US20050277832A1 - Percutaneous registration apparatus and method for use in computer-assisted surgical navigation - Google Patents
Percutaneous registration apparatus and method for use in computer-assisted surgical navigation Download PDFInfo
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- US20050277832A1 US20050277832A1 US11/199,419 US19941905A US2005277832A1 US 20050277832 A1 US20050277832 A1 US 20050277832A1 US 19941905 A US19941905 A US 19941905A US 2005277832 A1 US2005277832 A1 US 2005277832A1
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/56—Surgical instruments or methods for treatment of bones or joints; Devices specially adapted therefor
- A61B17/58—Surgical instruments or methods for treatment of bones or joints; Devices specially adapted therefor for osteosynthesis, e.g. bone plates, screws, setting implements or the like
- A61B17/68—Internal fixation devices, including fasteners and spinal fixators, even if a part thereof projects from the skin
- A61B17/70—Spinal positioners or stabilisers ; Bone stabilisers comprising fluid filler in an implant
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/56—Surgical instruments or methods for treatment of bones or joints; Devices specially adapted therefor
- A61B17/58—Surgical instruments or methods for treatment of bones or joints; Devices specially adapted therefor for osteosynthesis, e.g. bone plates, screws, setting implements or the like
- A61B17/68—Internal fixation devices, including fasteners and spinal fixators, even if a part thereof projects from the skin
- A61B17/70—Spinal positioners or stabilisers ; Bone stabilisers comprising fluid filler in an implant
- A61B17/7074—Tools specially adapted for spinal fixation operations other than for bone removal or filler handling
- A61B17/7083—Tools for guidance or insertion of tethers, rod-to-anchor connectors, rod-to-rod connectors, or longitudinal elements
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B34/00—Computer-aided surgery; Manipulators or robots specially adapted for use in surgery
- A61B34/20—Surgical navigation systems; Devices for tracking or guiding surgical instruments, e.g. for frameless stereotaxis
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/56—Surgical instruments or methods for treatment of bones or joints; Devices specially adapted therefor
- A61B17/58—Surgical instruments or methods for treatment of bones or joints; Devices specially adapted therefor for osteosynthesis, e.g. bone plates, screws, setting implements or the like
- A61B17/68—Internal fixation devices, including fasteners and spinal fixators, even if a part thereof projects from the skin
- A61B17/70—Spinal positioners or stabilisers ; Bone stabilisers comprising fluid filler in an implant
- A61B17/7001—Screws or hooks combined with longitudinal elements which do not contact vertebrae
- A61B17/7032—Screws or hooks with U-shaped head or back through which longitudinal rods pass
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B2017/00477—Coupling
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B34/00—Computer-aided surgery; Manipulators or robots specially adapted for use in surgery
- A61B34/20—Surgical navigation systems; Devices for tracking or guiding surgical instruments, e.g. for frameless stereotaxis
- A61B2034/2046—Tracking techniques
- A61B2034/2055—Optical tracking systems
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- A61B34/20—Surgical navigation systems; Devices for tracking or guiding surgical instruments, e.g. for frameless stereotaxis
- A61B2034/2072—Reference field transducer attached to an instrument or patient
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B90/00—Instruments, implements or accessories specially adapted for surgery or diagnosis and not covered by any of the groups A61B1/00 - A61B50/00, e.g. for luxation treatment or for protecting wound edges
- A61B90/36—Image-producing devices or illumination devices not otherwise provided for
- A61B2090/363—Use of fiducial points
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- A61B90/39—Markers, e.g. radio-opaque or breast lesions markers
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- A61B90/39—Markers, e.g. radio-opaque or breast lesions markers
- A61B2090/3983—Reference marker arrangements for use with image guided surgery
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- A61B90/00—Instruments, implements or accessories specially adapted for surgery or diagnosis and not covered by any of the groups A61B1/00 - A61B50/00, e.g. for luxation treatment or for protecting wound edges
- A61B90/10—Instruments, implements or accessories specially adapted for surgery or diagnosis and not covered by any of the groups A61B1/00 - A61B50/00, e.g. for luxation treatment or for protecting wound edges for stereotaxic surgery, e.g. frame-based stereotaxis
- A61B90/11—Instruments, implements or accessories specially adapted for surgery or diagnosis and not covered by any of the groups A61B1/00 - A61B50/00, e.g. for luxation treatment or for protecting wound edges for stereotaxic surgery, e.g. frame-based stereotaxis with guides for needles or instruments, e.g. arcuate slides or ball joints
Abstract
An apparatus and procedures for percutaneous placement of surgical implants and instruments such as, for example, screws, rods, wires and plates into various body parts using image guided surgery. An apparatus for use with a surgical navigation system, an attaching device rigidly connected to a body part, such as the spinous process of a vertebrae, with an identification superstructure rigidly but removably connected to the attaching device. This identification superstructure, for example, is a reference arc and fiducial array which accomplishes the function of identifying the location of the superstructure, and, therefore, the body part to which it is fixed, during imaging by CAT scan or MRI, and later during medical procedures.
Description
- This application is a continuation of U.S. patent application Ser. No. 10/423,332 filed on Apr. 24, 2003; which is a reissue of Ser. No. 09/148,498 filed Sep. 4, 1998 which is now U.S. Pat. No. 6,226,548 issued on May 1, 2001; which claims rights under 35 U.S.C. §119 on provisional application No. 60/059,915, filed on Sep. 24, 1997. The disclosures of the above applications are incorporated herein by reference.
- The present teachings relate generally to guiding, directing, or navigating instruments or implants in a body percutaneously, in conjunction with systems that use and generate images during medical and surgical procedures, which images assist in executing the procedures and indicate the relative position of various body parts, surgical implants, and instruments. In particular the teachings relate to apparatus and minimally invasive procedures for navigating instruments and providing surgical implants percutaneously in the spine, for example, to stabilize the spine, correct deformity, or enhance fusion in conjunction with a surgical navigation system for generating images during medical and surgical procedures.
- Typically, spinal surgical procedures used, for example, to provide stabilization, fusion, or to correct deformities, require large incisions and substantial exposure of the spinal areas to permit the placement of surgical implants such as, for example, various forms of screws or hooks linked by rods, wires, or plates into portions of the spine. This standard procedure is invasive and can result in trauma, blood loss, and post operative pain. Alternatively, fluoroscopes have been used to assist in placing screws beneath the skin. In this alternative procedure at least four incisions must be made in the patient's back for inserting rods or wires through previously inserted screws. However, this technique can be difficult in that fluoroscopes only provide two-dimensional images and require the surgeon to rotate the fluoroscope frequently in order to get a mental image of the anatomy in three dimensions. Fluoroscopes also generate radiation to which the patient and surgical staff may become over exposed over time. Additionally, the subcutaneous implants required for this procedure may irritate the patient. A lever arm effect can also occur with the screws that are not connected by the rods or wires at the spine. Fluoroscopic screw placement techniques have traditionally used rods or plates that are subcutaneous to connect screws from vertebra to vertebra. This is due in part to the fact that there is no fluoroscopic technique that has been designed which can always adequately place rods or plates at the submuscular region (or adjacent to the vertebrae). These subcutaneous rods or plates may not be well tolerated by the patient. They also may not provide the optimal mechanical support to the spine because the moment arm of the construct can be increased, thereby translating higher loads and stresses through the construct.
- A number of different types of surgical navigation systems have been described that include indications of the positions of medical instruments and patient anatomy used in medical or surgical procedures. For example, U.S. Pat. No. 5,383,454 to Bucholz; PCT Application No. PCT/US94/04530 (Publication No. WO 94/24933) to Bucholz; and PCT Application No. PCT/US95/12894 (Publication No. WO 96/11624) to Bucholz et al., the entire disclosures of which are incorporated herein by reference, disclose systems for use during a medical or surgical procedure using scans generated by a scanner prior to the procedure. Surgical navigation systems typically include tracking means such as, for example, an LED array on the body part, LED emitters on the medical instruments, a digitizer to track the positions of the body part and the instruments, and a display for the position of an instrument used in a medical procedure relative to an image of a body part.
- Bucholz et al. WO 96/11624 is of particular interest, in that it identifies special issues associated with surgical navigation in the spine, where there are multiple vertebral bodies that can move with respect to each other. Bucholz et al. describes a procedure for operating on the spine during an open process where, after imaging, the spinous process reference points may move with respect to each other. It also discloses a procedure for modifying and repositioning the image data set to match the actual position of the anatomical elements. When there is an opportunity for anatomical movement, such movement degrades the fidelity of the pre-procedural images in depicting the intra-procedural anatomy. Therefore, additional innovations are desirable to bring image guidance to the parts of the body experiencing anatomical movement.
- Furthermore, spinal surgical procedures are typically highly invasive. There is, thus, a need for more minimally invasive techniques for performing these spinal procedures, such as biopsy, spinal fixation, endoscopy, spinal implant insertion, fusion, and insertion of drug delivery systems, by reducing incision size and amount. One such way is to use surgical navigation equipment to perform procedures percutaneously, that is beneath the skin. To do so by means of surgical navigation also requires apparatus that can indicate the position of the spinal elements, such as, for example the vertebrae, involved in the procedure relative to the instruments and implants being inserted beneath the patient's skin and into the patient's spine. Additionally, because the spinal elements naturally move relative to each other, the user requires the ability to reorient these spinal elements to align with earlier scanned images stored in the surgical navigation system computer, to assure the correct location of those elements relative to the instruments and implants being applied or inserted percutaneously.
- In light of the foregoing, there is a need in the art for apparatus and minimally invasive procedures for percutaneous placement of surgical implants and instruments in the spine, reducing the size and amount of incisions and utilizing surgical navigation techniques.
- Accordingly, the present teachings are directed to apparatus and procedures for percutaneous placement of surgical implants and instruments such as, for example, screws, rods, wires and plates into various body parts using image guided surgery. Various embodiments are directed to apparatus and procedures for the percutaneous placement of surgical implants and instruments into various elements of the spine using image guided surgery.
- To achieve these objects and other advantages and in accordance with the purpose of the invention, as embodied and broadly described herein, an apparatus for use with a surgical navigation system and comprises an attaching device rigidly connected to a body part, such as the spinous process of a vertebrae, with an identification superstructure rigidly but removably connected to the attaching device. This identification superstructure is a reference arc and fiducial array, which accomplishes the function of identifying the location of the superstructure, and, therefore, the body part to which it is fixed, during imaging by CAT scan or MRI, and later during medical procedures.
- According to various embodiments, the attaching device is a clamp with jaws and sharp teeth for biting into the spinous process.
- According to various embodiments, the fixture is a screw, having a head, wherein the screw is implanted into the spinous process and a relatively rigid wire is attached to the head of the screw and also implanted into the spinous process at an angle to the axis of the screw to prevent the screw from rotating in either direction.
- According to various embodiments, the superstructure includes a central post, and a fiducial array and a reference arc rigidly but removably attached to the central post. The fiducial array is composed of image-compatible materials, and includes fiducials for providing a reference point, indicating the position of the array, which are rigidly attached to the fiducial array, composed of, for example titanium or aluminum spheres. The reference arc includes emitters, such as, for example Light Emitting Diodes (“LEDs”), passive reflective spheres, or other tracking means such as acoustic, magnetic, electromagnetic, radiologic, or micropulsed radar, for indicating the location of the reference arc and, thus, the body part it is attached to, during medical procedures.
- According to various embodiments, a method for monitoring the location of an instrument, surgical implants and the various portions of the body, for example, vertebrae, to be operated on in a surgical navigation system comprising the steps of: attaching a fixture to the spinous process; attaching a superstructure including a fiducial array with fiducials and a reference arc to the fixture; scanning the patient using CT, MRI or some other three-dimensional method, with fiducial array rigidly fixed to patient to identify it on the scanned image; and thereafter, in an operating room, using image-guided technology, touching an image-guided surgical pointer or other instrument to one or more of the fiducials on the fiducial array to register the location of the spinal element fixed to the array and emitting an audio, visual, radiologic, magnetic or other detectable signal from the reference arc to an instrument such as, for example, a digitizer or other position-sensing unit, to indicate changes in position of the spinal element during a surgical procedure, and performing a surgical or medical procedure percutaneously on the patient using instruments and implants locatable relative to spinal elements in a known position in the surgical navigation system.
- In another aspect, the method includes inserting screws or rigid wires in spinal elements in the area involved in the anticipated surgical procedure before scanning the patient, and after scanning the patient and bringing the patient to the operating area, touching an image-guided or tracked surgical pointer to these screws and wires attached to the vertebrae to positively register their location in the surgical navigation computer, and manipulating either the patient's spine or the image to align the actual position of the spinal elements with the scanned image.
- In another aspect, the method includes percutaneously implanting screws into spinal elements, which screws are located using image guided surgical navigation techniques, and further manipulating the orientation of the screw heads percutaneously using a head-positioning probe containing an emitter, that can communicate to the surgical navigation computer the orientation of the screw heads and position them, by use of a specially designed head-positioning tool with an end portion that mates with the heads of the screws and can rotate those screw heads to receive a rod, wire, plate, or other connecting implant. If a rod is being inserted into the screw heads for example, the method further includes tracking the location and position of the rod, percutaneously using a rod inserter having one or more emitters communicating the location and orientation of the rod to the surgical navigation computer.
- According to various embodiments, a system and method is provided to a user, such as a surgeon, to track an instrument and surgical implants used in conjunction with a surgical navigation system in such a manner to operate percutaneously on a patient's body parts, such as spinal vertebrae which can move relative to each other.
- According to various embodiments, is provided a system and method to simply and yet positively indicate to the user a change in position of body parts, such as spinal vertebrae segments, from that identified in a stored image scan, such as from an MRI or CAT scan, and provide a method to realign those body parts to correspond with a previously stored image or the image to correspond with the actual current position of the body parts.
- According to various embodiments, is provided a system or method for allowing a fiducial array or reference arc that is removable from a location rigidly fixed to a body part and replaceable back in that precise location.
- According to various embodiments, is provided a system and method for positively generating a display of instruments and surgical implants, such as, for example screws and rods, placed percutaneously in a patient using image-guided surgical methods and techniques.
- According to various embodiments, is provided a percutaneous reference array and fiducial array, as described herein, to be used to register and track the position of the vertebrae for the purposes of targeting a radiation dose to a diseased portion of said vertebrae using a traditional radiosurgical technique.
- Additional application of the teachings will be set forth in part in the description which follows, and in part will be obvious from the description, or may be learned by practice of the teaching. The applications of the teachings will be realized and attained by means of the elements and combinations particularly pointed out in this description.
- It is to be understood that both the foregoing general description and the following detailed description are exemplary and explanatory only and are not restrictive.
- Further areas of applicability of the present teachings will become apparent from the detailed description provided hereinafter. It should be understood that the detailed description and various examples, while indicating various embodiments, are intended for purposes of illustration only and are not intended to limit the scope of the teachings.
- The accompanying drawings, which are incorporated in and constitute a part of this specification, illustrate various embodiments of the teachings and together with the description, serve to explain the principles of the invention.
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FIG. 1 is a schematic diagram of various embodiments of a superstructure for use with the current teachings, including a reference arc, center post and fiducial array and rigid Kirschner wires (“K wires”) and screws placed in the spine for use with a surgical navigation system for percutaneous spinal surgical procedures. -
FIG. 1A is an enlarged view of the superstructure depicted inFIG. 1 engaging a vertebra by a clamp and also K wires implanted in adjacent vertebrae in the superior and inferior positions of the spinous process. -
FIG. 2 is a diagram of various embodiments of a clamp fixture for rigid connection to the spinous process of a single vertebrae with an H-shaped fiducial array attached to a center post rigidly attached to the clamp and a mating connector at the tip of the post for mating with a reference array, and a reference array for use in the current invention. -
FIG. 2A is a side view ofFIG. 2 . -
FIG. 2B is another side view ofFIG. 2 . -
FIG. 2C is a top view ofFIG. 2 . -
FIG. 2D is an exploded view ofFIG. 2 without the reference arc. -
FIG. 2E is an exploded view of the interface of the center post and clamp ofFIG. 2 . -
FIG. 3 is a diagram of a W-Shaped fiducial array mounted to a central post with generally spherical fiducials attached to the array, for mounting to a single vertebrae. -
FIG. 3A is a side view ofFIG. 3 . -
FIG. 3B is another side view ofFIG. 3 . -
FIG. 3C is a top view ofFIG. 3 . -
FIG. 4 is a diagram of a reference arc and fiducial attached to a center post for use in the current invention in mounting to a single vertebrae. -
FIG. 4A is a side view ofFIG. 4 . -
FIG. 4B is a back view ofFIG. 4 . -
FIG. 4C is a top view ofFIG. 4 . -
FIG. 4D is an expanded view ofFIG. 4 . -
FIG. 4E is an expanded side view ofFIG. 4 . -
FIG. 4F is an expanded view of the array foot and shoe ofFIG. 4E . -
FIG. 5 is a diagram according to various embodiments of a fixture using a cannulated screw for insertion into a vertebrae, with Kirschner wire mounted on a central post and including a fiduciary array and reference arc combined on a single structure. -
FIG. 6 is a side view of the screw and Kirschner wire fixture ofFIG. 5 implanted in a spinous process of a vertebrae. -
FIG. 7 is a diagram of a screw-head positioning probe and multiaxial screw for insertion into a single vertebrae. -
FIG. 7A is a diagram of the screw ofFIG. 7 . -
FIG. 8 is a diagram of a head positioning probe, multiaxial screw and spinal segment. -
FIG. 9 is a diagram of a rod inserter with an LED. -
FIG. 10 is a diagram of various embodiments of the teachings including a cannulated tube and attachment for holding a reference arc. -
FIG. 11 is a diagram of the cannulated tube ofFIG. 10 with a reference arc and screw for attachment to a spinal process. -
FIG. 12 is a posterior view of spinal segment and implanted screws before alignment. -
FIG. 13 is a posterior view of spinal segment and implanted screws after alignment. - Reference will now be made in detail to various embodiments, an example of which is illustrated in the accompanying drawings. Wherever possible, the same reference numbers will be used throughout the drawings to refer to the same or like parts. The following example is intended to be purely exemplary.
- As generally described in PCT/US95/12894, the entire disclosure of which is incorporated herein by reference, a typical surgical navigation system is shown in
FIG. 1 . A computer assisted image-guided surgery system, indicated generally at 10, generates an image for display on amonitor 106 representing the position of one or more body elements, such as spinal elements fixedly held in a stabilizing frame or device such as aspinal surgery frame 125 commonly used for spinal surgery. Areference arc 120 bearing tracking means or emitters, such as forexample LED emitters 122, is mounted to the spinous process by acentral post 150. Thestructures 20 and Kwires 260 ofFIG. 1 are depicted in more detail inFIG. 1A . Theimage 105 is generated from an image data set, usually generated preoperatively by a CAT scanner or by MRI for example, whichimage 105 has reference points for at least one body element, such as a spinal element or vertebrae. The reference points of the particular body element have a fixed spatial relation to the particular body element. - The system includes an apparatus such as a digitizer or other Position Sensing Unit (PSU), such as for
example sensor array 110 onsupport 112 for identifying, during the procedure, the relative position of each of the reference points to be displayed by tracking the position ofemitters 122 onarc 120. The system also includes aprocessor 114 such as a PC or other suitable workstation processor associated withcontroller 108 for modifying the image data set according to the identified relative position of each of the reference points during the procedure, as identified bydigitizer 110. Theprocessor 114 can then, for example, generate an image data set representing the position of the body elements during the procedure for display onmonitor 106. Asurgical instrument 130, such as a probe or drill or other tool, may be included in the system, which is positioned relative to a body part and similarly tracked bysensor array 110. - In summary, the general operation of a surgical navigating system is well known in the art and need not further be described here.
- With further reference to
FIGS. 1 through 6 , aregistration device 20 is rigidly fixed to a spinal element by, for example, a device such as abone clamp 30 depicted inFIG. 2 . Alternatively, ascrew retention device 40, such as the cannulatedscrew 42 depicted inFIG. 5 , and described in more detail below, can be used. - With reference now to
FIG. 2 ,bone clamp 30 is fixedly attached to the spinous process. Theclamp 30 includes at least two blades (or jaws) 32 with tips orteeth 34, which are preferably sharp, for driving together and penetrating soft tissue or more dense bone for rigid fixation to the spinous process. Theteeth 34 are also preferably sized to accommodate the bulb shape of the spinous process. Thedriving mechanism 40 is, for example, a screw driven into asleeve 41 and is also preferably located such that it will be accessible in a percutaneous manner. Attached to theclamp 30 is asuperstructure 20. Thesuperstructure 20 includes acentral post 150 which is relocatable, that is, it fixes to theclamp 30 in a rigid fashion, for example, as depicted inFIGS. 2D and 2E , by being inserted into a V-shapedwedge 44 orienting thepost 150 front to back and providing amating hole 48 along thewedge 44 for insertion ofpost 150 in a single orientation and also providing fasteners such asscrew 43 for tightening to lock thepost 150 in place. Thepost 150 can be removed and reapplied by loosening and tighteningscrew 43, such that the original geometry and orientation is maintained. Thecentral post 150 has at its apex aconnector 60 with unique geometrical configuration, such as, for example, a starburst, onto which aspinal reference arc 120 of thesuperstructure 20 attaches. Any suchstandard reference arc 120 can be used, such as depicted inFIGS. 1A, 4 , and 11, preferably includingemitters 122, such as for example LEDs or reflective spheres for providing a positive indication of movement to the surgical navigation system during a procedure. - Also rigidly attached to the
central post 150, as part of thesuperstructure 20 preferably at a location closer to the skin, or possibly collocated with or also performing the function of thereference arc 120, is afiducial array 170, which can be of various different shapes, such as, for example the H-shapedframe 170 depicted inFIG. 2 , the W-shapedframe 170′ as depicted inFIG. 3 , theU-shaped frame 170″ as depicted inFIG. 4 or theX-shaped frame 120′, 170′″ depicted inFIG. 5 (depicting a structure that is both a fiducial array and a reference arc). As depicted inFIGS. 2 and 3 , this array can includefiducial points 29 orspheres 17, rigidly attached tofiducial array FIG. 3 , substantially in the shape ofspheres 17 and of a material detectable by the CAT scan or MRI, preferably titanium or aluminum. This fiducial array such as 170 indicates to the surgical navigation system the location of the bone structure to which theclamp 30 andcentral post 150 are attached by touching a pointed surgical tracker tofiducial points 29 or a cup-shaped probe tofiducial spheres 17, thereby indicating the center of the fiducial to thesurgical navigation controller 114. Thearray 170 andcentral post 150 are also attached to theclamp 30, as described above, in such a way that they can be removed and replaced in the same geometric orientation and location, for example, by means of a uniquely shaped interface, for example, a triangle, or a single unique shape or a combination of unique angles or pins with theclamp 30 such that thepost 150 can only be reinserted the same way it was removed. - Additionally, the
fiducial array 170, can be located at various heights on thepost 150 to accommodate variations in patient tissue depth and size, preferably as close to the patient's body as possible, and then fixed at that specific height by the use of pins or indents matched to holes 19 (shown inFIG. 2 ) in thecentral post 150 or by placing therods 39 of H-shapedarray 170 indifferent holes 31. Thefiducial array 170 also has, for example, divots 29 (shown inFIG. 2 ) shaped to interface with an instrument such as asurgical pointer 130 which can touch thatdivot 29 to register the location of thedivot 29 and, thus, the location of thefiducial array 170 and likewise the spinal element in the surgical navigation system. Multiple divots can be registered to further increase accuracy of the registration system. In one preferred embodiment of the array, thefiducials FIG. 3 ) that pivots and folds together, to get the maximum distance between fiducials while not dramatically increasing the field of view required at the time of scanning. - Alternatively, rather than using
clamp 30, ascrew 42 andrigid wire 45 attachment, as depicted inFIGS. 5 and 6 , may be used to rigidly attach the central post of thesuperstructure 20 to a body element, such as, for example, a vertebrae. As depicted inFIG. 6 , screw 42 is screwed into the spinal process ofspinal element 100. Arigid wire 45, post, or other sufficiently rigid fastener such as for example a Kirschner wire (K-wire), is inserted through the cannulation in the center ofpost 150 and thescrew 42 or is otherwise fixed to thescrew 42, and exits the tip of thescrew 42 at some angle, and is also implanted into thespinal element 100 to prevent thescrew 42 from rotating in either direction. - Another embodiment for preventing the
superstructure 20 from rotating as depicted inFIGS. 10 and 11 includes the insertion of ascrew 85 through a cannulatedtube 86 which hasteeth 89 in the end (or V-shaped end) that would bite into the tip of the spinous process, preventing rotation. - Having described various embodiments of this apparatus of the present system, a method of using this apparatus for registering a single vertebrae will now be discussed. The operation of a surgical navigating system is generally well known and is described in PCT/US95/12894. According to various embodiments method of operation, clamp 30 of
FIG. 2 or screw 42 and K-Wire 45 ofFIG. 5 are implanted percutaneously through a small incision in the skin and rigidly attached to the spinal process. This attachment occurs with theclamp 30, by driving theblades 32 of theclamp 30 together to hold the spinous process rigidly. Thecentral post 150 is then rigidly fixed to theclamp 30 orscrew 42 and thefiducial array 170 is rigidly fixed to thecentral post 150. The patient is then scanned and imaged with a CAT scan or MRI with a field of view sufficiently large to display the spinal anatomy and theclamp 30 orscrew 42 and thefiducial array 170. This scan is loaded into the surgicalnavigation system processor 104. - After scanning the patient, the
array 120 and post 150 can be removed from the patient, while leaving in place the rigidly connectedclamp 30 orscrew 42. For example, as depicted inFIGS. 4D and 4E , afoot 55 located belowarray 170″ engages withshoe 56 and rigidly connected byscrews post 150,array 120 and other remaining portions of thesuperstructure 20, once removed, may be sterilized. The patient is then moved to the operating room or similar facility from, for example, the scanning room. - Once in the operating room, the patient may be positioned in an apparatus, such as, for example, a
spinal surgery frame 125 to help keep the spinal elements in a particular position and relatively motionless. Thesuperstructure 20 is then replaced on theclamp 30 orscrew 42 in a precise manner to the same relative position to the spinal elements as it was in the earlier CAT scan or MRI imaging. Thereference arc 120 is fixed to the starburst orother interface connector 60 on thecentral post 150 which is fixed to theclamp 30 orscrew 42. The operator, for example a surgeon, then touches an instrument with a tracking emitter such as asurgical pointer 130 withemitters 195 to thedivots 29 on thefiducial array 170 to register the location of thearray 170 and, thus, because the spinal process is fixed to thefiducial array 170, the location of the spinal element is also registered in the surgical navigation system. - Once the
superstructure 20 is placed back on the patient, anyinstrument 130 fitted with tracking emitters thereon such as, for example, a drill or screw driver, can be tracked in space relative to the spine in the surgical navigation system without further surgical exposure of the spine. The position of theinstrument 130 is determined by the user stepping on afoot pedal 116 to begin tracking theemitter array 190. Theemitters 195 generate infrared signals to be picked up bycamera digitizer array 110 and triangulated to determine the position of theinstrument 130. Additionally, other methods may be employed to track reference arcs, pointer probes, and other tracked instruments, such as with reflective spheres, or sound or magnetic emitters, instead of LED's. For example, reflective spheres can reflect infrared light that is emitted from thecamera array 110 back to thecamera array 110. The relative position of the body part, such as the spinal process is determined in a similar manner, through the use ofsimilar emitters 122 mounted on thereference frame 120 in mechanical communication with the spinal segment. As is well known in this art and described generally in PCT/US95/12894, based upon the relative position of the spinal segment and the instrument 130 (such as by touching a known reference point) the computer would illustrate a preoperative scan—such as the proper CAT scan slice—on the screen ofmonitor 106 which would indicate the position of thetool 130 and the spinal segment for the area of the spine involved in the medical procedure. - For better access by the operator of various areas near the
central post 150, thefiducial array 170 can be removed from thecentral post 150, by, for example, looseningscrew 42 and sliding thearray 170 offpost 150, leaving thereference arc 120 in place or replacing it after removal ofarray 170. By leaving thereference arc 120 in place, the registration of the location of the spinal process is maintained. Additionally, thecentral post 150,reference arc 120, andfiducial array 170 can be removed after the spinal element has been registered leaving only theclamp 30 orscrew 42 in place. The entire surgical field can then be sterilized and asterile post 150 andreference arc 170 fixed to theclamp 30 or screw 42 with the registration maintained. - This surgical navigation system, with spinal element registration maintained, can then be used, for example, to place necessary and desired screws, rods, hooks, plates, wires, and other surgical instruments and implants percutaneously, using image-guided technology. Once the location of the
spinal element 100 involved in the procedure is registered, by the process described above, in relation to the image data set andimage 105 projected onmonitor 106,other instruments 130 and surgical implants can be placed under the patient's skin at locations indicated by theinstrument 130 relative to thespinal element 100. - Additionally, the location of other spinal elements, relative to the
spinal element 100 containing thefiducial array 170, can be registered in the surgical navigation system by, for example, insertingadditional screws 250,rigid wires 260, or other rigid implants or imageable devices into the spinal segment. - For example, as depicted in
FIG. 1 , and in more detailFIG. 1A ,additional screws 250 or rigid and pointedwires 260 are placed in the vertebrae adjacent to the vertebrae containing theclamp 30 and post 150 prior to scanning. On theimage 105 provided bymonitor 106, the surgeon can see theclamp 30 orscrew 42 andfiducial array 170 and also theadditional screws 250,wires 260 or other imageable devices. When screws 250 or other devices are used, these screws 250 (as depicted inFIG. 7 ) may contain adivot 256 or other specially shaped interface on thehead 255 so that apointer probe 130 can be used to point to thehead 255 of the screw 250 (or wire) and indicate the orientation of thescrew 250 orwire 260 to the surgical navigation system by communicating to thecontroller 114 or by emission fromLEDs 195 onprobe 130 todigitizer 110. The image of theseadditional screws 250 also appear in the scan. Once the patient is then moved to the operating facility, rather than the scanning area, the image of thescrew 250 can be compared to the actual position of thescrew 250 as indicated by thepointer probe 130 that is touched to thehead 255 of thescrew 250 orwire 260. If necessary, the operator can manipulate the position of the patient to move the spinal element and thus the location of thescrew 250 orwire 260 to realign the spinal elements with the earlier image of the spine. Alternatively, the operator can manipulate the image to correspond to the current position of the spinal segments. - For additional positioning information, the operator can place additional
rigid wires 260 orscrews 250 into the vertebrae, for example, located at the superior (toward the patient's head) and inferior (towards the patient's feet) ends of the spinal process to more accurately position those vertebrae relative to the other vertebrae and the image data. Additionally, thewires 260 andscrews 250 implanted to provide positioning information can also be equipped with emitters, such as, for example, LEDs, to provide additional information to the surgical navigation system on the location of thewire 260 or screw 250, and thus the vertebra to which they are affixed. - Alternatively, the patient can be placed in a position stabilizing device, such as a
spinal surgery frame 125 or board, before a scan is taken, and then moved to the operating facility for the procedure, maintaining the spine segments in the same position from the time of scanning until the time of surgery. Alternatively, a fluoroscope can be used to reposition the spinal segments relative to the earlier image from the scan. An ultrasound probe can be used to take real-time images of the spinal segment which can be portrayed bymonitor 106 overlayed or superimposed onimage 105. Then the operator can manually manipulate the spinal elements and take additional images of these elements with the fluoroscope to, in an iterative fashion, align the spinal elements with the previously scannedimage 105. - Alternatively, a
clamp 30 orscrew 42 andsuperstructure 20 can be rigidly fixed to each vertebra involved in the surgical or medical procedure to register the position of each vertebra as explained previously for a single vertebra. - After the spinal elements are registered in the spine, various medical and surgical procedures can be performed on that patient. For example, spinal implants, endoscopes, or biopsy probes can be passed into the spine and procedures such as, for example, spinal fusion, manipulation, or disc removal can be performed percutaneously and facilitated by the surgical navigation image-guiding system. Additionally, a radiation dose can be targeted to a specific region of the vertebrae.
- One such procedure facilitated by the apparatus and methods described above is the percutaneous insertion of screws and rods, fixed to different vertebra in a spine to stabilize them. Once screws, for example
multiaxial screws 250, (as depicted inFIG. 12 , before manipulation) are implanted through small incisions they can be manipulated by a head-positioning probe 280. The final position ofscrews 250 and heads 255 are depicted inFIG. 13 . Thisprobe 280, as depicted inFIG. 7 , includes ahead 285 that mates in a geometrically unique fashion with thehead 255 of thescrew 250. An emitter, such as, for example, anLED array 380 on theprobe 280, indicates the location and orientation of thescrew head 255 to thecomputer 114 of the surgical navigation system by providing an optical signal received bydigitizer 110. Thescrew head 255 can then be rotatably manipulated under the patient's skin by thehead positioning probe 280 to be properly oriented for the receipt of arod 360 inserted through therotating head 255. The operator can then plan a path from thehead 255 of eachscrew 250 to theother screws 250 to be connected. Then, with reference now toFIG. 9 , an optically trackedrod inserter 245 also equipped with emitters, such as, forexample LEDs 247, can be placed through another small incision to mate with and guide arod 360 through the holes or slots in the screw heads 245, through and beneath various tissues of the patient, with therod inserter 245, and, therefore, therod 360, fixed to theinserter 245, being tracked in the surgical navigation system. The operator can also use thecomputer 114 to determine the required bending angles of therod 360. For greater visualization, the geometry of thescrews 250 could be loaded into thecomputer 114 and when the position and orientation of thehead 255 is given to thecomputer 114 via theprobe 280, thecomputer 114 could place this geometry onto the image data and three-dimensional model. Therod 360 geometry could also be loaded into thecomputer 114 and could be visible and shown in real time onmonitor 106 as the operator is placing it in the screw heads 255. - In an alternative procedure, one or more plates and/or one or more wires may be inserted instead of one or
more rods 360. - It will be apparent to those skilled in the art that various modifications and variations can be made in the present teachings and in construction of this surgical navigation system without departing from the scope or spirit of the teachings. Other embodiments of the teachings will be apparent to those skilled in the art from consideration of the specification and practice of the teachings disclosed herein. It is intended that the specification and examples be considered as exemplary only.
Claims (53)
1. An implant system for facilitating percutaneous placement of an implant in an anatomy and adapted for use with a surgical navigation system to tracks positions of the implant system in space, said implant system comprising:
an implant inserter adapted to releasably attach to the implant; and
a position identification structure rigidly and removably attached to said implant inserter;
wherein said position identification structure includes an assembly for providing position information to the surgical navigation system.
2. The implant system of claim 1 , wherein said position identification structure includes at least one optical emitter.
3. The implant system of claim 1 , wherein said position identification structure includes at least one light emitting diode.
4. The implant system of claim 1 , wherein said position identification structure includes a selected geometrical shape.
5. The implant system of claim 1 , wherein said position identification structure includes at least one of reflective spheres, sound emitters, magnets, eletromagnets, light emitting diodes, or combinations thereof.
6. The implant system of claim 5 , wherein said reflectors can reflect at least one of visible light, infrared light, ultraviolet light, or combinations thereof.
7. The implant system of claim 5 , wherein said magnets or electromagnets are operable to produce a magnetic field.
8. The implant system of claim 1 , further comprising:
a rod;
wherein said rod can form a portion of the surgical implant.
9. The implant system of claim 8 , wherein said rod extends between a first end and a second end;
wherein said implant inserter is releasably attached to at least one of said first end, said second end, or combinations thereof.
10. The implant system of claim 8 , wherein said rod holder is operable to assist in moving a rod along a selected path.
11. The implant system of claim 8 , wherein said rod holder is operably interconnected with the implant to determine a position of at least a portion of the implant.
12. The implant system of claim 11 , wherein the implant includes a
screw head and a rod;
wherein said position identification structure attached to said rod holder is operable to determine a position of the rod relative to the screw head.
13. The implant system of claim 1 , wherein said implant inserter includes a rod holder.
14. The implant system of claim 1 , further comprising:
a bone screw;
wherein said bone screw can form a portion of the implant.
15. The implant system of claim 14 , wherein said bone screw includes a slot operable to be aligned.
16. The implant system of claim 15 , further comprising:
a second screw having a slot operable to be aligned percutaneously with said bone screw.
17. The implant system of claim 1 , further comprising:
an imaging system operable to produce image data of the anatomy.
18. The implant system of claim 17 , further comprising:
a display;
wherein the position of the implant inserter, the position of the implant, or combinations thereof can be displayed on the display with the image data.
19. The implant system of claim 18 , further comprising:
a bone screw operable to be positioned in the anatomy;
wherein the geometry of the bone screw can be displayed on said display relative to the image data.
20. The implant system of claim 19 , wherein the position of the implant, the geometry of the screw, and combinations thereof can be used intra-operably to determine bending of a rod.
21. The implant system of claim 18 , wherein the display allows for substantially percutaneous placements of the implant relative to the anatomy.
22. The implant system of claim 1 , further comprising:
an optical tracking system; an acoustic tracking system; an electromagnetic tracking system; a micropulsed radar tracking system; or combinations thereof.
23. An implant system for facilitating percutaneous placement of an implant in an anatomy and adapted use with a surgical navigation system to track positions in space, said implant system comprising:
an implant inserter operably interconnected to the implant;
a reference structure operably interconnected with said implant inserter;
wherein said reference structure is operable with the surgical navigation system to determine a position of at least one of said implant inserter, said implant, said reference structure, or combinations thereof.
24. The implant system of claim 23 , further comprising:
a rod;
wherein said rod can form a portion of the implant;
wherein said rod extends between a first end and a second end.
25. The implant system of claim 24 , wherein said implant inserter is operable to be interconnected with at least one of said first end, said second end, or combinations thereof.
26. The implant system of claim 24 , wherein said implant inserter is operable to assist in moving said rod along a selected path.
27. The implant system of claim 26 , further comprising:
a bone screw;
wherein said bone screw can form a portion of the implant.
28. The implant system of claim 27 , wherein the surgical navigation system assists in displaying a position of said rod relative to said bone screw to intra-operatively determine a configuration of said rod.
29. The implant system of claim 23 , wherein said position identification structure includes a selected geometrical shape.
30. The implant system of claim 23 , wherein said position identification structure includes at least one of reflective spheres, sound emitters, magnets, electromagnets, emitting members, or combinations thereof.
31. The implant system of claim 24 , wherein said emitting members include light emitting diodes.
32. The implant system of claim 30 , wherein said reflectors can reflect at least one of visible light, infrared light, ultraviolet light, or combinations thereof.
33. The implant system of claim 23 , further comprising:
an imaging system operable to produce image data of the anatomy.
34. The implant system of claim 33 , further comprising:
a display;
wherein the position of the implant inserter, the position of the surgical implant, or combinations thereof can be displayed on the display with the image data.
35. The implant system of claim 34 , further comprising:
a bone screw operable to be positioned in the anatomy;
wherein the geometry of the bone screw can be displayed on said display relative to the image data.
36. The implant system of claim 35 , wherein the position of the implant, the geometry of the screw, and combinations thereof can be used intra-operably to determine bending of a rod.
37. The implant system of claim 34 , wherein the display allows for substantially percutaneous placements of the implant relative to the anatomy.
38. The implant system of claim 23 , wherein said reference structure is removably connected to said implant inserter.
39. The implant system of claim 23 , further comprising:
an optical tracking system; an acoustic tracking system; an electromagnetic tracking system; a micropulsed radar tracking system; or combinations thereof.
40. An implant system for facilitating percutaneous placement of an implant in an anatomy that can be used with a surgical navigation system to track positions in space, the implant system comprising:
an implant having a head and a body operable to be positioned relative to a selected portion of the anatomy;
an implant inserter operable to be interconnected to said head of said implant; and
a reference structure operable to be interconnected with said implant inserter;
wherein said reference structure is operable with the surgical navigation system to determine a position and produce position data of at least one of said implant inserter, said implant, said reference structure, or combinations thereof;
wherein said implant inserter is operable to move said implant relative to the anatomy.
41. The implant system of claim 40 , wherein said implant includes a screw and said body includes a thread operable to engage the anatomy;
wherein said implant inserter is operable to interconnect with at least the head of said screw.
42. The implant system of claim 40 , further comprising:
an imaging device that produces image data of the anatomy.
43. The implant system of claim 42 , further comprising:
a display;
wherein said display is operable to display the image data of the anatomy.
44. The implant system of claim 43 , wherein the position data of said implant is determined by determining a position of the reference's structure relative to the anatomy;
wherein said implant position data is displayed on the display.
45. The implant system of claim 44 , wherein said implant position data includes a position of said head.
46. The implant system of claim 42 , wherein said head includes a slot.
47. The implant system of claim 46 , wherein said implant position data includes a position of said slot.
48. The implant system of claim 44 , wherein said position data displayed on the display is determined with a processor.
49. The implant system of claim 40 , wherein said implant is operable to be positioned percutaneously relative to the anatomy via said implant inserter;
wherein said implant is operable to be manipulated percutaneously via said implant inserter and said referenced structure.
50. The implant system of claim 49 , wherein the position image data of the implant is displayed on a display relative to image data of the anatomy to facilitate percutaneous placement of the implant relative to the anatomy.
51. The implant system of claim 50 , wherein positioning of the implants includes positioning a head of a bone screw in a selected orientation relative to the anatomy.
52. The implant system of claim 37 , wherein said implant is a screw.
53. The implant system of claim 52 , further comprising:
a rod implant;
a rod implant inserter;
a rod inserter reference structure operably interconnected with said rod inserter, wherein said rod inserter reference structure is operable with the surgical navigation system to determine a position of at least a portion of said rod implant;
wherein said implant inserter is operable to position said head relative to the anatomy percutaneously;
wherein said rod inserter is operable to position said rod implant relative to said head that has been positioned with said implant inserter.
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AU9662998A (en) | 1999-04-12 |
USRE44305E1 (en) | 2013-06-18 |
USRE45509E1 (en) | 2015-05-05 |
USRE39133E1 (en) | 2006-06-13 |
WO1999015097A3 (en) | 1999-06-17 |
USRE42194E1 (en) | 2011-03-01 |
US6226548B1 (en) | 2001-05-01 |
WO1999015097A2 (en) | 1999-04-01 |
USRE42226E1 (en) | 2011-03-15 |
US20060009780A1 (en) | 2006-01-12 |
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