaces that are parallel to each other.

197. The apparatus of claim 192, wherein said spine engaging portions are substantially in line with said side of said guard so that said spine engaging portions do not substantially increase the outer cross-sectional dimension of said guard near the distal end of said guard.

198. The apparatus of claim 165, wherein said extension is substantially in line with said side of said guard.

199. The apparatus of claim 165, in combination with a spinal implant.

200. The apparatus of claim 199, wherein said implant has opposed upper and lower surfaces including at least one opening to permit bone growth from adjacent vertebral body to adjacent vertebral body through said implant.

201. The apparatus of claim 199, wherein said spinal implant is in combination with a fusion promoting material.

202. The apparatus of claim 201, wherein said fusion promoting material is selected from at least one of harvested bone, hydroxyapatite, hydroxyapatite tricalcium phosphate, and bone morphogenetic protein.

203. The apparatus of claim 165, in combination with a bone removal device having a portion sized for movement through said passage for forming through said guard an implantation space at least in part across the surgically corrected height of the disc space.

204. The combination of claim 203, wherein said bone removal device is one of a drill, a trephine, a reamer, an end mill, a chisel, and a burr.

205. The combination of claim 203, further in combination with a spinal insert adapted for insertion into the implantation space formed by said bone removal device.

206. The combination of claim 205, wherein said spinal insert is one of a dowel, an interbody spinal implant, and an interbody spinal fusion implant.

207. The combination of claim 205, wherein said spinal insert comprises at least in part bone.

208. The combination of claim 205, wherein said spinal insert is a bone graft.

209. The combination of claim 205, further in combination with a fusion promoting substance.

210. The combination of claim 209, wherein said fusion promoting substance is bone.

211. The combination of claim 209, further in combination with a press for compressing said fusion promoting substance into said spinal insert.

212. The combination of claim 205, further in combination with an implant driver configured to insert said spinal insert into the implantation space formed by said bone removal device.

213. The combination of claim 205, further in combination with an instrument for removing from the spine the bone cut by said bone removal device.

214. The apparatus of claim 165, in combination with a tap for insertion through said guard for tapping the two adjacent vertebral bodies.

215. The apparatus of claim 165, in combination with a distractor adapted to urge apart the adjacent vertebral bodies.

216. The combination of claim 215, wherein said distractor is an interbody distractor.

217. The combination of claim 215, further in combination with at least a second distractor, said at least second distractor being differently sized relative to said distractor to form a set of distractors of graduated sizes.

218. An apparatus for use in human spinal surgery across at least a portion of the height of a surgically corrected disc space between two adjacent vertebral bodies of a human spine, said apparatus comprising:

a guard having a passage for providing access to the disc space and the adjacent vertebral bodies, said passage having a maximum height as measured along the longitudinal axis of the human spine, said guard having a proximal end and an opposite distal end and at least one side therebetween, said proximal end having an increased outer dimension, said guard having at least one opening in said side in communication with said passage; and

at least one extension extending from said distal end of said guard adapted to be inserted into the disc space between the adjacent vertebral bodies said extension having a portion adapted to bear against each of the adjacent endplates of the adjacent vertebral bodies from within the disc space, said portion of said extension having an upper surface adapted to contact one of the adjacent endplates of the adjacent vertebral bodies and a lower surface adapted to contact the other of the adjacent endplates of the adjacent vertebral bodies, said portion of said extension having a height between said upper and lower surfaces and a length sufficient to align and distance apart the adjacent vertebral bodies.

219. The apparatus of claim 218, wherein said opening is at least one of a slot and a key-hole.

220. The apparatus of claim 218, further comprising at least a second opening.

221. The apparatus of claim 218, wherein said guard is a hollow tubular sleeve.

222. The apparatus of claim 218, wherein guard has a circular cross section.

223. The apparatus of claim 218, wherein said passage has a circular cross section.

224. The apparatus of claim 218, wherein said distal end of said guard is contoured to the curvature of the adjacent vertebral bodies against which said guard is adapted to be placed.

225. The apparatus of claim 218, wherein said guard has a footplate.

226. The apparatus of claim 218, wherein said proximal end of said guard is configured to cooperatively engage an impaction member for receiving an impaction force for driving into the spine.

227. The apparatus of claim 218, further comprising a cap adapted to engage said proximal end of said guard.

228. The apparatus of claim 218, further comprising a removable inner guard.

229. The apparatus of claim 228, wherein said removable inner guard is a hollow tubular sleeve.

230. The apparatus of claim 228, wherein said removable inner guard is adapted to be inserted into said guard.

231. The apparatus of claim 228, wherein said inner guard has a collar at one end larger than said passage of said guard.

232. The apparatus of claim 218, further comprising a second extension extending from said guard adapted to be inserted into the disc space and to bear against the endplates of the adjacent vertebral bodies.

233. The apparatus of claim 232, wherein said extensions are diametrically opposed to each other and spaced apart from one another to provide access to the adjacent vertebral bodies from within the disc space.

234. The apparatus of claim 232, wherein said extensions have the same height.

235. The apparatus of claim 218, wherein the height of said extension has at least a portion that approximates the surgically corrected height of the disc space between the adjacent vertebral bodies.

236. The apparatus of claim 218, wherein said upper and lower surfaces adapted to contact the adjacent endplates of the adjacent vertebral bodies diverge away from said guard along at least a portion of their length.

237. The apparatus of claim 218, wherein said upper and lower surfaces adapted to contact the end plates of the adjacent vertebral bodies converge away from said guard member along at least a portion of their length.

238. The apparatus of claim 218, further comprising a second passage in said guard for providing access to the disc space and the adjacent vertebral bodies.

239. The apparatus of claim 238, wherein said passage and said second passage are parallel to each other along at least a portion of their length.

240. The apparatus of claim 238, wherein said passage and said second passage converge along at least a portion of their length.

241. The apparatus of claim 238, wherein said passage and said second passage overlap at least in part.

242. The apparatus of claim 238, wherein said passage and said second passage are spaced apart.

243. The apparatus of claim 218, wherein said extension has a tapered leading end to facilitate placement of said extension into the disc space.

244. The apparatus of claim 218, wherein said guard comprises spine engaging portions at said distal end of said guard for holding said guard to the spine.

245. The apparatus of claim 244, wherein said spine engaging portions are selected from at least one of teeth and pins.

246. The apparatus of claim 244, wherein said spine engaging portions are adapted to penetrate the adjacent vertebral bodies.

247. The apparatus of claim 244, wherein at least one of said spine engaging portions has a tapered leading end to facilitate placement of at least one of said spine engaging portions into the spine.

248. The apparatus of claim 244, wherein at least one of said spine engaging portions has upper and lower surfaces that are parallel to each other.

249. The apparatus of claim 244, wherein said spine engaging portions are substantially in line with said side of said guard so that said spine engaging portions do not substantially increase the outer cross-sectional dimension of said guard near the distal end of said guard.

250. The apparatus of claim 218, wherein said extension is substantially in line with said side of said guard.

251. The apparatus of claim 218, in combination with a spinal implant.

252. The apparatus of claim 251, wherein said implant has opposed upper and lower surfaces including at least one opening to permit bone growth from adjacent vertebral body to adjacent vertebral body through said implant.

253. The apparatus of claim 251, wherein said spinal implant is in combination with a fusion promoting material.

254. The apparatus of claim 253, wherein said fusion promoting material is selected from at least one of harvested bone, hydroxyapatite, hydroxyapatite tricalcium phosphate, and bone morphogenetic protein.

255. The apparatus of claim 218, in combination with a bone removal device having a portion sized for movement through said passage for forming through said guard an implantation space at least in part across the surgically corrected height of the disc space.

256. The combination of claim 255, wherein said bone removal device is one of a drill, a trephine, a reamer, an en a chisel, and a burr.

257. The combination of claim 255, further in combination with a spinal insert adapted for insertion into the implantation space formed by said bone removal device.

258. The combination of claim 257, wherein said spinal insert is one of a dowel, an interbody spinal implant, and interbody spinal fusion implant.

259. The combination of claim 257, wherein said spinal insert comprises at least in part bone.

260. The combination of claim 257, wherein said spinal insert is a bone graft.

261. The combination of claim 257, further in combination with a fusion promoting substance.

262. The combination of claim 261, wherein said fusion promoting substance is bone.

263. The combination of claim 261, further in combination with a press for compressing said fusion promoting substance into said spinal insert.

264. The combination of claim 257, further in combination with an implant driver configured to insert said spinal insert into the implantation space formed by said bone removal device.

265. The combination of claim 255, further in combination with an instrument for removing from the spine the bone cut by said bone removal device.

266. The apparatus of claim 218, in combination with a tap for insertion through said guard for tapping the two adjacent vertebral bodies.

267. The apparatus of claim 218, in combination with a distractor adapted to urge apart the adjacent vertebral bodies.

268. The combination of claim 267, wherein said distractor is an interbody distractor.

269. The combination of claim 267, further in combination with at least a second distractor, said at least second distractor being differently sized relative to said distractor to form a set of distractors of graduated sizes.

270. An apparatus for use in human spinal surgery across at least a portion of the height of a surgically corrected disc space between two adjacent vertebral bodies of a human spine, said apparatus comprising:

a guard having a passage for providing access to the disc space and the adjacent vertebral bodies, said passage having a maximum height as measured along the longitudinal axis of the human spine, said guard having a proximal end and an opposite distal end and at least one side therebetween, said distal end being contoured to the curvature of the adjacent vertebral bodies against which said guard is adapted to be placed, said guard having at least one opening in said side in communication with said passage; and

at least one extension extending from said distal end of said guard adapted to be inserted into the disc space between the adjacent vertebral bodies, said extension having a portion adapted to bear against each of the adjacent endplates of the adjacent vertebral bodies from within the disc space, said portion of said extension having an upper surface adapted to contact one of the adjacent endplates of the adjacent vertebral bodies and a lower surface adapted to contact the other of the adjacent endplates of the adjacent vertebral bodies, said portion of said extension having a height between said upper and lower surfaces and a length sufficient to align and distance apart the adjacent vertebral bodies.

271. The apparatus of claim 270, wherein said opening is at least one of a slot and a key-hole.

272. The apparatus of claim 270, further comprising at least a second opening.

273. The apparatus of claim 270, wherein said guard is a hollow tubular sleeve.

274. The apparatus of claim 270, wherein said guard has a circular cross section.

275. The apparatus of claim 270, wherein said passage has a circular cross section.

276. The apparatus of claim 270, wherein said guard has a footplate.

277. The apparatus of claim 270, wherein said proximal end of said guard is configured to cooperatively engage an impaction member for receiving an impaction force for driving said guard into the spine.

278. The apparatus of claim 270, further comprising a cap adapted to engage said proximal end of said guard.

279. The apparatus of claim 270, further comprising a removable inner guard.

280. The apparatus of claim 279, wherein said removable inner guard is a hollow tubular sleeve.

281. The apparatus of claim 279, wherein said removable inner guard is adapted to be inserted into said guard.

282. The apparatus of claim 279, wherein said inner guard has a collar at one end larger than said passage of said guard.

283. The apparatus of claim 270, further comprising a second extension extending from said guard adapted to be inserted into the disc space and to bear against the end plates of the adjacent vertebral bodies.

284. The apparatus of claim 283, wherein said extensions are diametrically opposed to each other and spaced apart from one another to provide access to the adjacent vertebral bodies from within the disc space.

285. The apparatus of claim 283, wherein said extensions have the same height.

286. The apparatus of claim 270, wherein the height of said extension has at least a portion that approximates the surgically corrected height of the disc space between the adjacent vertebral bodies.

287. The apparatus of claim 270, wherein said upper and lower surfaces adapted to contact the adjacent endplates of the adjacent vertebral bodies diverge away from said guard along at least a portion of their length.

288. The apparatus of claim 270, wherein said upper and lower surfaces adapted to contact the end plates of the adjacent vertebral bodies converge away from said guard member along at least a portion of their length.

289. The apparatus of claim 270, further comprising a second passage in said guard for providing access to the disc space and the adjacent vertebral bodies.

290. The apparatus of claim 289, wherein said passage and said second passage are parallel to each other along at least a portion of their length.

291. The apparatus of claim 289, wherein said passage and said second passage converge along at least a portion of their length.

292. The apparatus of claim 289, wherein said passage and said second passage overlap at least in part.

293. The apparatus of claim 289, wherein said passage and said second passage are spaced apart.

294. The apparatus of claim 270, wherein said extension has a tapered leading end to facilitate placement of said extension into the disc space.

295. The apparatus of claim 270, wherein said guard comprises spine engaging portions at said distal end of said guard for holding said guard to the spine.

296. The apparatus of claim 295, wherein said spine engaging portions are selected from at least one of teeth and pins.

297. The apparatus of claim 295, wherein said spine engaging portions are adapted to penetrate the adjacent vertebral bodies.

298. The apparatus of claim 295, wherein at least one of said spine engaging portions has a tapered leading end to facilitate placement of at least one of said spine engaging portions into spine.

299. The apparatus of claim 295, wherein at least one of said spine engaging portions has upper and lower surfaces that are parallel to each other.

300. The apparatus of claim 295, wherein said spine engaging portions are substantially in line with said side of said guard so that said spine engaging portions do not substantially increase the outer cross-sectional dimension of said guard near the distal end of said guard.

301. The apparatus of claim 270, wherein said extension is substantially in line with said side of said guard.

302. The apparatus of claim 270, in combination with a spinal implant.

303. The apparatus of claim 302, wherein said implant has opposed upper and lower surfaces including at least one opening to permit bone growth from adjacent vertebral body to adjacent vertebral body through said implant.

304. The apparatus of claim 302, wherein said spinal implant is in combination with a fusion promoting material.

305. The apparatus of claim 304, wherein said fusion promoting material is selected from at least one of harvested bone, hydroxyapatite, hydroxyapatite tricalcium phosphate, and bone morphogenetic protein.

306. The apparatus of claim 270, in combination with a bone removal device having a portion sized for movement through said passage for forming through said guard an implantation space at least in part across the surgically corrected height of the disc space.

307. The combination of claim 306 wherein said bone removal device is one of a drill, a trephine, a reamer, an end mill, a chisel, and a burr.

308. The combination of claim 306, further in combination with a spinal insert adapted for insertion into the implantation space formed by said bone removal device.

309. The combination of claim 308, wherein said spinal insert is one of a dowel, an interbody spinal implant, and an interbody spinal fusion implant.

310. The combination of claim 308, wherein said spinal insert comprises at least in part bone.

311. The combination of claim 308, wherein said spinal insert is a bone graft.

312. The combination of claim 308, further in combination with a fusion promoting substance.

313. The combination of claim 312, wherein said fusion promoting substance is bone.

314. The combination of claim 312, further in combination with a press for compressing said fusion promoting substance into said spinal insert.

315. The combination of claim 308, further in combination with an implant driver configured to insert said spinal insert into the implantation space formed by said bone removal device.

316. The combination of claim 306, further in combination with an instrument for removing from the spine the bone cut by said bone removal device.

317. The apparatus of claim 270, in combination with a tap for insertion through said guard for tapping the two adjacent vertebral bodies.

318. The apparatus of claim 270, in combination with a distractor adapted to urge apart the adjacent vertebral bodies.

319. The combination of claim 318, wherein said distractor is an interbody distractor.

320. The combination of claim 318, further in combination with at least a second distractor, said at least second distractor being differently sized relative to said distractor to form a set of distractors of graduated sizes.

321. An apparatus for use in human spinal surgery across at least a portion of the height of a surgically corrected disc space between two adjacent vertebral bodies of a human spine, said apparatus comprising:

a guard having a passage for providing access to the disc space and the adjacent vertebral bodies, said passage having a maximum height as measured along the longitudinal axis of the human spine, said guard having a proximal end and an opposite distal end and at least one side therebetween, said guard having at least one opening in said side in communication with said passage, said guard having a footplate; and

at least one extension extending from said distal end of said guard adapted to be inserted into the disc space between the adjacent vertebral bodies, said extension having a portion adapted to bear against each of the adjacent endplates of the adjacent vertebral bodies from within the disc space, said portion of said extension having an upper surface adapted to contact one of the adjacent endplates of the adjacent vertebral bodies and a lower surface adapted to contact the other of the adjacent endplates of the adjacent vertebral bodies, said portion of said extension having a height between said upper and lower surfaces and a length sufficient to align and distance apart the adjacent vertebral bodies.

322. The apparatus of claim 321, wherein said opening is at least one of a slot and a key-hole.

323. The apparatus of claim 321, further comprising at least a second opening.

324. The apparatus of claim 321, wherein said guard is a hollow tubular sleeve.

325. The apparatus of claim 321, wherein said guard has a circular cross section.

326. The apparatus of claim 321, wherein said passage has a circular cross section.

327. The apparatus of claim 321, wherein said proximal end of said guard is configured to cooperatively engage an impaction member for receiving an impaction force for driving said guard into the spine.

328. The apparatus of claim 321, further comprising a cap adapted to engage said proximal end of said guard.

329. The apparatus of claim 321, further comprising a removable inner guard.

330. The apparatus of claim 329, wherein said removable inner guard is a hollow tubular sleeve.

331. The apparatus of claim 329, wherein said removable inner guard is adapted to be inserted into said guard.

332. The apparatus of claim 329, wherein said inner guard has a collar at one end larger than said passage of said guard.

333. The apparatus of claim 321, further comprising a second extension extending from said guard adapted to be inserted into the disc space and to bear against the endplates of the adjacent vertebral bodies.

334. The apparatus of claim 333, wherein said extensions are diametrically opposed to each other and spaced apart from one another to provide access to the adjacent vertebral bodies from within the disc space.

335. The apparatus of claim 333, wherein said extensions have the same height.

336. The apparatus of claim 321, wherein the height of said extension has at least a portion that approximates the surgically corrected height of the disc space between the adjacent vertebral bodies.

337. The apparatus of claim 321, wherein said upper and lower surfaces adapted to contact the adjacent end plates of the adjacent vertebral bodies diverge away from said guard along at least a portion of their length.

338. The apparatus of claim 321, wherein said upper and lower surfaces adapted to contact the endplates of the adjacent vertebral bodies converge away from said guard member along at least a portion of their length.

339. The apparatus of claim 321, further comprising a second passage in said guard for providing access to the disc space and the adjacent vertebral bodies.

340. The apparatus of claim 339, wherein said passage and said second passage are parallel to each other along at least a portion of their length.

341. The apparatus of claim 339, wherein said passage and said second passage converge along at least a portion of their length.

342. The apparatus of claim 339, wherein said passage and said second passage overlap at least in part.

343. The apparatus of claim 339, wherein said passage and said second passage are spaced apart.

344. The apparatus of claim 321, wherein said extension has a tapered leading end to facilitate placement of said extension into the disc space.

345. The apparatus of claim 321, wherein said guard comprises spine engaging portions at said distal end of said guard for holding said guard to the spine.

346. The apparatus of claim 345, wherein said spine engaging portions are selected from at least one of teeth and pins.

347. The apparatus of claim 345, wherein said spine engaging portions are adapted to penetrate the adjacent vertebral bodies.

348. The apparatus of claim 345, wherein at least one of said spine engaging portions has a tapered leading end to facilitate placement of at least one of said spine engaging portions into the pine.

349. The apparatus of claim 345, wherein at least one of said spine engaging portions has upper and lower surfaces that are parallel to each other.

350. The apparatus of claim 345, wherein said spine engaging portions are substantially in line with said side of said guard so that said spine engaging portions do not substantially increase the outer cross-sectional dimension of said guard near the distal end of said guard.

351. The apparatus of claim 321, wherein said extension is substantially in line with said side of said guard.

352. The apparatus of claim 321, in combination with a spinal implant.

353. The apparatus of claim 352, wherein said implant has opposed upper and lower surfaces including at least one opening to permit bone growth from adjacent vertebral body to adjacent vertebral body through said implant.

354. The apparatus of claim 352, wherein said spinal implant is in combination with a fusion promoting material.

355. The apparatus of claim 354, wherein said fusion promoting material is selected from at least one of harvested bone, hydroxyapatite, hydroxyapatite tricalcium phosphate, and bone morphogenetic protein.

356. The apparatus of claim 321, in combination with a bone removal device having a portion sized for movement through said passage for forming through said guard an implantation space at least in part across the surgically corrected height of the disc space.

357. The combination of claim 356, wherein said bone removal device is one of a drill, a trephine, a reamer, an end mill, a chisel, and a burr.

358. The combination of claim 356, further in combination with a spinal insert adapted for insertion into the implantation space formed by said bone removal device.

359. The combination of claim 358, wherein said spinal insert is one of a dowel, an interbody spinal implant, and interbody spinal fusion implant.

360. The combination of claim 358, wherein said spinal insert comprises at least in part bone.

361. The combination of claim 358, wherein said spinal insert is a bone graft.

362. The combination of claim 358, further in combination with a fusion promoting substance.

363. The combination of claim 362, wherein said fusion promoting substance is bone.

364. The combination of claim 362, further in combination with a press for compressing said fusion promoting substance into said spinal insert.

365. The combination of claim 358, further in combination with an implant driver configured to insert said spinal insert into the implantation space formed by said bone removal device.

366. The combination of claim 356, further in combination with an instrument for removing from the spine the bone cut by said bone removal device.

367. The apparatus of claim 321, in combination with a tap for insertion through said guard for tapping the two adjacent vertebral bodies.

368. The apparatus of claim 321, in combination with a distractor adapted to urge apart the adjacent vertebral bodies.

369. The combination of claim 368, wherein said distractor is an interbody distractor.

370. The combination of claim 368, further in combination with at least a second distractor, said at least second distractor being differently sized relative to said distractor to form a set of distractors of graduated sizes.

371. An apparatus for use in human spinal surgery across at least a portion of the height of a surgically corrected disc space between two adjacent vertebral bodies of a human spine, said apparatus comprising:

a guard having a passage for providing access to the disc space and the adjacent vertebral bodies, said passage having a maximum height as measured along the longitudinal axis of the human spine, said guard having a proximal end and an opposite distal end and at least one side therebetween, said guard having at least one opening in said side in communication with said passage;

at least one extension extending from said distal end of said guard adapted to be inserted into the disc space between the adjacent vertebral bodies, said extension having a portion adapted to bear against each of the adjacent endplates of the adjacent vertebral bodies from within the disc space, said portion of said extension having an upper surface adapted to contact one of the adjacent endplates of the adjacent vertebral bodies and a lower surface adapted to contact the other of the adjacent endplates of the adjacent vertebral bodies, said portion of said extension having a height between said upper and lower surfaces and a length sufficient to align and distance apart the adjacent vertebral bodies; and

a removable inner hollow tubular sleeve.

372. The apparatus of claim 371, wherein said opening is at least one of a slot and a key-hole.

373. The apparatus of claim 371, further comprising at least a second opening.

374. The apparatus of claim 371, wherein said guard is a hollow tubular sleeve.

375. The apparatus of claim 371, wherein said guard has a circular cross section.

376. The apparatus of claim 371, wherein said passage has a circular cross section.

377. The apparatus of claim 371, wherein said proximal end of said guard is configured to cooperatively engage an impaction member for receiving an impaction force for driving said guard into the spine.

378. The apparatus of claim 371, further comprising a cap adapted to engage said proximal end of said guard.

379. The apparatus of claim 371, wherein said removable inner sleeve is adapted to be inserted into said guard.

380. The apparatus of claim 371, wherein said inner sleeve has a collar at one end larger than said passage of said guard.

381. The apparatus of claim 371, further comprising a second extension extending from said guard adapted to be inserted into the disc space and to bear against the endplates of the adjacent vertebral bodies.

382. The apparatus of claim 381, wherein said extensions are diametrically opposed to each other and spaced apart from one another to provide access to the adjacent vertebral bodies from within the disc space.

383. The apparatus of claim 381, wherein said extensions have the same height.

384. The apparatus of claim 371, wherein the height of said extension has at least a portion that approximates the surgically corrected height of the disc space between the adjacent vertebral bodies.

385. The apparatus of claim 371, wherein said upper and lower surfaces adapted to contact the adjacent end plates of the adjacent vertebral bodies diverge away from said guard along at least a portion of their length.

386. The apparatus of claim 371, wherein said upper and lower surfaces adapted to contact the endplates of the adjacent vertebral bodies converge away from said guard member along at least a portion of their length.

387. The apparatus of claim 371, further comprising a second passage in said guard for providing access to the disc space and the adjacent vertebral bodies.

388. The apparatus of claim 387, wherein said passage and said second passage are parallel to each other along at least a portion of their length.

389. The apparatus of claim 387, wherein said passage and said second passage converge along at least a portion of their length.

390. The apparatus of claim 387, wherein said passage and said second passage overlap at least in part.

391. The apparatus of claim 387, wherein said passage and said second passage are spaced apart.

392. The apparatus of claim 371, wherein said extension has a tapered leading end to facilitate placement of said extension into the disc space.

393. The apparatus of claim 371, wherein said guard comprises spine engaging portions at said distal end of said guard for holding said guard to the spine.

394. The apparatus of claim 393, wherein said spine engaging portions are selected from at least one of teeth and pins.

395. The apparatus of claim 393, wherein said spine engaging portions are adapted to penetrate the adjacent vertebral bodies.

396. The apparatus of claim 393, wherein at least one of said spine engaging portions has a tapered leading end to facilitate placement of at least one of said spine engaging portions into the spine.

397. The apparatus of claim 393, wherein at least one of said spine engaging portions has upper and lower surfaces that are parallel to each other.

398. The apparatus of claim 393, wherein said spine engaging portions are substantially in line with said side of said guard so that said spine engaging portions do not substantially increase the outer cross-sectional dimension of said guard near the distal end of said guard.

399. The apparatus of claim 371, wherein said extension is substantially in line with said side of said guard.

400. The apparatus of claim 371, in combination with a spinal implant.

401. The apparatus of claim 400, wherein said implant has opposed upper and lower surfaces including at least one opening to permit bone growth from adjacent vertebral body to adjacent vertebral body through said implant.

402. The apparatus of claim 400, wherein said spinal implant is in combination with a fusion promoting material.

403. The apparatus of claim 402, wherein said fusion promoting material is selected from at least one of harvested bone, hydroxyapatite, hydroxyapatite tricalcium phosphate, and bone morphogenetic protein.

404. The apparatus of claim 371, in combination with a bone removal device having a portion sized for movement through said passage for forming through said guard an implantation space at least in part across the surgically corrected height of the disc space.

405. The combination of claim 404, wherein said bone removal device is one of a drill, a trephine, a reamer, an end mill, a chisel, and a burr.

406. The combination of claim 404, further in combination with a spinal insert adapted for insertion into the implantation space formed by said bone removal device.

407. The combination of claim 406, wherein said spinal insert is one of a dowel, an interbody spinal implant, and an interbody spinal fusion implant.

408. The combination of claim 406, wherein said spinal insert comprises at least in part bone.

409. The combination of claim 406, wherein said spinal insert is a bone graft.

410. The combination of claim 406, further in combination with a fusion promoting substance.

411. The combination of claim 410, wherein said fusion promoting substance is bone.

412. The combination of claim 410, further in combination with a press for compressing said fusion promoting substance into said spinal insert.

413. The combination of claim 406, further in combination with an implant driver configured to insert said spinal insert into the implantation space formed by said bone removal device.

414. The combination of claim 404, further in combination with an instrument for removing from the spine the bone cut by said bone removal device.

415. The apparatus of claim 371, in combination with a tap for insertion through said guard for tapping the two adjacent vertebral bodies.

416. The apparatus of claim 371, in combination with a distractor adapted to urge apart the adjacent vertebral bodies.

417. The combination of claim 416, wherein said distractor is an interbody distractor.

418. The combination of claim 416, further in combination with at least a second distractor, said at least second distractor being differently sized relative to said distractor to form a set of distractors of graduated sizes.

419. An apparatus for use in human spinal surgery across at east a portion of the height of a surgically corrected disc space between two adjacent vertebral bodies of a human spine, said apparatus comprising:

a guard having a passage for providing access to the disc space and the adjacent vertebral bodies, said passage having a maximum height as measured along the longitudinal axis of the human spine, said guard having a proximal end and an opposite distal end and at least one side therebetween, said guard having at least one opening in said side in communication with said passage; and

at least two extensions extending from said distal end of said guard adapted to be inserted into the disc space between the adjacent vertebral bodies, said extensions having a portion adapted to bear against each of the adjacent endplates of the adjacent vertebral bodies from within the disc space, said portion of said extensions having an upper surface adapted to contact one of the adjacent end plates of the adjacent vertebral bodies and a lower surface adapted to contact the other of the adjacent end plates of the adjacent vertebral bodies, said portion of said extensions having a height between said upper and lower surfaces and a length sufficient to align and distance apart the adjacent vertebral bodies.

420. The apparatus of claim 419, wherein said opening is at least one of a slot and a key-hole.

421. The apparatus of claim 419, further comprising at least a second opening.

422. The apparatus of claim 419, wherein said guard is a hollow tubular sleeve.

423. The apparatus of claim 419, wherein said guard has a circular cross section.

424. The apparatus of claim 419, wherein said passage has a circular cross section.

425. The apparatus of claim 419, wherein said proximal end of said guard is configured to cooperatively engage an impaction member for receiving an impaction force for driving said guard into the spine.

426. The apparatus of claim 419, further comprising a cap adapted to engage said proximal end of said guard.

427. The apparatus of claim 419, wherein said extensions are diametrically opposed to each other and spaced apart from one another to provide access to the adjacent vertebral bodies from within the disc space.

428. The apparatus of claim 419, wherein said extensions have the same height.

429. The apparatus of claim 419, wherein the height of said extensions has at least a portion that approximates the surgically corrected height of the disc space between the adjacent vertebral bodies.

430. The apparatus of claim 419, wherein said upper and lower surfaces adapted to contact the adjacent endplates of the adjacent vertebral bodies diverge away from said guard along at least a portion of their length.

431. The apparatus of claim 419, wherein said upper and lower surfaces adapted to contact the endplates of the adjacent vertebral bodies converge away from said guard member along at least a portion of their length.

432. The apparatus of claim 419, further comprising a second passage in said guard for providing access to the disc space and the adjacent vertebral bodies.

433. The apparatus of claim 432, wherein said passage and said second passage are parallel to each other along at least a portion of their length.

434. The apparatus of claim 432, wherein said passage and said second passage converge along at least a portion of their length.

435. The apparatus of claim 432, wherein said passage and said second passage overlap at least in part.

436. The apparatus of claim 432, wherein said passage and said second passage are spaced apart.

437. The apparatus of claim 419, wherein said extensions have a tapered leading end to facilitate placement of said extensions into the disc space.

438. The apparatus of claim 419, wherein said guard comprises spine engaging portions at said distal end of said guard for holding said guard to the spine.

439. The apparatus of claim 438, wherein said spine engaging portions are selected from at least one of teeth and pins.

440. The apparatus of claim 438, wherein said spine engaging portions are adapted to penetrate the adjacent vertebral bodies.

441. The apparatus of claim 438, wherein at least one of said spine engaging portions has a tapered leading end to facilitate placement of at least one of said spine engaging portions into the spine.

442. The apparatus of claim 438, wherein at least one of said spine engaging portions has upper and lower surfaces that are parallel to each other.

443. The apparatus of claim 438, wherein said spine engaging portions are substantially in line with said side of said guard so that said spine engaging portions do not substantially increase the outer cross-sectional dimension of said guard near the distal end of said guard.

444. The apparatus of claim 419, wherein said extensions are substantially in line with said side of said guard.

445. The apparatus of claim 419, in combination with a spinal implant.

446. The apparatus of claim 445, wherein said implant has opposed upper and lower surfaces including at least one opening to permit bone growth from adjacent vertebral body to adjacent vertebral body through said implant.

447. The apparatus of claim 445, wherein said spinal implant is in combination with a fusion promoting material.

448. The apparatus of claim 447, wherein said fusion promoting material is selected from at least one of harvested bone, hydroxyapatite, hydroxyapatite tricalcium phosphate, and bone morphogenetic protein.

449. The apparatus of claim 419, in combination with a bone removal device having a portion sized for movement through said passage for forming through said guard an implantation space at least in part across the surgically corrected height of the disc space.

450. The combination of claim 449, wherein said bone removal device is one of a drill, a trephine, a reamer, an end mill, a chisel, and a burr.

451. The combination of claim 449, further in combination with a spinal insert adapted for insertion into the implantation space formed by said bone removal device.

452. The combination of claim 451, wherein said spinal insert is one of a dowel, an interbody spinal implant, and an interbody spinal fusion implant.

453. The combination of claim 451, wherein said spinal insert comprises at least in part bone.

454. The combination of claim 451, wherein said spinal insert is a bone graft.

455. The combination of claim 451, further in combination with a fusion promoting substance.

456. The combination of claim 455, wherein said fusion promoting substance is bone.

457. The combination of claim 455, further in combination with a press for compressing said fusion promoting substance into said spinal insert.

458. The combination of claim 451, further in combination with an implant driver configured to insert said spinal insert into the implantation space formed by said bone removal device.

459. The combination of claim 449, further in combination with an instrument for removing from the spine the bone cut by said bone removal device.

460. The apparatus of claim 419, in combination with a tap for insertion through said guard for tapping the two adjacent vertebral bodies.

461. The apparatus of claim 419, in combination with a distractor adapted to urge apart the adjacent vertebral bodies.

462. The combination of claim 461, wherein said distractor is an interbody distractor.

463. The combination of claim 461, further in combination with at least a second distractor, said at least second distractor being differently sized relative to said distractor to form a set of distractors of graduated sizes.

464. An apparatus for use in human spinal surgery across at least a portion of the height of a surgically corrected disc space between two adjacent vertebral bodies of a human spine, said apparatus comprising:

a guard having first and second passages for providing access to the disc space and the adjacent vertebral bodies, said first and second passages having a maximum height as measured along the longitudinal axis of the human spine, said guard having a proximal end and an opposite distal end and at least one side therebetween, said guard having at least one opening in said side in communication with at least one of said first and second passages; and

at least one extension extending from said distal end of said guard adapted to be inserted into the disc space between the adjacent vertebral bodies, said extension having a portion adapted to bear against each of the adjacent endplates of the adjacent vertebral bodies from within the disc space, said portion of said extension having an upper surface adapted to contact one of the adjacent end plates of the adjacent vertebral bodies and a lower surface adapted to contact the other of the adjacent end plates of the adjacent vertebral bodies, said portion of said extension having a height between said upper and lower surfaces and a length sufficient to align and distance apart the adjacent vertebral bodies.

465. The apparatus of claim 464, wherein said opening is at least one of a slot and a key-hole.

466. The apparatus of claim 464, further comprising at least a second opening.

467. The apparatus of claim 464, wherein said guard is a hollow tubular sleeve.

468. The apparatus of claim 464, wherein said guard has a circular cross section.

469. The apparatus of claim 464, wherein at least one of said first and second passages has a circular cross section.

470. The apparatus of claim 464, wherein said proximal end of said guard is configured to cooperatively engage an impaction member for receiving an impaction force for driving said guard into the spine.

471. The apparatus of claim 464, further comprising a cap adapted to engage said proximal end of said guard.

472. The apparatus of claim 464, wherein the height of said extension has at least a portion that approximates the surgically corrected height of the disc space between the adjacent vertebral bodies.

473. The apparatus of claim 464, wherein said upper and lower surfaces adapted to contact the adjacent endplates of the adjacent vertebral bodies diverge away from said guard along at least a portion of their length.

474. The apparatus of claim 464, wherein said upper and lower surfaces adapted to contact the endplates of the adjacent vertebral bodies converge away from said guard member along at least a portion of their length.

475. The apparatus of claim 464, wherein said first and second passages are parallel to each other along at least a portion of their length.

476. The apparatus of claim 464, wherein said first and second passages converge along at least a portion of their length.

478. The apparatus of claim 464, wherein said first and second passages are spaced apart.

479. The apparatus of claim 464, wherein said extension has a tapered leading end to facilitate placement of said extension into the disc space.

480. The apparatus of claim 464, wherein said guard comprises spine engaging portions at said distal end of said guard for holding said guard to the spine.

481. The apparatus of claim 480, wherein said spine engaging portions are selected from at least one of teeth and pins.

482. The apparatus of claim 480, wherein said spine engaging portions are adapted to penetrate the adjacent vertebral bodies.

483. The apparatus of claim 480, wherein at least one of said spine engaging portions has a tapered leading end to facilitate placement of at least one of said spine engaging portions into the spine.

484. The apparatus of claim 480, wherein at least one of said spine engaging portions has upper and lower surfaces that are parallel to each other.

485. The apparatus of claim 480, wherein said spine engaging portions are substantially in line with said side of said guard so that said spine engaging portions do not substantially increase the outer cross-sectional dimension of said guard near the distal end of said guard.

486. The apparatus of claim 464, wherein said extension is substantially in line with said side of said guard.

487. The apparatus of claim 464, in combination with a spinal implant.

488. The apparatus of claim 487, wherein said implant has opposed upper and lower surfaces including at least one opening to permit bone growth from adjacent vertebral body to adjacent vertebral body through said implant.

489. The apparatus of claim 486, wherein said spinal implant is in combination with a fusion promoting material.

490. The apparatus of claim 487, wherein said fusion promoting material is selected from at least one of harvested bone, hydroxyapatite, hydroxyapatite tricalcium phosphate, and bone morphogenetic protein.

491. The apparatus of claim 464, in combination with a bone removal device having a portion sized for movement through at least one of said first and second passages for forming through said guard an implantation space at least in part across the surgically corrected height of the disc space.

492. The combination of claim 491, wherein said bone removal device is one of a drill, a trephine, a reamer, an end mill, a chisel, and a burr.

493. The combination of claim 491, further in combination with a spinal insert adapted for insertion into the implantation space formed by said bone removal device.

494. The combination of claim 493, wherein said spinal insert is one of a dowel, an interbody spinal implant, and an interbody spinal fusion implant.

495. The combination of claim 493, wherein said spinal insert comprises at least in part bone.

496. The combination of claim 493, wherein said spinal insert is a bone graft.

497. The combination of claim 493, further in combination with a fusion promoting substance.

498. The combination of claim 497, wherein said fusion promoting substance is bone.

499. The combination of claim 497, further in combination with a press for compressing said fusion promoting substance into said spinal insert.

500. The combination of claim 493, further in combination with an implant driver configured to insert said spinal insert into the implantation space formed by said bone removal device.

501. The combination of claim 491, further in combination with an instrument for removing from the spine the bone cut by said bone removal device.

502. The apparatus of claim 464, in combination with a tap for insertion through said guard for tapping the two adjacent vertebral bodies.

503. The apparatus of claim 464, in combination with a distractor adapted to urge apart the adjacent vertebral bodies.

504. The combination of claim 503, wherein said distractor is an interbody distractor.

505. The combination of claim 503, further in combination with at least a second distractor, said at least second distractor being differently sized relative to said distractor to form a set of distractors of graduated sizes.

477. The apparatus of claim wherein said first and second passages overlap at least in part.