US20180132910A1 - Bone anchor receiver with upstanding planar arms - Google Patents
Bone anchor receiver with upstanding planar arms Download PDFInfo
- Publication number
- US20180132910A1 US20180132910A1 US15/868,978 US201815868978A US2018132910A1 US 20180132910 A1 US20180132910 A1 US 20180132910A1 US 201815868978 A US201815868978 A US 201815868978A US 2018132910 A1 US2018132910 A1 US 2018132910A1
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- US
- United States
- Prior art keywords
- tool
- guide
- rod
- bone screw
- guide tool
- Prior art date
- Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
- Abandoned
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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
- A61B17/7074—Tools specially adapted for spinal fixation operations other than for bone removal or filler handling
- A61B17/7076—Tools specially adapted for spinal fixation operations other than for bone removal or filler handling for driving, positioning or assembling spinal clamps or bone anchors specially adapted for spinal fixation
- A61B17/7082—Tools specially adapted for spinal fixation operations other than for bone removal or filler handling for driving, positioning or assembling spinal clamps or bone anchors specially adapted for spinal fixation for driving, i.e. rotating, screws or screw parts specially adapted for spinal fixation, e.g. for driving polyaxial or tulip-headed screws
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- 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
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- A61B17/7001—Screws or hooks combined with longitudinal elements which do not contact vertebrae
- A61B17/7002—Longitudinal elements, e.g. rods
- A61B17/7004—Longitudinal elements, e.g. rods with a cross-section which varies along its length
- A61B17/7008—Longitudinal elements, e.g. rods with a cross-section which varies along its length with parts of, or attached to, the longitudinal elements, bearing against an outside of the screw or hook heads, e.g. nuts on threaded rods
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- A61B17/7019—Longitudinal elements having flexible parts, or parts connected together, such that after implantation the elements can move relative to each other
- A61B17/702—Longitudinal elements having flexible parts, or parts connected together, such that after implantation the elements can move relative to each other having a core or insert, and a sleeve, whereby a screw or hook can move along the core or in the sleeve
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- A61B17/7038—Screws or hooks, wherein a rod-clamping part and a bone-anchoring part can pivot relative to each other to a different extent in different directions, e.g. within one plane only
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- 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
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- A61B17/70—Spinal positioners or stabilisers ; Bone stabilisers comprising fluid filler in an implant
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- A61B17/7083—Tools for guidance or insertion of tethers, rod-to-anchor connectors, rod-to-rod connectors, or longitudinal elements
- A61B17/7085—Tools for guidance or insertion of tethers, rod-to-anchor connectors, rod-to-rod connectors, or longitudinal elements for insertion of a longitudinal element down one or more hollow screw or hook extensions, i.e. at least a part of the element within an extension has a component of movement parallel to the extension's axis
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- 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
- A61B17/7086—Rod reducers, i.e. devices providing a mechanical advantage to allow a user to force a rod into or onto an anchor head other than by means of a rod-to-bone anchor locking element; rod removers
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- A61B17/68—Internal fixation devices, including fasteners and spinal fixators, even if a part thereof projects from the skin
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- A61B17/7088—Rod reducers, i.e. devices providing a mechanical advantage to allow a user to force a rod into or onto an anchor head other than by means of a rod-to-bone anchor locking element; rod removers wherein the rod is moved transverse to the axis of the bone anchor
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- A61B17/70—Spinal positioners or stabilisers ; Bone stabilisers comprising fluid filler in an implant
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- A61B17/7091—Tools specially adapted for spinal fixation operations other than for bone removal or filler handling for applying, tightening or removing longitudinal element-to-bone anchor locking elements, e.g. caps, set screws, nuts or wedges
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Definitions
- the present invention relates to apparatuses and methods for use in performing spinal surgery and, in particular, to tools and methods of using such tools, especially for percutaneously implanting spinal screws and for implanting a rod for spinal support and alignment, using minimally invasive techniques.
- spinal osteosynthesis apparatuses have been utilized to correct spinal deformities, injuries or disease.
- elongate rods are surgically attached to vertebrae of the spine to provide support and/or to realign or reposition certain vertebrae.
- Such rods are secured to vertebrae utilizing bone screws and other spinal implants.
- a desirable approach is to insert such implants percutaneously or with surgical techniques that are minimally invasive to the body of the patient.
- the tools may be bulky, oversized or have irregular surfaces or protrusions.
- a projecting actuator arm or fastening member may be useful with respect to the spinal screw implantation process or the rod reduction process, but there is insufficient clearance to use such structure and/or such structure may produce additional invasive trauma which the percutaneous surgery is attempting to avoid.
- a percutaneous procedure also presents a problem with implantation of rods that are elongate and have historically required a long incision and open wound in order to provide for the length of the rod and the space required for the surgeon's hands to manipulate the rod. Such problems are then compounded by the implants and insertion tools used with the rod.
- a tool assembly and a set of tools according to the invention is provided for percutaneously implanting bone screws and an associated spinal rod in a patient.
- the tool assembly includes an elongate guide tool with implant engaging members and a multi-purpose installation tool.
- the multi-purpose tool is a stabilizer for the guide tool implant engaging members which also functions as a rod stabilizer tang container and deployer and a rod pusher and reducer.
- the guide tool has a lower end configured with opposed implant engaging members for releaseable attachment to a spinal implant bone screw, hook, etc.
- the multi-purpose installation tool is elongate, and preferably includes a translation nut and attached sleeve which has a lower end for engaging and containing the rod stabilizer tang prior to rod insertion and later pushing on the rod for reduction.
- the translation nut is coaxial and freely rotatable with respect to the sleeve.
- the nut is configured for rotatable attachment to an upper end of the guide tool.
- the multi-purpose installation tool sleeve is attachable or securable to the guide tool in a first bone screw implantation orientation and in an alternative second rod pushing orientation. In the first, bone screw implantation orientation, the sleeve is disposed in a fixed, stationary position with respect to the guide tool, with the sleeve substantially surrounding the guide tool and retaining a flexible tang.
- the sleeve In the second or rod pushing orientation, the sleeve is slidable along an axis of the guide tool and the nut can be rotated, thereby translating the rod pushing end between a first location substantially spaced from the guide tool end and a second location near the guide tool end for rod reduction.
- the tool assembly may further include a driver having a handle, a guide tool attachment portion and a stem, the stem having an end configured for rotatable engagement with a spinal implant screw.
- the driver is in coaxial relationship with both the guide tool and the multi-purpose installation tool when the stem is disposed within the guide tool with the guide tool attached to the multi-purpose installation tool.
- the attachment portion of the driver is configured for rigid attachment to the guide tool, preventing rotation of the driver in relation to the guide tool.
- a tool set according to the invention includes at least a pair of end guide tools.
- Each end guide tool includes an elongate body having opposed implant engaging members with lower attachment structure adapted for attachment to a respective bone screw.
- the body has an inner surface defining an elongate and laterally opening channel.
- the guide tool body further defines an elongate opening communicating with the channel and a back wall with a flexible holding structure, the wall and holding structure disposed opposite the lateral opening.
- the back wall flexible holding structure includes first and second elongate and parallel slits in the lower back wall portion creating a movable tab or tang disposed between the first and second slits.
- the flexible flap or tang partially defines the elongate channel.
- the tang may be pushed so as to flex, hinge or spring at an upper end thereof and so that a lower end angulates and translates outwardly or to a location lateral relative to a remainder of the back wall, with the channel adapted to receive a respective rod therein.
- the tang may be resiliently flexed further outwardly to accommodate the length of the rod while maintaining, containing and stabilizing the rod in a desired position relative to bone screws.
- the multi-purpose installation tool is attachable to the end guide tool in a first, bone screw implantation configuration position and in an opposite second, rod pushing configuration or position.
- first position an elongate slot or opening in the sleeve of the tool support is aligned with and fixed in adjacent relationship to the channel opening of the end guide tool, with the sleeve of the tool being held adjacent to the back wall portion and retaining the spring tang.
- second, rod pushing position the end guide tool back wall portion and the tool sleeve opening are fixed in adjacent relationship with the back wall tang portion protrudeable into the tool sleeve opening.
- An intermediate guide tool includes an end with opposed first and second implant engaging legs defining a longitudinal pass-through opening, passageway or slot for receiving a rod therethrough.
- the tool sleeve When attached to a multi-purpose installation tool in the first, bone screw implantation orientation, the tool sleeve is disposed in a fixed, stationary position substantially surrounding and supporting both the intermediate guide tool legs.
- the sleeve In the second or rod pushing orientation, the sleeve is in sliding relation along an axis of the intermediate guide tool, with the sleeve and associated rod pushing end translatable along the first and second legs between a first location spaced from the intermediate guide tool end and a second location adjacent or near the guide tool end.
- a vertebral support rod implantation kit adapted for use with a plurality of vertebrae, includes a plurality of polyaxial bone screws, each bone screw being adapted for implantation in one vertebra, each of the bone screws having an attachment structure. It is foreseen that the polyaxial bone screws can be cannulated and/or fixed.
- the kit also includes an elongate rod having first and second ends, the rod sized and shaped to extend between a pair of end bone screws of the plurality of bone screws, which can be fixed, polyaxial and cannulated or not cannulated.
- the kit further includes a plurality of closure tops with each closure top being sized and shaped to mate with a respective bone screw and capture or retain the elongate rod within a cavity or channel defined by the respective arms of the bone screw.
- the kit includes a pair of end guide tools, and may include one or more intermediate guide tools, each guide tool being attachable to multi-purpose installation tools, as described herein and bone screw drivers, the drivers being configured to be rigidly attached to a respective end guide tool or intermediate guide tool.
- a spinal fixation tool assembly is assembled by first attaching a bone screw head of a spinal implant screw to a mating attachment structure disposed at a first end of an elongate guide tool implant engaging member, the guide tool defining a laterally opening channel and having a second attachment structure disposed at a second end thereof.
- the guide tool and attached spinal implant screw may then be inserted into a multi-purpose installation tool, the tool having a translation nut, or the like, and a sleeve-like structure.
- the nut or similar part is rotated or manipulated in a first direction to mate the tool support with the second attachment structure on the guide tool and translate the sleeve or similar surrounding structure to a location near the guide tool first end.
- a driver is inserted into the guide tool channel, the driver having a handle and a spinal implant screw engagement end.
- the driver is attached to the guide tool at the second attachment structure with the driver engagement end engaging the spinal implant screw. It is foreseen that the guide tool could be attached to the screw and the screw inserted with the driver without the need for additional tools.
- a method according to the invention may also include the steps of inserting the attached driver, guide tool and spinal implant screw into an incision, especially a minimally invasive incision sized to snugly or closely receive the assembled tools and bone screw, and into contact with a vertebra, followed by turning the driver handle.
- the driver, the associated tools and the spinal implant screw are rotated as one assemblage or unit, driving the spinal implant screw into the vertebra.
- Further method steps according to the invention include detaching the drivers from the attached guide tool and multi-purpose installation tool, if used, and withdrawing the drivers from the incisions, followed by detaching the multi-purpose installation tools, if used, from the end guide tools and thereby deploying the end tangs. If used, it may also be desirable to detach the multi-purpose installation tools from the intermediate guide tools, if any.
- a respective multi-purpose installation tool may be utilized for rod reduction and accordingly replaced on each end guide tool with the sleeve opening thereof aligned with the end guide tool flexible wall or tang to allow the tang to remain flexed outward.
- a rod first end may be inserted into an incision through which one of the end guide tools has been inserted, and then guided into a channel of an adjacent end or intermediate guide tool. The rod is then guided into and through all remaining channels with first and second ends of the rod each in contact with a flexible wall or deployed tang of a respective end guide tool with the tangs biasing against the rod ends, and with the rod extending through all associated guide tools.
- the multi-purpose installation tool sleeve is then utilized as a rod pusher by rotating the nut and sliding the closed end of the sleeve toward the lower guide tool end, the sleeve end contacting the rod and pushing the rod toward the bone screw.
- the attachment structure for joining the guide tool to the bone screw includes radial mating projections and receivers or grooves that allow the guide tool to be twisted on and twisted from the head of the bone screw.
- an external attachment on the bone screw head can have tapered undercut upper surfaces.
- Additional attachment structures according to the invention include snap-on/twist off, snap-on/pry-off, slide-on/push-off, snap- or slide-on/slide off, and other combinations. It is foreseen that other attachment structure could be used such as clip-on/clip-off, clip-on/twist-off, snap-on/snap-off, spring-on/spring-off, spring-on/twist-off, set screws, etc.
- the attachment structure secures the guide tool to the bone screw during insertion of the screw into bone, but allows the tool to release from the bone screw for removal of the tool at the end of the procedure by rotation of the tool about a central axis thereof or by some other mechanism, as described herein.
- the objects of the present invention are: to provide a compact tool assembly for supporting and installing bone screws and other implants with minimal surgical invasion to the patient; to provide such an assembly wherein a tool providing support and stabilization for implant engaging members of the assembly during bone screw implantation may also be utilized for deployment of rod containment tangs and as a rod reducer; to further provide a set of tools for implanting a spinal rod for support or alignment along a human spine with minimal surgical invasion of the patient; to provide such a set of tools including a pair of end tool guides for slidably guiding opposed ends of the rod toward end bone screws attached to the end guide tools; to provide such a set of tools including intermediate guide tools for each intermediate bone screw that guide the rod in slots therethrough to respective bone screws; to provide such a set of tools including rod and closure top installation tools for assisting in securing the rod in the bone screws; to provide such a set of tools wherein the guide tools are easily attached to and disengaged from the bone screws; to provide such a set of tools wherein the guide tools, guide tool supports
- FIG. 1 is an exploded front elevational view of a tool assembly according to the present invention showing a driver tool, a multi-purpose installation tool implant engaging member stabilizer sleeve/tang container and deployer/rod pusher and reducer and an end guide tool shown with an attached polyaxial bone screw.
- FIG. 2 is an enlarged front elevational view of an intermediate guide tool of the invention.
- FIG. 3 is an enlarged side elevational view of the intermediate guide tool of FIG. 2 .
- FIG. 4 is an enlarged rear elevational view of the intermediate guide tool of FIG. 2 .
- FIG. 5 is an enlarged front elevational view of the end guide tool of FIG. 1 .
- FIG. 6 is an enlarged side elevational view of the end guide tool of FIG. 5 .
- FIG. 7 is an enlarged rear elevational view of the end guide tool of FIG. 5 .
- FIG. 8 is a cross-sectional view of the end guide tool, taken along the line 8 - 8 of FIG. 5 .
- FIG. 9 is an enlarged cross-sectional view of the intermediate guide tool, taken along the line 9 - 9 of FIG. 2 .
- FIG. 10 is an enlarged cross-sectional view of the intermediate guide tool, taken along the line 10 - 10 of FIG. 2 .
- FIG. 11 is an enlarged bottom plan view of the intermediate guide tool of FIG. 2 .
- FIG. 12 is an enlarged and fragmentary perspective view of a polyaxial bone screw of the invention.
- FIG. 13 is an enlarged and fragmentary front elevational view of the polyaxial bone screw of FIG. 12 .
- FIG. 14 is an enlarged and fragmentary side elevational view of the polyaxial bone screw of FIG. 12 .
- FIG. 15 is an enlarged and fragmentary side elevational view of the polyaxial bone screw of FIG. 12 disposed opposite the side shown in FIG. 14 .
- FIG. 16 is an enlarged top plan view of the polyaxial bone screw of FIG. 12 .
- FIG. 17 is an enlarged and fragmentary front elevational view of the polyaxial bone screw of FIG. 12 and the intermediate guide tool of FIG. 2 , shown at an early stage of a twist-on installation of the intermediate guide tool to the bone screw head.
- FIG. 18 is an enlarged and fragmentary cross-sectional view of the intermediate guide tool and polyaxial bone screw installation, taken along the line 18 - 18 of FIG. 17 .
- FIG. 19 is an enlarged and fragmentary cross-sectional view similar to FIG. 18 , showing a later stage of the twist-on installation of the intermediate guide tool to the bone screw head.
- FIG. 20 is an enlarged and fragmentary cross-sectional view similar to FIGS. 18 and 19 , showing the intermediate guide tool installed on the bone screw head.
- FIG. 21 is an enlarged, fragmentary and cross-sectional view, taken along the line 21 - 21 of FIG. 20 , showing the intermediate guide tool installed on the bone screw head.
- FIG. 22 is an enlarged front elevational view of the multi-purpose tool shown in FIG. 1 .
- FIG. 23 is a cross-sectional view of the multi-purpose tool taken along the line 23 - 23 of FIG. 22 .
- FIG. 24 is an enlarged bottom plan view of the multi-purpose tool of FIG. 22 .
- FIG. 25 is an enlarged and fragmentary cross-sectional view of a portion of the multi-purpose tool shown in FIG. 23 .
- FIG. 26 is an enlarged and fragmentary side elevational view of the driver shown in FIG. 1 having a handle, a nut fastener and a stem, with the nut fastener being shown in a first, unengaged position.
- FIG. 27 is an enlarged and fragmentary front elevational view of the driver tool similar to FIG. 26 , showing the nut fastener in a second or intermediate position.
- FIG. 28 is an enlarged and fragmentary side elevational view similar to FIG. 27 and further showing a cross-sectional view of the nut fastener, taken along the line 28 - 28 of FIG. 27 .
- FIG. 29 is an enlarged cross-sectional view similar to FIG. 23 , showing an early stage of the installation of the multi-purpose tool to the end guide tool (shown in side elevation as in FIG. 6 ).
- FIG. 30 is an enlarged cross-sectional view similar to FIG. 29 , showing the multi-purpose tool installed to the end guide tool (shown in side elevation).
- FIG. 31 is an enlarged cross-sectional view of the multi-purpose tool, taken along the line 31 - 31 of FIG. 30 , showing the end guide tool in front elevation.
- FIG. 32 is an enlarged and fragmentary cross-sectional view of the multi-purpose tool similar to FIG. 31 , shown attached to the end guide tool and also showing a sliding engagement stage of attachment to the driver (shown in front elevation).
- FIG. 33 is an enlarged and fragmentary front elevational view similar to FIG. 32 , showing the driver nut fastener in the intermediate position shown in FIG. 27 .
- FIG. 34 is an enlarged and fragmentary front elevational view similar to FIG. 33 , showing the driver in fixed engagement with the guide tool.
- FIG. 35 is an enlarged and fragmentary view similar to FIG. 34 , showing the driver in fixed engagement with the guide tool and with the driver nut fastener shown in cross-section as in FIG. 28 , and the multi-purpose tool shown in cross-section as in FIG. 32 .
- FIG. 36 is a partial and generally schematic cross-sectional view of a patient's spine, showing a thin guide pin installed at a first side thereof and a bone screw tap tool and threaded bore made thereby at a second side thereof.
- FIG. 37 is a partial and generally schematic view of a patient's spine showing a tool assembly according to the invention with attached bone screw being guided toward the threaded bore in a vertebra in an early stage of a process according to the invention.
- FIG. 38 is a partial and generally schematic view of a patient's spine, showing an end guide tool and the multi-purpose tool of the present invention being positioned for use in a process according to the invention.
- FIG. 39 is a partial and generally schematic view of a patient's spine, showing a pair of end tools and a pair of intermediate tools of the present invention being positioned for use in a process according to the invention.
- FIG. 40 is a partial and generally schematic view of a patient's spine, showing a pair of end tools with the flexible tangs containing a rod which has now been inserted and a pair of intermediate tools of the present invention with one of the intermediate tools shown with an attached multi-purpose tool in a rod reduction application and one of the end guide tools shown partially cut-away, illustrating a closure top installation tool disposed within the end tool and cooperating with a bone screw closure member, the tools being utilized in an early stage of rod implantation to guide the rod toward the bone screws.
- FIG. 41 is a partial and generally schematic cross-sectional view of the spine, taken along the line 41 - 41 of FIG. 40 , showing an early stage of implanting a rod according to a process of the invention.
- FIG. 42 is a partial and generally schematic view of a patient's spine similar to FIG. 40 , showing cut-away portions of all four tool assemblies, illustrating an intermediate stage of implanting a rod.
- FIG. 43 is a partial and generally schematic view of a patient's spine similar to FIG. 42 , showing cut-away portions of three of the tool assemblies and one assembly without an end tool, illustrating the rod fully installed in all the bone screws.
- FIG. 44 is an exploded front elevational view of an anti-torque tool assembly according to the present invention showing an antitorque tool and a closure top installation tool cooperating with a break-away bone screw closure member.
- FIG. 45 is a bottom plan view of the anti-torque tool shown in FIG. 44 .
- FIG. 46 is a fragmentary and front elevational view of a bone screw with attached break-away closure member and installed rod, and further showing the closure top installation tool of FIG. 44 with the anti-torque tool.
- FIG. 47 is a fragmentary and front elevational view of a bone screw and anti-torque tool with portions broken away to show a torque driver advancing toward the break-away closure member in a process according to the invention.
- FIG. 48 is a fragmentary and front elevational view of the bone screw and anti-torque tool similar to FIG. 47 , with portions broken away to show a fully installed rod and closure member with the break-away head removed from the top by the torque driver.
- FIG. 49 is an enlarged and fragmentary front elevational view showing an alternative snap- or twist-on and twist-off attachment structure according to the invention on a guide tool and on a cooperating polyaxial bone screw head.
- FIG. 50 is an enlarged and fragmentary front elevational view of the attachment structure shown in FIG. 49 showing the guide tool installed on the bone screw head.
- FIG. 51 is an enlarged and fragmentary view of the attachment structure shown in FIG. 49 with portions removed to show the detail thereof showing an early stage of the snap on installation of the guide tool on the bone screw head.
- FIG. 52 is an enlarged and fragmentary view similar to FIG. 51 showing a later stage of installation of the guide tool on the bone screw head.
- FIG. 53 is an enlarged and fragmentary view similar to FIGS. 51 and 52 showing the guide tool installed on the bone screw head.
- FIG. 54 is an enlarged and fragmentary front elevational view of a polyaxial bone screw shank with a pivotally attached head or receiver and shown with a guide tool, with portions broken away to show the detail thereof, illustrating a second alternative snap-on and pry-off attachment structure according to the invention on a guide tool and on the polyaxial bone screw head, showing and early stage of snap-on installation.
- FIG. 55 is an enlarged and fragmentary view, identical to FIG. 54 with the exception that an intermediate stage of snap-on installation is shown.
- FIG. 56 is an enlarged and fragmentary view, identical to FIG. 54 with the exception that the guide tool is shown fully installed on the bone screw head.
- FIG. 57 is an exploded perspective view of a bone screw having a shank and a head or receiver, the receiver having a third alternative snap-on or slide-on and slide-off or push-off attachment structure according to the invention.
- FIG. 58 is an enlarged front elevational view of the receiver of FIG. 57 .
- FIG. 59 is an enlarged side elevational view of the receiver and shank of FIG. 57 shown with a guide tool with cooperating attachment structure.
- reference numeral 1 generally designates a tool assembly according to the present invention
- reference numeral 2 generally designates a tool set according to the invention, made up of a number and variety of tool assemblies 1 for use in installing a set of bone screws 4 into a patient's spine 6 , followed by the installation of an orthopedic spinal rod or longitudinal member 8 into the bone screws 4 in a process according to the present invention.
- the tool embodiment assembly 1 includes an end guide tool 9 or an intermediate guide tool 10 mated with a multi-purpose installation tool 12 configured to function as a guide tool stabilizer and supporter, a tang container and deployer and a rod pusher and reducer.
- the tool assembly 1 may further include a driver 14 .
- a set 2 of the illustrated embodiment includes a pair of end guide tools 9 and a plurality of intermediate guide tools 10 , which in the illustrated embodiment includes a pair of intermediate guide tools 10 on each side of a patient's spine 6 , but which can include none, one or many intermediate guide tools 10 depending upon the particular application, so that one intermediate guide tool 10 is used for each intermediate bone screw 4 to which the rod 8 is to be attached.
- the driver 14 is used in conjunction with the guide tool 9 and the guide tool 10 to implant bone screws 4 in the patient's spine 6 and, in particular, in vertebrae 16 along the spine 6 as shown in FIG. 37 .
- Each end guide tool 9 and intermediate guide tool 10 is configured to cooperate with the multi-purpose installation tool 12 to install the rod 8 .
- Rods 8 or other longitudinal members are often installed on both sides of the spine 6 during the same procedure.
- any reference to the words top, bottom, up and down, and the like, in this application refers to the alignment shown in the various drawing figures, as well as the normal connotations applied to such devices, and is not intended to restrict positioning of the assembly 1 or the tool set 2 in actual use.
- each end guide tool 9 has an elongate body 18 that is sized and shaped to be sufficiently long to extend from implanted bone screws 4 through an exterior of a patient's skin 20 so as to provide an outwardly extending and upper handle portion 22 that allows and provides for gripping by a surgeon during procedures utilizing the tool set 2 , with or without an attached multi-purpose installation tool 12 and/or driver 14 .
- Each of the end guide tools 9 further includes an intermediate portion 24 and a lower implant engaging portion 26 which includes opposed implant engaging members for securing one the implants there between.
- Each end guide tool 9 has a substantially flat back wall 28 joining a pair of substantially cylindrically shaped side walls 32 and 33 .
- the back wall 28 provides a flexible holding structure that includes a pair of parallel slits 34 extending from near the lower handle portion 22 to an end 36 of the tool 9 .
- a flap or flexible tang 38 disposed between the slits 34 in the back wall portion is configured to flex or spring radially outwardly from the bottom and about the top thereof in a deployed position, as is shown in FIG. 6 .
- the back wall portion flap or tang 38 provides a surgeon with some additional working space and flexibility when working with the rod 8 during surgery, so the rod 8 can extend beyond the bone screws 4 while remaining under resilient tension produced by outward biasing of the flexible back wall portion so that the rod 8 remains in a desired position and under control. Further, the tang or flap 38 also functions to urge the rod 8 toward the other tools in the tool set 2 , as shown in FIG. 40 and as will be discussed more fully below.
- each end guide tool 9 includes a laterally or sideways opening channel 39 , forming a U-shaped cross-section, a C-shaped cross-section, a crescent shaped cross-section or the like having a generally elongate and axially extending opening 40 with a side-to-side width 42 .
- the channel 39 mates with other channel structure described below so as to extend the entire length of the end guide tool 9 .
- the opening 40 communicates with and forms part of the channel 39 that opens at an upper end 43 of the guide tool 9 and also opens perpendicularly with respect to a central axis of the guide tool 9 or laterally to one side of the end guide tool 9 , thus defining the opening 40 .
- the opening 40 narrows near the upper end 43 providing a slot 44 having a side-to-side width 45 that is smaller than the side-to-side width 42 .
- the slot 44 is configured for sliding engagement with a rotational locking pin 46 disposed on the driver 14 and discussed more fully below.
- Disposed on either side of the slot 44 are co-planar surfaces 47 and 48 that are parallel with the back wall 28 .
- the surfaces 47 and 48 , as well as the back wall 28 provide alignment surfaces when the multi-purpose tool 12 is inserted onto the guide tool 9 discussed more fully below.
- the opening 40 is of substantially constant width through a mid-section 48 of the handle portion 22 , sufficiently wide to receive additional tools and/or a closure top for sideways loading into the channel 39 , as will be discussed below.
- the upper portion 22 also includes an outer helically wound discontinuous guide and advancement structure 50 disposed on outer surfaces of both of the substantially cylindrically shaped side walls 32 and 33 , which may include conventional helically wound V type threads, buttress threads, helically wound square threads, or other guide and advancement structure to cooperate with equivalent or mateable structure within the multi-purpose installation tool 12 and the driver 14 , as described more fully below.
- the advancement structure 50 extends from near the intermediate portion 24 to the open end 43 .
- the back wall 28 extending between the threaded sides 32 and 33 has an outer substantially planar and smooth surface finish.
- each end guide tool 9 Extending from the upper portion 22 and into the intermediate portion 24 of each end guide tool 9 is an outward facing channel 51 that has an opening 52 with a side-to-side width 53 that is somewhat smaller than the width 42 of the upper handle portion 22 , such that the channel 51 and opening 52 are sized and shaped to receive and allow passage of certain tools and implants, as described below.
- a remaining portion of the end guide tool intermediate portion 24 and the lower portion 26 includes a groove or channel 55 , with an elongate, axially extending and radially outward opening 57 , having a side-to-side width 58 that is slightly smaller than the width 42 of the opening 40 , but larger than the slot width 45 and the opening width 53 .
- the channel opening 57 is disposed opposite the flexible tang or flap 38 . All of the channels 39 , 51 and 55 communicate with one another and are aligned with one another so as to provide a continuous elongate interior and sideways open passageway with an open side from near the top end 43 to near the bottom 36 thereof.
- each end guide tool channel opening 57 is sized and shaped to slidingly receive a respective end 59 of the rod 8 therein. It is foreseen that one or all of the channel openings forming the open side that extends from near the top end 43 to near the bottom 36 of the guide tool 9 may be sized and shaped to receive the end 59 of the rod 8 .
- the rod 8 may be of uniform or non-uniform diameter, regular or uneven surface construction, or smooth or roughened surface finish, and that the channel openings may in turn be sized and shaped to receive such a rod end that may exhibit a greater or smaller width or diameter than at other locations along the rod.
- the slits 34 are spaced in order to have a back wall or flap flex region having a size and shape to allow at least partial passage of a respective end 59 of the rod 8 between the side walls 32 and 33 .
- a rod abutment recess 61 located near the end guide bottom 36 is a rod abutment recess 61 that is sized and shaped for the purpose of bridging the rod 8 when the end guide tool 9 is rotated for removal, as described below. However, it is foreseen that other removal means could be used.
- the end guide tool 9 also receives a closure top 62 , as will be described below.
- a helical wound, discontinuous guide and advancement structure 64 which may include conventional helically wound V-shaped threads, buttress threads, reverse angle threads, helically wound square threads, or other guide and advancement structure to cooperate with equivalent or mateable structure within the bone screw heads 4 and on the closure top 62 , as also described below.
- the substantially cylindrical side walls 32 and 33 include an outer radially extending bevel 66 and substantially cylindrical outer side walls 68 and 69 , respectively.
- the walls 68 and 69 uniformly increase the thickness of the respective side walls 32 and 33 , resulting in a substantially cylindrical cross-section of greater diameter than a diameter created by an outer surface of the side walls 32 and 33 at the intermediate portion 24 .
- the walls 68 and 69 are configured with co-planar front walls or facets 70 and co-planar back walls or facets 71 with the facets 70 being disposed parallel to the facets 71 , providing for alignment and mating with an interior of the multi-purpose installation tool 12 to ensure that the end guide tool 9 is retained in a selected, non-rotatable position with respect to the multi-purpose installation tool 12 when installed therein.
- Each of the walls 68 and 69 can include an abutment pin 67 located at an outer surface thereof and near the bottom or end 36 . The pin 67 may serve as a stop for the multi-purpose installation tool 12 as will be described more fully below; however, such a pin stop is not always needed.
- each end guide tool 9 disposed on an inner surface of each of the side walls 32 and 33 , is a radially inward facing attachment structure, generally 72 , that will be described below in conjunction with a similar structure on the intermediate guide tool 10 and the bone screw 4 .
- Each of the intermediate guide tools 10 have a somewhat similar overall shape when compared to the end guide tools 9 in that both are preferably of the same axial length and width and also have much structure in common; however with certain differences as noted.
- Each intermediate guide tool 10 has an overall elongate body 74 with an upper handle portion 76 , an intermediate portion 77 and a lower implant engaging portion 78 which includes opposed implant engaging members for securing one of the implants there between.
- the body 74 is generally C-shaped defining a radially outward opening 79 communicating with an elongate and axially extending channel 80 defined by a rear wall 81 having a lower web edge 96 and side walls 82 and 83 .
- the channel 80 front opening 79 extends parallel to an axis B of the body 74 and has a side-to-side width 85 configured to receive tools and elements described below.
- the opening 85 narrows near an upper end 87 providing an elongate slot 88 having a side-to-side width 89 that is smaller than the width 85 .
- the slot 88 is configured for sliding engagement with the pin 46 disposed on the driver 14 and discussed more fully below.
- Disposed on either side of the slot 88 are co-planar surfaces 91 and 92 that are parallel with the rear wall 81 .
- the surfaces 91 and 92 , as well as the rear wall 81 provide alignment surfaces when the multi-purpose tool 12 is inserted onto the guide tool 10 , discussed more fully below.
- the side-to-side opening width 85 is substantially constant through a mid-section 90 of the handle portion 76 , sufficient to receive additional tools and/or a closure top, as will be discussed below.
- the upper or handle portion 76 also includes an outer helically wound discontinuous guide and advancement structure 93 disposed on outer sides of both of the substantially cylindrically shaped side walls 82 and 83 , which may include conventional helically wound V-threads, helically wound square threads, buttress threads or other guide and advancement structure to cooperate with equivalent or mateable structure within the multi-purpose installation tool 12 and the driver 14 as described more fully below.
- the advancement structure 93 extends from near the intermediate portion 77 to the open end 87 .
- An outer surface of the rear wall 81 extending between the threaded sides 32 and 33 is substantially planar and smooth.
- the upper or handle portion 76 further includes an outward facing channel 94 communicating with the channel 80 .
- the channel 94 is defined in part by a rear wall or web 95 having a lower end with the web edge 96 , the wall 95 being integral with the wall 81 .
- Communicating with the channel 94 is an elongate and axially extending opening 98 having a side-to-side width 99 that is somewhat smaller than the width 85 of the opening 79 .
- the opening 98 is further defined by the walls 82 and 83 .
- the channel 94 and opening 98 are configured to receive, contain and allow translational movement therealong or rotational relative movement of certain tools, as described more fully below.
- channel 94 may extend into the intermediate portion 77 to provide greater strength and stability to the lower portion 78 of the intermediate tool 10 , with the opening 98 also extending into the lower portion 78 providing greater retention of small tools or parts being inserted through the channel 94 .
- the intermediate portion 77 of the intermediate tool 10 includes two spaced side walls or legs 102 and 103 , extending from and integral with the side walls 82 and 83 , respectively.
- the legs 102 and 103 have outer surfaces that are partially cylindrical.
- each of the legs 102 and 103 include an outwardly facing radially extending bevel 106 integral with substantially cylindrical outer side walls 107 and 108 , respectively.
- the outer walls 107 and 108 extend along the length of the lower portion 78 and uniformly increase the thickness of the respective legs 102 and 103 , resulting in a substantially cylindrical cross-section of greater outer diameter at the lower portion 78 than an outer diameter created by the outer surfaces of the legs 102 and 103 along the intermediate portion 77 .
- the walls 107 and 108 are configured with co-planar front facets or walls with flat surfaces 109 and co-planar rear facets or walls with flat surfaces 110 , the facets 109 disposed parallel to the facets 110 , providing for alignment with an interior of the multi-purpose installation tool 12 to ensure that the intermediate guide tool 10 is properly mated with and retained in a selected, non-rotatable position with respect to the multi-purpose installation tool 12 when installed therein.
- the legs 102 and 103 define an elongate and axially extending passthrough slot 111 sized and shaped to slidingly receive the rod 8 .
- the slot or opening extends from the lower edge of the web end 96 of the rear wall 95 to an open end or bottom 112 of the tool 10 configured to secure an open ended spinal surgery implant there between.
- each implant engaging leg member 102 and 103 of the intermediate guide tool 10 Near the bottom 112 of each implant engaging leg member 102 and 103 of the intermediate guide tool 10 is a helically wound but discontinuous square thread 114 and it is foreseen that other type of guide and advancement structure may be utilized such as helically wound flange forms, reverse angle threads, buttress threads, etc.
- the thread form 114 cooperates with the closure top 62 , as described below.
- the lower end of each leg 102 and 103 of the intermediate guide tool 10 also includes a cutout or rod-abutment recess 116 similar to the recess 61 described with respect to the end tool 9 .
- Each of the walls 107 and 108 can include an abutment pin 118 located at an outer surface thereof and near the bottom or end 112 .
- the pin 118 may serve as a stop for the multi-purpose installation tool 12 as will be described more fully below.
- each leg 102 and 103 of the intermediate guide tool 10 disposed on inner substantially cylindrical surfaces 120 and 121 , respectively, is a radially inward facing attachment structure, generally 124 , substantially similar to the structure 72 disposed on the end guide tool 9 .
- the structure 124 will be described herein in conjunction with the bone screw 4 .
- the embodiment shown includes an attachment structure 124 having a first projection, stop or pin 126 in spaced relation with a second smaller projection, stop or pin 127 , both pins being disposed on the surface 120 .
- the structure 123 further includes a cooperating third projection, stop or pin 130 in spaced relation with a fourth smaller projection, stop or pin 131 , the pins 130 and 131 being disposed on the surface 121 .
- the larger pins 126 and 130 are substantially configured the same, both being substantially rounded, radially inward projecting nodules, each having a ridge or lip 132 and 133 , respectively, projecting upwardly toward the guide and advancement structure 114 and that preferably follows the curvature of the respective leg inner surface 120 and 121 .
- the lips 132 and 133 with respective surfaces 120 and 121 define slots 134 and 135 , respectively, for receiving the bone screw 4 as will be discussed more fully below.
- the pin 126 is configured slightly larger than the pin 130 , requiring similar modification in the bone screw 4 , resulting in a method of operation wherein the bone screw 4 may only be mated with the guide 9 or 10 from a single direction, ensuring appropriate alignment between the bone screw 4 and guide tool advancement structure 114 with respect to the installment of the closure top 62 .
- Each of the larger pins 126 and 130 is also disposed at substantially the same distance from respective bottom surfaces 138 and 139 , at the end 112 of the guide tool 10 and adjacent a rod-abutment recess 116 . Furthermore, each of the larger pins 126 and 130 is also disposed at substantially the same distance from respective parallel seating surfaces 140 and 141 , that form a base of the guide and advancement structure 114 . Additionally, in this embodiment the pins 126 and 130 are disposed in diametrically opposed relation when viewed in cross-section as shown in FIG. 10 .
- the smaller pins 127 and 131 are also substantially configured the same, the pin 131 being slightly larger than the pin 127 , but otherwise both pins 127 and 131 being substantially rounded, radially inwardly projecting nubs, each disposed at substantially the same distance from the respective bottom surfaces 138 and 139 and the respective seating surfaces 140 and 141 . Furthermore, the pins 127 and 131 are disposed in diametrically opposed relation when viewed in cross-section as shown in FIG. 10 . Each of the pins 127 and 131 are disposed closer to the respective end surfaces 138 and 139 than are the larger pins 126 and 130 .
- pins are of different sizes to provide for mating of the guide tool 9 or 10 with the bone screw 4 from a single direction, resulting in a desired alignment between the bone screw 4 guide and advancement structure 114 and the closure top 62 guide and advancement structure.
- each of the bone screws 4 further includes a threaded shank 148 attached to the head 146 , the shank 148 for screwing into and seating in a vertebra 16 that is part of the human spine 6 .
- the head 146 includes first and second arms 150 and 151 that define a rod receiving channel 153 passing therethrough.
- Each of the bone screw shanks 148 includes an upper portion 154 that extends into the head 146 and is operationally secured therein, so that the head 146 is rotatable on the shank 148 until locked in position through engagement with the rod 8 under pressure.
- the receiver portion 145 is disposed on outer surfaces of the arms 150 and 151 .
- the receiver portion 145 of arm 150 includes a slot or groove 158 communicating with a recess 159 defined in part by a flange 160 .
- the groove 158 and recess 159 open at a front surface 162 of the arm 150 and extend across a facet 163 and into a side surface 164 thereof.
- the groove 158 is configured to mate with the large pin 126 with the lip 132 extending into the recess 159 and the flange 160 disposed in the slot 134 when the guide tool 10 is attached to the bone screw head 146 .
- the width of the slot 134 is sized to prevent passage therethrough of the pin 126 except by twisting or rotational relative movement therebetween.
- the receiver portion 145 of the arm 150 further includes a rounded aperture 165 disposed substantially centrally on a face or facet 167 of the arm 150 , the facet 167 disposed adjacent to the side surface 163 .
- the aperture 165 is configured to mate with the small pin 127 .
- the receiver portion 145 of the arm 151 defines a groove 168 communicating with a recess 169 defined in part by a flange 170 .
- the groove 168 and recess 169 open at a back surface 172 of the arm 151 and extend across a facet 173 into a side surface 174 thereof.
- the groove 168 is configured to mate with the large pin 130 with the lip 133 extending into the recess 169 and the flange 170 disposed in the slot 135 when the guide tool 10 is attached to the bone screw head 146 .
- the receiver portion 145 of the arm 151 further includes a rounded aperture 175 disposed substantially centrally on a face or facet 177 of the arm 151 , the facet 177 disposed adjacent to the side surface 173 .
- the aperture 175 is configured to mate with the small pin 131 .
- the guide tool 10 is rotated about its axis B such that the legs 102 and 103 are lowered into place as shown in FIGS. 17 and 18 , with the facets 167 and 177 of the head 146 disposed between the guide tool legs 102 and 103 , with the facet 167 adjacent the leg 102 and the facet 177 adjacent the leg 103 , thereby aligning the groove 158 with the large pin 126 and the groove 168 with the large pin 130 .
- the head 146 may then be twisted into place as shown by the arrow T in FIGS. 18, 19 and 20 .
- the legs 102 and 103 may splay slightly as the head is twisted into place, but come to rest in a generally non-splayed configuration and held in place by the structure of the attachment mechanism to resist splaying.
- the guide tool 9 , 10 In order to disengage the guide tool 9 or the guide tool 10 from the bone screw 4 , the guide tool 9 , 10 is rotated counterclockwise from an attaching configuration (opposite to the arrow T), when viewing from the top so as to disengage the lips 132 and 133 from the recesses 159 and 169 , respectively. In this manner, end guide tools 9 and intermediate guide tools 10 that have previously twisted on, now twist off of respective bone screws 4 .
- a preferred embodiment of the invention has the respective pins of the attachment structure on the guide tools and the grooves on the bone screw heads, it is foreseen that these elements could be reversed in total or part in accordance with the invention.
- other suitable attachment structure could be used, such as sloped or tapered undercut surfaces on the screw heads that overlap, mate and interlock with radially or linearly projecting structure on or near the ends of the guide tools. Such projecting structure can be snapped on or clipped on and translated up to provide for anti-splay overlapping surfaces.
- a groove could be put in the outer surface of the screw head and a fin on the guide tool could snap or slide into the groove.
- the recesses 61 and 116 disposed on the respective guide tools 9 and 10 are sized, shaped and positioned so that when the rod 8 is located in the bone screws 4 , the guide tools 9 and 10 can rotate about respective axes A and B, with the recess 61 and 116 allowing the respective guide tool 9 and 10 to straddle over the rod 8 , thereby allowing the guide tool 9 and 10 to twist relative to the bone screw 4 and free the attachment structures 72 and 124 from the receiver portion 145 of the bone screw 4 and thereafter be removed after all procedures are complete, as described below.
- the closure top 62 closes between the spaced bone screw arms 150 and 151 to secure the rod 8 in the channel 153 .
- the closure top 62 can be any of many different plug type closures. With reference to FIGS. 46-48 , preferably the closure top 62 has a cylindrical body 180 that has a helically wound mating guide and advancement structure 181 .
- the guide and advancement structure 181 can be of any type, including V-type threads, buttress threads, reverse angle threads, or square threads.
- the guide and advancement structure 181 is a helically wound flange form that interlocks with a reciprocal flange form as part of a guide and advancement structure 183 on the interior of the bone screw arms 150 and 151 .
- a suitable locking guide and advancement structure of this type is disclosed in U.S. Pat. No. 6,726,689 from Ser. No. 10/236,123 which is incorporated herein by reference.
- the helically wound guide and advancement structures 64 and 114 in the respective guide tools 9 and 10 are sized and shaped to receive the mating guide and advancement structure 181 of the closure top 62 and align with the guide and advancement structure 183 of the bone screw 4 to form a generally continuous helically wound pathway, but does not require locking between the closure top 62 and the tools 9 and 10 , even when an interlocking flange form is utilized on the closure top 62 .
- the guides 64 and 114 allow the closure top 62 to be rotated and the surgeon to develop mechanical advantage to urge or drive the rod 8 , while still outside or partially outside the bone screw 4 , toward and into the bone screw head 146 . This is especially helpful where the rod 8 is bent relative to the location of the vertebra 16 (which is sometimes the case) to which the rod 8 is to attach and is not easily placed in the bone screw head 146 without force and the mechanical advantage provided by the guides 64 and 114 .
- the guide and advancement structures 64 and 114 on the respective tools 9 and 10 are located and positioned to align with the guide and advancement structure 183 on the insides of the bone screw arms 150 and 151 , as shown in FIG. 42 and pass the closure top 62 therebetween while allowing the closure top 62 to continue to rotate and to continuously apply force to the rod 8 , so as to aid in seating the rod 8 in the bone screw head 146 .
- Each closure top 62 also preferably includes a break-off head 186 that breaks from the cylindrical body 180 in a break-off region 187 upon the application of a preselected torque, such as 95 to 120 inch-pounds.
- the break-off head 186 preferably has a hexagonal cross section faceted exterior that is configured to mate with a similarly shaped socket of a final closure driving or torquing tool 190 described below. It is foreseen that different driving heads or other methods of driving the closure top 62 can be utilized with certain embodiments of the invention, such as non-break-off closure top designs.
- the present invention is not intended to be restricted to a particular type of bone screw, bone screw closure mechanism, or bone screw and guide tool attachment mechanism.
- a polyaxial type bone screw 4 is utilized wherein the shank 148 is locked in position by direct contact with the rod 8 .
- the tool set 2 of the present invention can be used with virtually any type of bone screw, including fixed monoaxial and polyaxial bone screws of many different types wherein the head is locked relative to the shank by structure other than in the manner described in the illustrated embodiment. It is also foreseen that the screws could be cannulated.
- the multi-purpose installation tool 12 of the tool assembly 1 of the invention includes an upper translation nut 202 rotatably and free wheelingably attached to a lower guide tool stabilizer or support sleeve 204 .
- the sleeve 204 has an inner substantially cylindrical surface 205 defining a substantially hollow passageway 206 sized and shaped to slidingly receive an end tool 9 or an intermediate tool 10 therein. Alternatively, is foreseen that the sleeve could have an inner and outer planar surface.
- the sleeve 204 is elongate and includes a receiving end 207 , a substantially cylindrical outer body 208 and a translation nut attachment end portion 210 disposed opposite the receiving end 207 .
- the receiving end 207 not only functions to receive the guide tool 9 or 10 into the sleeve 204 , but also as a pressing block 218 for contacting the flexible flap or spring tang 38 and as a pressing end 207 for contacting the rod 8 and translating the rod 8 toward the bone screw head 146 when the multi-purpose installation tool 12 is installed on the guide tool 9 or 10 , as will be discussed more fully below.
- the cylindrical body 208 further defines a slotted U-shaped or C-shaped channel 212 that opens radially at an opening 213 and also opens at the receiving end 207 and extends substantially along a length of the body 208 to a location 214 spaced from the nut attachment end portion 210 .
- the channel opening has a side-to-side width 216 sized to receive the back wall tang portion or flexible flap 38 of the end guide tool 9 therethrough, when aligned therewith.
- the multi-purpose installation tool 12 is shown partially removed from an end guide tool 9 and deploying the tang 38 after the bone screw has been inserted.
- the multi-purpose installation tool 12 can be removed, turned 180° and reattached to the end guide tool 9 thereby providing access through the channel opening 213 for protrusion of the back wall tang portion or flap 38 of the end guide tool 9 .
- the flap 38 is thus not encumbered or restricted by the tool 12 during the rod pushing application and the flap 38 can be flexed outwardly by a rod 8 (not shown) or other forces, when the devices are assembled in this configuration.
- the block 218 Disposed flush to the lower sleeve end 207 and rigidly attached to the inner cylindrical surface 205 is the solid guide tool alignment and tang/rod pressing block 218 .
- the block 218 has a substantially smooth, planar and rectangular surface 220 facing inwardly radially from the inner surface 205 .
- the block 218 also follows the curve of the cylindrical surface 220 at a surface 222 thereof.
- the block 218 has a segment shape when observed from a bottom plan view.
- the term segment used herein is defined as the part of a circular area bounded by a chord and an arc of a circle cut off by the chord. This segment shape of the block 218 provides a mechanical advantage for compressing the flexible flap 38 flush with the end guide tool 9 and for advancing the rod 8 into the bone screw 4 with the multi-purpose installation tool 12 which will be discussed more fully below.
- the flat, rectangular surface 220 provides structure for installing the guide tool 9 or 10 in a mating and desired alignment with respect to the multi-purpose installation tool 12 .
- a preferred alignment is that the rear wall 81 of the tool 10 be disposed adjacent to the surface 220 when inserting the tool 10 into the multi-purpose installation tool 12 .
- the tool 10 is slid into the multi-purpose tool sleeve 204 , with the block 218 preventing axial rotation of the tool 10 with respect to the sleeve 204 , and resulting in the preferred alignment of the opening 79 and the pass-through slot 11 of the tool 10 and the U-shaped channel 212 of the multi-purpose tool in this application.
- the block 218 with the planar surface 220 provides for the insertion of the tool 9 in a first, installation tang containing position or a second, rod pushing position.
- the flexible back wall portion or tang 38 of the tool 9 it is advantageous for the flexible back wall portion or tang 38 of the tool 9 to be fully restrained by the multi-purpose installation tool 12 and for the walls 68 and 69 to be locked in a non-splayable or anti-splay position. Therefore, in the first, bone screw installation tang containing position, the multi-purpose installation tool 12 is inserted onto the tool 9 with the back wall 28 of the tool 9 disposed adjacent to the sleeve surface 220 .
- the tool 9 and the sleeve 204 are attached with the block 218 preventing axial rotation of the tool 9 with respect to the multi-purpose installation tool 12 .
- the multi-purpose installation tool 12 is removed from the end guide tool 9 and replaced thereon with the slot 44 and channel openings 40 and 94 adjacent to and facing the alignment block 218 .
- the translation nut 202 of the multi-purpose installation tool 12 is substantially cylindrical in shape and is shown with outer grooves 223 to aid a surgeon in handling the multi-purpose installation tool 12 and rotating the nut 202 .
- the nut 202 further includes an inner cylindrical surface 224 defining an inner substantially cylindrical passage 226 communicating with the passage 206 of the sleeve 204 .
- the inner surface 224 further includes a helical guide and advancement structure as shown by a V-shaped thread 228 that is configured to mate with the guide and advancement structure 50 of the end guide tool 9 or the guide and advancement structure 93 of the intermediate guide tool 10 .
- the inner cylindrical surface 224 extends from an upper open end 230 of the translation nut 202 to an annular seating surface 232 extending radially outwardly and perpendicular to the cylindrical surface 224 .
- the surface 224 with associated thread 228 is of a length that provides an equivalent translation distance of the multi-purpose installation tool 12 , and in particular the tang/rod pressing block 218 , with respect to the guide tool 9 or 10 such that the pressing block 218 can be used to gradually push the rod 8 toward the bone screw 4 for the entire translation distance by rotating the nut 202 which can be continued until the rod is fully seated in the head of the bone screw.
- the sleeve 204 is in sliding contact with the nut 202 .
- a lower portion 234 of the nut 202 further defines a second inner cylindrical surface 236 of greater diameter than the surface 224 .
- the surface 236 has a diameter slightly greater than a diameter of the sleeve 204 and is configured to slidingly receive the sleeve 204 into the nut 202 along the surface 236 .
- the nut 202 further defines an annular recess or groove 238 configured to receive a pin 240 rigidly fixed to the sleeve 204 .
- the pin 240 may be accessed for attachment and removal from the sleeve 204 through an aperture 242 disposed in the translation nut 202 .
- the pin 240 slidingly mates with the nut 202 within the recess 238 , keeping the nut 202 and sleeve 204 in an attached but freely rotatable relation.
- the driver 14 of an assembly 1 includes a handle 250 , a guide tool fastener or nut 252 , and an elongate cylindrical stem or shaft 254 having a lower cylindrical portion 255 integral with a bone screw engager shown as a socket 256 .
- the socket 256 is configured to mate with the upper part of the bone screw shank 154 .
- the shaft 254 with attached socket 256 is receivable in and passes through the interior of the guides 9 and 10 , such as the channel 80 of the guide tool 10 .
- the lower portion 255 has a slightly smaller diameter than a diameter of the remainder of the shaft 254 , this smaller diameter provides for adequate clearance of the portion 254 from the guide and advancement structures 64 and 114 when the shaft 254 is installed within the interior of the respective guide tools 9 and 10 .
- the stem or shaft 254 is rigidly attached to the handle 250 and coaxial therewith. Both the handle 250 and the guide tool fastener 252 include outer grooves 258 and 259 respectively, about outer cylindrical surfaces thereof to aid in gripping and rotating the respective components.
- the guide tool fastener 252 is a substantially hollow cylinder disposed in coaxial relationship with the handle 250 and the shaft 254 .
- the fastener has a threaded inner cylindrical surface 262 disposed at a lower portion 263 thereof, the threaded surface 262 configured to mate with the guide and advancement structure 50 of the end guide tool 9 or the guide and advancement structure 93 of the intermediate guide tool 10 .
- the fastener 252 is disposed on the driver 14 between an annular surface 264 of the handle 250 and the pin 46 that is fixed to the shaft 254 and extends laterally therefrom.
- the driver 12 further includes a lateral pin 266 projecting radially outwardly from a cylindrical surface 268 adjacent the handle 250 .
- the cylindrical surface 268 is integral with the handle 250 and fixedly attached to the shaft 254 .
- the pin 266 is disposed within an annular recess 270 defined by the cylindrical surface 268 , and surfaces of the fastener 252 , including an upper seating surface 272 , a lower seating surface 274 and an inner cylindrical surface 276 .
- the pin 266 disposed in the recess 270 allows for both rotational and axial or vertical translational movements of the fastener 252 with respect to the shaft 254 .
- the fastener 252 is rotatable about an axis C.
- the fastener is slidable along the axis C between the annular surface 264 and the pin 46 , with FIG. 26 showing a first or unattached position with the fastener 252 in contact with the annular surface 264 and FIGS. 27 and 28 showing a second, engagement position, with the fastener 252 partially covering, but not contacting the pin 46 , with the pin 266 abutting the upper seating surface 272 prohibiting further downward or vertical (axial) translational movement of the fastener 252 with respect to the shaft 254 .
- the pin 46 is configured for sliding engagement with both the slot 44 of the guide tool 9 and the slot 88 of the guide tool 10 when the driver shaft 254 is disposed in an interior of the guide tool 9 or 10 .
- the pin 46 is received in the slot 44 or the slot 88 , any relative rotational movement between the guide tool 9 or 10 and the driver 14 is prevented, but the driver is free to slide axially with respect to the guide tool 9 or 10 .
- the fastener or nut 252 is slid into the second position shown in FIGS.
- a three-component assembly 1 including the guide tool 9 , the multi-purpose installation tool 12 and the driver 14 may be assembled as follows:
- the guide tool 9 shown with attached bone screw 4 is inserted into the multi-purpose installation tool 12 with the upper end 43 being inserted into the receiving end 207 of the multi-purpose installation tool 12 .
- illustrated is a particular assembly wherein the multi-purpose installation tool 12 is being utilized as a support or stabilizer for the end guide tool 9 during installation of the bone screw 4 into the vertebra 16 , specifically, to contain and compress the tang 38 and to provide extra support to the walls, such as walls 68 and 69 of tool 9 .
- the guide tool 9 is received into the multi-purpose installation tool 12 with the rear wall 28 facing the alignment block 218 as shown in FIG. 29 .
- the translation nut 202 is then rotated clock-wise as viewed from the top end 230 and shown by the arrow X, with the thread 50 of the guide tool 9 mating with the thread 228 disposed on the inner surface 224 of the translation nut 202 .
- the translation nut 202 is preferably rotated until the upper end 43 of the guide tool 9 is positioned outside of the body of the nut 202 with a few of the threads 50 exposed as shown in FIGS. 30 and 31 .
- the sleeve 204 cannot be translated beyond the pin 67 that stops the sleeve near the rod abutment recess 61 disposed near the end of the guide tool 9 .
- the guide tool 9 is held in a preferred bone screw installation position and any rotational movement of the tool 9 is prevented by the alignment block 218 in contact with the co-planar back walls or facets 71 of the guide tool 9 as well as the planar back surface of the tang 38 .
- the flexible back wall portion or flap 38 is compressed and retained in place between the side walls 32 and 33 by the alignment block 218 .
- the multi-purpose installation tool 12 When the multi-purpose installation tool 12 is used as a rod pusher with the guide tool 9 as shown in FIGS. 38 and 41 , the multi-purpose installation tool 12 is preferably used first as an end guide tool stabilizer and tang 38 container, as already described herein, and thus must first be removed by rotating the translation nut 202 counter-clockwise until the multi-purpose installation tool 12 is disengaged from the end tool guide 9 thereby deploying the tang 38 . Thereafter, the multi-purpose installation tool 12 is removed and replaced on the guide tool 9 with the slot 44 and channel openings 40 and 94 adjacent to and facing the alignment block 218 .
- the translation nut 202 is then rotated clock-wise as shown by the arrow X ( FIG. 29 ), with the thread 50 of the guide tool 9 mating with the thread 228 disposed on the inner surface 224 of the translation nut 202 . Similar to what is shown in FIGS. 30 and 31 , the translation nut 202 is rotated clockwise as shown by the arrow X, until the upper end 43 of the guide tool 9 is positioned outside of the body of the nut 202 with some of the threads 50 exposed.
- the guide tool 9 is held in position and any rotational movement of the tool 9 is prevented by the alignment block 218 in contact with the co-planar front walls or facets 70 of the guide tool 9 .
- the flexible back wall tang portion or flap 38 is not obstructed by the sleeve 204 of the multi-purpose installation tool 12 and may spring out or be further pushed out through the opening 213 of the U-shaped channel 212 .
- An assembly 1 according to the invention may also include the intermediate guide tool 10 in the place of the guide tool 9 as shown in FIGS. 40-42 .
- the intermediate guide tool 10 includes a pass-through slot 111 rather than a flexible back wall tang portion 38 , the alignment between the multi-purpose installation tool 12 and the guide tool 10 may be the same during bone screw installation as for the pushing of the rod 8 . Therefore, the tool guide 10 may be inserted into the multi-purpose installation tool 12 with either the rear wall 81 or the slot 88 adjacent to and facing the alignment block 218 .
- the translation nut 202 is then rotated clock-wise as viewed looking toward the top 87 of the tool 10 , with the thread 93 of the guide tool 10 mating with the thread 228 disposed on the inner surface 224 of the translation nut. Similar to what is shown in FIGS. 30 and 31 , the translation nut 202 is rotated until the upper end 87 of the guide tool 10 is positioned outside of the body of the nut 202 with some of the threads 93 exposed.
- the guide tool 10 is held in position, with rotational movement of the tool 10 being prevented by the alignment block 218 in contact with the co-planar front walls or facets 109 or the co-planar rear walls or facets 110 of the guide tool 10 .
- the driver 14 is inserted into the guide tool 9 /multi-purpose installation tool 12 combination by inserting the socket end 256 into the end 43 of the guide tool 9 and sliding the shaft 254 into the interior of the guide tool 9 until the socket end 256 contacts and surrounds the upper part of the shank 154 of the bone screw 4 as shown in FIG. 35 .
- the pin 46 on the shaft 254 of the driver 14 is aligned with and slid into the slot 44 of the guide tool 9 .
- the guide tool fastener 252 is placed in the first or unattached position with the fastener 252 in contact with the annular surface 264 as shown in FIG. 32 . Also as shown in FIG. 32 , preferably, the pin 46 is slid to a position disposed substantially within the slot 44 when the socket end 256 engages the shank 154 of the bone screw 4 .
- the guide tool fastener or nut 252 is then rotated clockwise as viewed from the handle and illustrated by the arrow Y in FIG. 33 , from the first unattached position toward the second engaged position, mating the thread 50 located near the end 43 of the guide tool 9 with the inner threaded surface 262 of the nut 252 of the driver 14 .
- the translation nut 202 may then be rotated counter-clockwise as shown by an arrow Z in FIG. 33 , and hand-tightened until the translation nut 202 abuts against the fastener 252 , as shown in FIG. 34 .
- the assembly 1 is then fully assembled and may be used to install the bone screw 4 into the vertebra 16 as will be described more fully below.
- the driver 14 may be removed by rotating the fastener 252 in a counter-clockwise direction (arrow Z) and sliding the shaft 254 out of the multi-purpose installation tool 12 through the open end 230 .
- FIGS. 44 and 45 Another tool used in implanting a spinal rod 8 is an antitorque tool 300 illustrated in FIGS. 44 and 45 and further shown in FIG. 44 with a closure top installation tool 302 engaging the break-away portion 186 of the closure top 62 .
- the closure top installation tool 302 includes an upper handle portion 303 and a lower, closure top engagement portion 304 configured to mate with and rotate the closure top 62 .
- the antitorque tool 300 is also preferably used with a closure top torquing tool 305 , shown in FIGS. 47 and 48 .
- the tool 305 is used to torque and set the closure top 62 , so it is snug against the rod 8 , and thereafter break away the break-off head 186 in the manner shown in FIG. 48 .
- the torquing tool 305 is preferably in the form of a socket as shown in the drawings to allow for adequate tightening of the closure top 62 and also ease in removal of the break-off head 186 as shown in FIG. 48 .
- the antitorque tool 300 includes a tubular hollow shaft 306 that is sized and shaped to be slidably received over the installation tool 302 and also the torquing tool 305 .
- the shaft 306 has a lower end portion 308 that has a pair of diametrically spaced, curved bridges 310 .
- Each of the bridges 310 is sized and shaped to fit over the rod 8 , shown in FIGS. 47 and 48 .
- the antitorque tool 300 allows a surgeon to counter torque applied by the torquing tool 305 , when applying torque to and breaking away the break-off head 186 .
- the antitorque tool 300 also has an upper handle 316 disposed perpendicular to the shaft 306 and having an opening 318 through which the installation tool 302 and the torquing tool 305 passes in the manner suggested by FIGS. 46-48 .
- the previously described tools are utilized to attach one or more rods 8 to the human spinal column 6 .
- the procedure is begun by selection of a bone screw 4 in accordance with the size of the patient's vertebra 16 and the requirements of the spinal support needed.
- Bone screws 4 having a rotatable or polyaxial head 146 are preferred but not required for the procedure, as such allow relatively easy adjustment of the rod 8 in the tools 9 and 10 during placement and for movement of the tools 9 and 10 , as described below.
- the bone screw 4 is also preferably cannulated so as to be receivable over and guided by a guide pin 355 as discussed more fully below.
- a relatively small incision, such as an incision 350 in the skin 20 is then made for each bone screw 4 to be used.
- the incisions are sized so as to snugly receive the tools of the invention.
- the incisions 350 are stretched into a round shape with a circumference equal to or just slightly larger than the multi-purpose installation tool 12 .
- the skin 20 is relatively flexible and allows the surgeon to move the incision 350 around relative to the spine 6 to manipulate the various tools and implants, as required. In some cases, two screws can be inserted through one or the same incision.
- a drill (not shown) is utilized to form a first guide bore 366 in a vertebra 16 under guidance of non invasive imaging techniques, which procedure is well known and established.
- the thin pin or guide wire 355 is then inserted in the first guide bore 366 .
- This first guide bore 366 and associated thin pin 355 function to minimize stressing the vertebra 16 and provide an eventual guide for the placement and angle of the bone screw shank 148 with respect to the vertebra 16 .
- the guide bore 366 is enlarged utilizing a cannulated drilling tool or tap 360 having an integral or otherwise attached cannulated and threaded bit 362 with an outer surface sized and shaped to correspond to the size and shape of the chosen threaded bone screw 4 .
- the drilling tool 360 cooperates with a cylindrical holder or sleeve 368 having an inner surface in slidable mating arrangement with the tool 360 and being held in a position substantially coaxial therewith.
- the holder 368 is sized and shaped to fit within the incision 350 and prevents soft tissues from being rolled up in the threaded bit 362 as it is rotated.
- the tool 360 further includes a handle 370 fixedly attached to the tool 360 located at an end portion 372 thereof and of a size and shape for rotating the bit 362 along the pin 355 and into the first bore 366 .
- the enlargement of the guide bore 366 begins by threading the thin pin 355 through the end of the tap and inserting the holder 368 into the incision until the holder comes into contact with the vertebra 16 .
- the drill bit 362 is advanced downward along the pin 355 until the drill bit 362 comes into contact with the vertebra 16 .
- the tool 360 is then rotated within the holder 368 using the handle 370 , driving the bit 362 along the pin 355 until a full sized bore 380 is drilled to a depth desired by the surgeon.
- the holder 368 remains stationary, shielding the surrounding tissue from the rotational movement of the bit 362 and tool 360 .
- the tool 360 is then removed by rotating the bit 362 in reverse until the bit 362 is outside the bore 380 .
- the tool 360 is then removed from the holder 368 , followed by the removal of the holder 368 through the incision 350 .
- the bone screw 4 Before placing the bone screw 4 in the vertebra 16 , the bone screw 4 is preferably joined to an associated guide tool 9 or 10 , with or without an associated multi-purpose installation tool 12 , and an associated driver 14 . It is foreseen that the driver can also be cannulated. It is possible, but typically not desirable, to join a guide tool 9 or 10 to the bone screw 4 after the installation of the bone screw 4 to the vertebra 16 . There also may be instances wherein it is desirable to join the bone screw 4 to an associated guide tool 9 or 10 , but not to the multi-purpose installation tool support 12 or the driver 14 until after the bone screw 4 is installed in the vertebra 16 , if at all.
- the driver 14 cannulated or not, may be used with a guide tool 9 or 10 without the multi-purpose installation tool 12 .
- the multi-purpose installation tool 12 may be preferable to utilize the multi-purpose installation tool 12 during installation of a bone screw 4 into the vertebra 16 as the tool 12 provides some mechanical advantage and aids in preventing inadvertent splaying of side walls 32 and 33 of the end guide tool 9 and legs 102 and 103 of the intermediate guide tool 10 .
- the attachment structure 124 of the intermediate guide tool 10 is joined to a bone screw 4 by first rotating the tool 10 relative to the bone screw 4 so that the legs 102 and 103 are positioned as shown in FIGS. 17 and 18 , with the facets 167 and 177 of the head 146 disposed between the guide tool legs 102 and 103 , and with the facet 167 adjacent the leg 102 and the facet 177 adjacent the leg 103 , thereby aligning the groove 158 with the large pin 126 and the groove 168 with the large pin 130 .
- a slight splaying of the legs 102 and 103 is possible during alignment with the head arms 150 and 151 .
- the head 146 is then twisted into place by rotating the tool 10 axially in a clockwise direction as shown by the arrow T in FIGS. 18 and 19 .
- the twist-on procedure described herein with respect to the attachment structure 124 of the intermediate tool 10 is also followed with respect to the end guide tool 9 attachment structure 72 .
- the attachment structure 72 is substantially similar to the attachment structure 124 of the intermediate tool 10 , with the only difference being that the end guide tool 9 includes a flexible back wall tang portion 38 rather than the pass-through slot 111 of the intermediate guide tool 10 .
- a multi-purpose installation tool 12 can be attached to each of the guide tools 9 and 10 .
- the multi-purpose installation tool 12 is preferably installed as follows: The rear wall 81 of the tool 10 is positioned adjacent to the surface 220 and the tool 10 is inserted into the hollow passage 206 and slid into the rod pusher sleeve 204 until the end 87 contacts the translation nut 210 , with the block 218 preventing axial rotation of the guide tool 10 with respect to the multi-purpose installation tool 12 , and resulting in the preferred alignment of the sleeve slot 11 and the opening 79 of the tool 10 with the U-shaped channel 212 of the multi-purpose installation tool 12 .
- the slot 11 is a pass-through slot
- the alignment of the guide tool 10 with respect to the multi-purpose installation tool 12 is not critical to processes according to the invention. Therefore, in most instances the rear wall 81 of the tool 10 may also be positioned opposite the surface 220 upon entry into the multi-purpose installation tool 12 .
- the translation nut 202 is then rotated with the thread 228 of the nut 202 mating with the thread 93 of the tool 10 .
- the nut 202 is rotated in a clockwise direction as illustrated by the arrow X in FIG. 29 until the end 87 is disposed outside of the nut 202 and positioned similar to what is shown with respect to the multi-purpose installation tool 12 and end guide tool 9 assembly shown in FIGS. 30 and 31 .
- the abutment pin 118 prevents further rotation of the nut 202 and advancement of the sleeve 204 beyond the pin 118 .
- the end guide tools 9 are similarly equipped with multi-purpose installation tools 12 .
- the tool 9 is received into the multi-purpose installation tool 12 with the back wall 28 of the tool 9 disposed adjacent to the surface 220 .
- the multi-purpose installation tool 12 is slid onto the tool 9 until the end 43 contacts the translation nut 202 , with the block 218 preventing axial rotation of the tool 9 with respect to the multi-purpose installation tool 12 , and resulting in the preferred alignment wherein the flexible back wall tang portion or flap 38 is disposed adjacent to the guide tool sleeve 204 disposed opposite the U-shaped channel 212 .
- the translation nut 202 is then rotated with the thread 228 of the nut 202 mating with the thread 50 of the end guide tool 9 .
- the nut 202 is rotated in a clockwise direction as illustrated by the arrow X in FIG. 29 until the end 43 is disposed outside of the nut 202 and positioned as shown in FIGS. 30 and 31 , but not beyond the pin 67 .
- the driver 14 is then installed into the guide tool 9 as shown in FIGS. 32-35 and as follows:
- the driver 14 is first prepared for ease of insertion by placing the guide tool fastener 252 in the first or unattached position with the fastener 252 in contact with the annular surface 264 of the driver 14 as shown in FIG. 32 .
- the driver end 256 is inserted into the guide tool 9 at the end 43 with the stem 254 being slid into the guide tool 9 with the pin 46 aligned with the channel 39 until coming to a stop with the pin 46 disposed in the slot 44 and the bone screw engager 256 in contact with the bone screw upper shank 154 .
- a slight rotation or jiggling of the bone screw shank 148 may be required for the hex socket of the bone screw engager 256 to become positioned in operational engagement with the hex shaped upper shank 154 .
- the guide tool fastener or nut 252 is then moved downward and toward the end 43 and then rotated clockwise as viewed from the handle 250 and illustrated by the arrow Y in FIG. 33 , mating the thread 50 disposed near the end 43 of the guide tool 9 with the inner threaded surface 262 of the nut 252 of the driver 14 .
- the nut 252 is rotated in this clock-wise fashion and hand-tightened until further translation of the nut 252 along the guide tool 9 is prevented by the pin 266 abutting the upper seating surface 272 .
- the translation nut 202 is rotated counter-clockwise as shown by the arrow Z in FIG. 33 , and hand-tightened until the translation nut 202 abuts against the fastener 252 as shown in FIG. 34 .
- the assembly 1 is now ready for bone screw installation into the vertebra 16 .
- the driver 14 is installed into the intermediate guide tool 10 and multi-purpose installation tool 12 assembly in steps similar to that described above with respect to the end guide tool 9 .
- a series of bone screws 4 are installed in each vertebra 16 to be attached to the rod 8 by inserting each of the assemblies 1 through the skin incision 350 as shown in FIG. 37 .
- the screw 4 is then rotated and driven into the tapped bore 380 with the surgeon holding and rotating the assembly 1 with the driver handle 250 , thereby rotating the entire assembly 1 as one unit until the shank 148 is disposed at a desired depth in the tapped bore 380 of the respective vertebra 16 .
- the shank 148 , along with the screw driver 14 are also cannulated to receive the pin 355 , providing additional guidance for installation of the bone screw 4 into the vertebra 16 .
- the driver 14 is removed from either the guide tool 9 or 10 by rotating the fastener 252 in a counter-clockwise direction (illustrated by the arrow Z in FIG. 33 ) and sliding the shaft 254 towards the open end 230 of the multi-purpose installation tool 12 , if used, and pulling the driver 14 out of the assembly 1 by the handle 250 .
- the multi-purpose installation tool 12 With respect to the end guide tools 9 , the multi-purpose installation tool 12 , if used, is then removed by rotating the translation nut 202 counter-clockwise until the thread 228 disposed on the inner surface 224 of the translation nut 202 is disengaged from the thread 50 of the tool 9 . The multi-purpose installation tool 12 is then slid off of the tool 9 deploying the flexible flap 38 , as shown in FIG. 38 . If desired at this junction of a process according to the invention, the multi-purpose installation tool 12 many then be rotated 180 degrees and replaced on the tool 9 with the slot 44 and the channel openings 40 and 94 aligned adjacent to and facing the alignment block 218 of the multi-purpose installation tool 12 for a rod pushing application. The translation nut 202 is then rotated clockwise as illustrated by the arrow X in FIG. 29 . In this rod pushing position, the flexible tang 38 is extendible into the U-shaped channel 212 of the multi-purpose installation tool 12 .
- an associated guide tool 9 or 10 extends through the skin 14 , as illustrated in FIG. 39 .
- An end guide tool 9 is located at each end of the series of bone screws 4 and an intermediate guide tool 10 is located on each intermediate bone screw 4 .
- each guide tool 9 or 10 it may not be necessary to equip each guide tool 9 or 10 with a multi-purpose installation tool 12 .
- a multi-purpose installation tool 12 for a particular procedure, it may be desirable to utilize only one multi-purpose installation tool 12 with a tool set 2 according to the invention.
- the multi-purpose installation tools 12 have been removed from both of the end guide tools 9 and both of the intermediate guide tools 10 after which a rod 8 has been inserted and a multi-purpose tool 12 reattached to one tool 10 .
- Some pushing of the rod may be accomplished by just extending a rod or tool down the central channel of the guide tools 9 and 10 when mechanical advantage is not required to move the rod 8 .
- one or more multi-purpose installation tools 12 may be added or removed at any time during the course of the rod pushing or reducing procedure.
- the end guide tools 9 are turned or rotated so the channels 55 therein face one another and the intermediate guide tools 10 are aligned so the pass-through slots 111 align with the channels 55 .
- the rod 8 has been inserted diagonally through one of the end skin incisions 350 with the adjacent end guide 9 pushed to the side, so that one of the rod ends 59 first passes through the slots 111 in the intermediate guide tools 10 and then into the channel 55 of one of the guide tools 9 .
- Back muscle tissue separates easily here to allow the upper insertion of the rod 8 and can be further separated by finger separation or cutting through one of the incisions 350 , if required.
- the remaining opposed end 59 of the rod 8 is positioned in the channel 55 of the end guide tool 9 that is located next to the insertion point of the rod 8 .
- Manipulation of the rod 8 in the channels 55 is aided by the back wall tang portions or flexible flaps 38 of the guide tools 9 which may also be moved like a joy-stick toward or away from each other by the surgeon.
- the back wall portions or flaps 38 resiliently bias against the rod ends 59 , substantially holding and containing the rod 8 in place between the end guide tools 9 of the tool set 2 .
- the tangs 38 allow the rod 8 to be controlled and positioned outwardly of the end bone screws 8 .
- the position of the rod 8 is controlled by equal pressure applied by the tangs 38 so that the rod 8 extends past the bone screws 4 approximately an equal amount on each side.
- the multi-purpose installation tool 12 may be utilized to push the rod 8 toward the bone screw 4 , normally when mechanical advantage is needed to seat the rod 8 in the bone screws 4 . This is accomplished by rotating the translation nut 202 in a clockwise direction (as viewed from above the skin 20 ), thereby translating the sleeve 204 in a downward direction toward the bone screw 4 , with the guide tool alignment block 218 abutting and pushing against the rod 8 . It is also possible to reduce or realign vertebral bodies by this maneuver.
- a closure top 62 is placed in the elongate top to bottom channel associated with the guide tools 9 and 10 , preferably by entry from the side such as into the channel opening 40 of the guide tool 9 or alternatively into the channel 39 through the top end 43 of the guide tool 9 . If the guide tool 9 or 10 has the multi-purpose installation tool 12 attached, the closure top 62 can be placed into the guide tool by side insertion into the U-shaped channel 212 .
- the closure top installation tool 302 is then inserted into the top end 43 and through the channels disposed within the guide tool 9 , until the engagement portion 304 mates with a cooperating aperture disposed in the break-off head 186 .
- the closure top 62 is then driven or pushed under manual control of the surgeon by use of the installation tool 145 toward the rod 4 .
- the closure top 62 engages the helically wound guide and advancement structures 64 and 114 of respective guide tools 9 and 10 .
- the tools 302 and mated closure tops 62 are then rotated, mating the closure tops 62 with associated guide tools 9 and 10 so as to drive the closure top 62 downward against the rod 8 and to urge the rod 8 downward into the bone screw channel 153 .
- the translation nut 202 of the multi-purpose installation tool 12 is rotated in a clockwise direction, translating the sleeve 204 and block 218 downwardly slightly in advance or substantially concurrent with the advancement of the closure tops 62 , providing additional mechanical advantage for the block flat surface 222 against the rod 8 .
- the closure top mating structure 181 engages and begins to mate with the guide and advancement structure 183 on the respective bone screw 4 and continued rotation of the tool 302 drives the rod 8 downward and into engagement with the upper part of the bone screw shank 154 , so as to snug against and frictionally lock the shank 148 in position relative to the bone screw head 146 .
- any and all multi-purpose installation tools 12 are removed by rotating the nut 202 counter-clockwise followed by sliding the sleeve 204 off of the guide tool 9 and 10 and out of the incision 350 .
- each of the guide tools 9 and 10 are now removed by rotating each guide tools 9 and 10 ninety degrees so that the recesses 116 straddle the rod 8 to allow the attachment structure 72 or 124 to disengage from the receiver portion 145 on the bone screw 4 .
- the guide tool 9 or 10 is then pulled axially upward away from the bone screw 4 , along the tool 302 and then out of the incision 350 .
- the antitorque tool 300 is mounted over each closure top installation tool 302 , utilizing the tool 302 as a guide for re-entry through the incision 350 .
- the antitorque tool 300 is slid along the tool 302 until the bridges 310 straddle the rod 8 , preventing axial rotation of the tool 300 .
- the closure top installation tool 302 is then pulled axially upward away from the bone screw 4 and out of the incision 350 .
- the closure top torquing tool 305 is then inserted into the antitorque tool 300 and engaged with the break-off head 186 .
- a preselected torque is manually applied to the break-off head 186 which breaks from the closure top 62 as illustrated in FIG. 48 and is thereafter removed, followed by removal of the antitorque tool 300 , after which the incision 165 is closed.
- an alternative attachment structure generally 401 .
- a portion of the structure 401 is located on a polyaxial bone screw head or receiver 406 that is pivotally attached to a shank 407 .
- the threaded shank 407 is cannulated, having a small central bore 408 extending an entire length of the shank body.
- the bore 408 provides a passage through the shank interior for a length of wire or pin inserted into a vertebra prior to the insertion of the threaded shank body 407 , the wire or pin providing a guide for insertion of the shank 407 into the vertebra.
- the attachment structure 401 for holding cooperation between the polyaxial bone screw head or receiver 406 and a guide tool 410 is also located at a lower end portion 411 of the guide tool 410 .
- the lower end portion 411 has a cutout 412 and an inner attachment ledge 413 .
- the attachment ledge 413 has a body 414 with an upperwardly extending, projection, flange or hook member 415 that follows an inner curvature of the guide tool 410 .
- the body 414 extends radially inwardly and is sized and shaped to mate with and set within a tool receiving recess or groove 418 formed on the bone screw head 406 .
- the recess 418 is sufficiently wide to simultaneously receive both the body 414 and the hook member 415 in a radially inward direction, as is shown in FIG. 52 .
- the attachment 413 is then set by axially raising the guide tool 410 relative to the bone screw 406 so at least part of the hook member 415 is located in an upper hidden recess 420 , thereby securing the guide tool 410 to a respective bone screw 406 , as shown in FIG. 53 .
- This locks the guide tool 410 to a respective bone screw 406 and prevents outward splaying of the guide tool 410 .
- This is a snap-on type installation or assembly as seen in FIG. 49 where the leg 411 splays outward during initial placement of the guide tool 410 over the bone screw 406 and then returns to an unsplayed position when the inner attachment structure 413 seats in the receiving recess 418 , as shown in FIG. 52 .
- the guide tool 410 can be rotated approximately 90° about a rotational axis thereof prior to joining with a respective bone screw 406 , the attachment structure 413 lowered through the opening between bone screw arms 424 and 425 and aligned with the tool receiving recess 418 , after which the guide tool 410 is rotated back to the first position shown in FIG. 53 in a twist on type assembly.
- the guide tool 410 is rotated somewhat more or less than ninety degrees to make the necessary alignment for removal which depends on the specific construction of the parts.
- the guide tool 410 is rotated ninety degrees to align the inner attachment ledge 413 with the opening between bone screw arms 424 and 425 , to allow the attachment structure 413 to disengage from the recess 418 .
- the guide tool 410 is then pulled axially upward away from the bone screw 406 .
- a second alternative attachment structure for holding attachment of a bone attachment structure and a guide tool is illustrated.
- a polyaxial bone screw head or receiver 434 with a pivotally attached bone screw shank 435 is shown cooperating with a guide tool 436 having a lower end portion 438 thereof.
- the attachment structure 430 includes tool engaging apertures 440 formed on outer surfaces of arms 444 and 445 for holding the receiver 434 during procedures such as bone screw assembly, implantation of the shank 435 into a vertebra, and subsequent procedures, such as rod reduction and closure top installation.
- the illustrated apertures 440 are substantially circular in cross-section and are disposed opposite one another, each including an upwardly projecting, hidden inner recess 448 for cooperating with complimentary bone screw holding components of the guide tool 436 , discussed more fully below. It is noted that the apertures 440 and the cooperating guide tool holding components may be configured to be of a variety of sizes and locations for attachment to the guide tool along any of the surfaces of the arms 444 and 445 .
- the attachment structure 430 is disposed at the lower portion 438 and on inner slightly recessed surfaces 452 and 453 of respective legs or surfaces 456 and 457 .
- the attachment structure 430 includes diametrically opposed projections or pins 460 and 462 , extending radially inwardly from the surfaces 452 and 453 , respectively.
- the pins 460 and 462 are substantially configured the same, both being substantially rounded, radially inward projecting nodules, each having a lip 464 projecting upwardly and away from a bottom surface 468 and 469 , respectively.
- Each lip 464 partially defines a groove 470 for receiving the bone screw receiver 434 .
- the groove 470 is further defined by a base surface 472 and a wall 474 that faces the inner surface 452 or 453 .
- An upper wall 476 is substantially parallel to the base or bottom surface 468 or 469 .
- the pins 460 and 462 are configured to mate with the opposed apertures 440 of the bone screw head or receiver 434 with the lip 464 extending into the inner recess 448 , when the guide tool 436 is fully installed on the bone screw head 434 as shown in FIG. 56 and described more fully below. While a preferred embodiment of the invention has pins 460 and 462 of the implant engaging structure 430 on the guide tool 436 , and apertures 440 on the bone screw head 434 , it is foreseen that these elements could be reversed in total or part in accordance with the invention.
- the bone screw head or receiver 434 is preferably joined to the guide tool 436 before implanting the bone screw shank 435 in a vertebra. It is also possible to join the guide tool 436 to the bone screw receiver 434 after the installation of the bone screw to the vertebra.
- the cooperating implant engaging structure 430 disposed on the guide tool 436 and the head or receiver 434 is joined by first manually spreading the legs 456 and 457 apart and inserting the guide tool 436 onto the bone screw head 434 as illustrated in FIG. 54 .
- the inwardly projecting pins 460 and 462 are generally aligned with the apertures 440 and the tool is slid downwardly along the head 434 surface until the pins 460 and 462 snap into the apertures 440 as shown in FIG. 55 .
- the guide tool 435 is then pulled upwardly and away from the bone screw head 434 , causing the lips 464 to enter the recesses 448 .
- Engagement between the lips 464 and the structure defining the recesses 448 result in a firm attachment that also resists any attempt to spread or splay the legs 456 and 457 .
- downward force is first placed on the guide tool 436 by the surgeon to move the lips 464 of the guide tool implant engaging structure 430 out of the inner recesses 448 of the bone screw head 434 .
- a prying tool may be inserted between the legs 456 and 457 to spread the lower portions of the legs 456 and 457 away from one another, while pulling up on the guide tool 436 to allow the guide tool to slide upwardly along the bone screw head 434 (as illustrated in reverse by FIGS. 56, 55 and 54 ).
- the guide tool 436 is then pulled axially upwardly away from the bone screw head 434 .
- a third alternative attachment structure for holding a bone attachment, such as the bone screw, generally 482 , to a guide or holding tool 484 is illustrated.
- the illustrated bone screw 482 includes a head or receiver 486 hingedly attached to a bone screw shank 487 .
- the shank 487 is bottom loaded into the receiver 486 and then rotated ninety degrees to seat an upper portion 489 of the shank 487 within the receiver 486 as shown in FIG. 59 .
- First and second arms 490 and 492 of the receiver 486 each include outer substantially planar surfaces 494 .
- Each outer surface 494 of each arm 490 and 492 also includes a substantially V-shaped undercut 496 disposed near and running parallel to a top surface 498 , the undercut 496 extending along and through end surfaces 497 of the receiver 486 and sized and shaped for cooperating with complimentary bone screw holding components of the guide tool 484 .
- the under cut 496 includes a planar surface 500 disposed at an acute angle with respect to a second surface 501 , the surface 501 being perpendicular to the top surface 498 .
- the attachment structure 480 includes diametrically opposed projections in the form of straight, hook-like ledges 502 extending along inner surfaces of the tool 484 and projecting inwardly and upwardly (operably in a direction away from the bone screw 482 and toward a remainder of the tool 484 ).
- the hook-like ledges 502 are sized and shaped to be received in the undercut 496 and be in frictional engagement with the angled surfaces 500 .
- First and second set screws 504 rotatably attached to the guide tool 484 are sized and shaped for frictional engagement with the top surface 498 of the receiver arms 490 and 492 , respectively, thereby frictionally fixing the projecting ledges 502 within the undercut 496 .
- the bone screw head or receiver 486 is preferably joined to the guide tool 484 before implanting the bone screw shank 487 in a vertebra. It is also possible to join the guide tool 484 to the bone screw receiver 486 after the installation of the bone screw to the vertebra.
- the cooperating implant engaging structure 480 disposed on the guide tool 484 and the head or receiver 486 may be joined in more than one way.
- One option is to manually spread opposed legs or portions 506 and insert the guide tool 484 onto the bone screw receiver 486 outer arm surface 494 at a location spaced from the top surfaces 498 , thereby snapping the guide tool 484 onto the receiver 486 and thereafter pulling the guide tool 484 upwardly and away from the receiver 486 , the guide tool 484 sliding upwardly along an inwardly sloping surface 507 leading up to the undercut 496 until the ledges 502 are received in the undercut 496 . Engagement between the ledges 502 and the sloped surfaces 500 result in a firm attachment that also resists any attempt to spread or splay the legs 506 . The set screws 504 may then be rotated and thereby moved into frictional engagement with the top surfaces 498 .
- the implant engaging structure 480 on the guide tool 484 may be aligned with the undercut 496 on the receiver 486 , the tool 484 disposed laterally of the bone screw receiver 486 . Then the tool 484 may be slid onto the bone screw receiver 486 with the ledges 502 in sliding engagement in the surfaces 500 of the undercuts 496 until the ledges 502 are fully received in the undercuts 496 . To fully engage the ledges 502 with the surfaces 500 , the guide tool 484 is pulled upwardly and away from the receiver 486 . The set screws 504 may then be rotated and placed in frictional engagement with the top surfaces 498 .
- the set screws 504 are first rotated until the screws 504 are spaced from the top surfaces 498 . Downward force is then placed on the guide tool 484 by the surgeon to move the ledges 502 of the guide tool implant engaging structure 480 slightly out of the undercut 496 . Then the guide tool 484 is slid in a lateral direction, out of the undercut 496 .
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Abstract
A tool set for implanting bone screws in a human spine, followed by the implantation of a rod into the bone screws includes end guide tools having flexible back wall flaps that receive opposite ends of the rod and intermediate guide tools that hold the rod in intermediate locations between the end guide tools. Both the end and intermediate guide tools include an attachment structure for operably connecting the guide tool to a bone screw. The attachment structure includes an undercut and/or recess so as to resist splaying and separation of the guide tool from an attached bone screw.
Description
- This application claims the benefit of U.S. Provisional Application No. 60/630,536 filed Nov. 23, 2004; and is a continuation-in-part of U.S. patent application Ser. No. 10/996,289 filed Nov. 23, 2004; and also is a continuation-in-part of U.S. patent application Ser. No. 10/789,149, filed Feb. 27, 2004, all of which are incorporated herein by reference.
- The present invention relates to apparatuses and methods for use in performing spinal surgery and, in particular, to tools and methods of using such tools, especially for percutaneously implanting spinal screws and for implanting a rod for spinal support and alignment, using minimally invasive techniques.
- For many years, spinal osteosynthesis apparatuses have been utilized to correct spinal deformities, injuries or disease. In such procedures, elongate rods are surgically attached to vertebrae of the spine to provide support and/or to realign or reposition certain vertebrae. Such rods are secured to vertebrae utilizing bone screws and other spinal implants. In order to reduce the impact of such surgery on the patient, a desirable approach is to insert such implants percutaneously or with surgical techniques that are minimally invasive to the body of the patient.
- Problems arise when implantation tools designed for traditional surgery that is highly invasive are utilized in percutaneous surgery. The tools may be bulky, oversized or have irregular surfaces or protrusions. A projecting actuator arm or fastening member may be useful with respect to the spinal screw implantation process or the rod reduction process, but there is insufficient clearance to use such structure and/or such structure may produce additional invasive trauma which the percutaneous surgery is attempting to avoid.
- A percutaneous procedure also presents a problem with implantation of rods that are elongate and have historically required a long incision and open wound in order to provide for the length of the rod and the space required for the surgeon's hands to manipulate the rod. Such problems are then compounded by the implants and insertion tools used with the rod.
- Consequently, it is desirable to develop apparatuses and techniques that allow for the insertion of bone screws, the insertion and reduction of a rod into the bone screws and the securing of the rod to the bone screws with significantly less invasion into the body of the patient and with minimal surgical incision of the skin over the operational site.
- A tool assembly and a set of tools according to the invention is provided for percutaneously implanting bone screws and an associated spinal rod in a patient. The tool assembly includes an elongate guide tool with implant engaging members and a multi-purpose installation tool. The multi-purpose tool is a stabilizer for the guide tool implant engaging members which also functions as a rod stabilizer tang container and deployer and a rod pusher and reducer. The guide tool has a lower end configured with opposed implant engaging members for releaseable attachment to a spinal implant bone screw, hook, etc. The multi-purpose installation tool is elongate, and preferably includes a translation nut and attached sleeve which has a lower end for engaging and containing the rod stabilizer tang prior to rod insertion and later pushing on the rod for reduction. The translation nut is coaxial and freely rotatable with respect to the sleeve. The nut is configured for rotatable attachment to an upper end of the guide tool. The multi-purpose installation tool sleeve is attachable or securable to the guide tool in a first bone screw implantation orientation and in an alternative second rod pushing orientation. In the first, bone screw implantation orientation, the sleeve is disposed in a fixed, stationary position with respect to the guide tool, with the sleeve substantially surrounding the guide tool and retaining a flexible tang. In the second or rod pushing orientation, the sleeve is slidable along an axis of the guide tool and the nut can be rotated, thereby translating the rod pushing end between a first location substantially spaced from the guide tool end and a second location near the guide tool end for rod reduction.
- The tool assembly may further include a driver having a handle, a guide tool attachment portion and a stem, the stem having an end configured for rotatable engagement with a spinal implant screw. The driver is in coaxial relationship with both the guide tool and the multi-purpose installation tool when the stem is disposed within the guide tool with the guide tool attached to the multi-purpose installation tool. The attachment portion of the driver is configured for rigid attachment to the guide tool, preventing rotation of the driver in relation to the guide tool.
- A tool set according to the invention includes at least a pair of end guide tools. Each end guide tool includes an elongate body having opposed implant engaging members with lower attachment structure adapted for attachment to a respective bone screw. The body has an inner surface defining an elongate and laterally opening channel. Preferably, the guide tool body further defines an elongate opening communicating with the channel and a back wall with a flexible holding structure, the wall and holding structure disposed opposite the lateral opening. The back wall flexible holding structure includes first and second elongate and parallel slits in the lower back wall portion creating a movable tab or tang disposed between the first and second slits. The flexible flap or tang partially defines the elongate channel. Furthermore, during insertion procedures, the tang may be pushed so as to flex, hinge or spring at an upper end thereof and so that a lower end angulates and translates outwardly or to a location lateral relative to a remainder of the back wall, with the channel adapted to receive a respective rod therein. When an end of the rod is inserted in the lower end channel, the tang may be resiliently flexed further outwardly to accommodate the length of the rod while maintaining, containing and stabilizing the rod in a desired position relative to bone screws.
- The multi-purpose installation tool is attachable to the end guide tool in a first, bone screw implantation configuration position and in an opposite second, rod pushing configuration or position. In the first position, an elongate slot or opening in the sleeve of the tool support is aligned with and fixed in adjacent relationship to the channel opening of the end guide tool, with the sleeve of the tool being held adjacent to the back wall portion and retaining the spring tang. In the second, rod pushing position, the end guide tool back wall portion and the tool sleeve opening are fixed in adjacent relationship with the back wall tang portion protrudeable into the tool sleeve opening.
- An intermediate guide tool according to the invention includes an end with opposed first and second implant engaging legs defining a longitudinal pass-through opening, passageway or slot for receiving a rod therethrough. When attached to a multi-purpose installation tool in the first, bone screw implantation orientation, the tool sleeve is disposed in a fixed, stationary position substantially surrounding and supporting both the intermediate guide tool legs. In the second or rod pushing orientation, the sleeve is in sliding relation along an axis of the intermediate guide tool, with the sleeve and associated rod pushing end translatable along the first and second legs between a first location spaced from the intermediate guide tool end and a second location adjacent or near the guide tool end.
- A vertebral support rod implantation kit according to the invention, adapted for use with a plurality of vertebrae, includes a plurality of polyaxial bone screws, each bone screw being adapted for implantation in one vertebra, each of the bone screws having an attachment structure. It is foreseen that the polyaxial bone screws can be cannulated and/or fixed. The kit also includes an elongate rod having first and second ends, the rod sized and shaped to extend between a pair of end bone screws of the plurality of bone screws, which can be fixed, polyaxial and cannulated or not cannulated. The kit further includes a plurality of closure tops with each closure top being sized and shaped to mate with a respective bone screw and capture or retain the elongate rod within a cavity or channel defined by the respective arms of the bone screw. Additionally, the kit includes a pair of end guide tools, and may include one or more intermediate guide tools, each guide tool being attachable to multi-purpose installation tools, as described herein and bone screw drivers, the drivers being configured to be rigidly attached to a respective end guide tool or intermediate guide tool.
- In a method according to the invention, a spinal fixation tool assembly is assembled by first attaching a bone screw head of a spinal implant screw to a mating attachment structure disposed at a first end of an elongate guide tool implant engaging member, the guide tool defining a laterally opening channel and having a second attachment structure disposed at a second end thereof. The guide tool and attached spinal implant screw may then be inserted into a multi-purpose installation tool, the tool having a translation nut, or the like, and a sleeve-like structure. The nut or similar part is rotated or manipulated in a first direction to mate the tool support with the second attachment structure on the guide tool and translate the sleeve or similar surrounding structure to a location near the guide tool first end. Then, a driver is inserted into the guide tool channel, the driver having a handle and a spinal implant screw engagement end. In the illustrated embodiment, the driver is attached to the guide tool at the second attachment structure with the driver engagement end engaging the spinal implant screw. It is foreseen that the guide tool could be attached to the screw and the screw inserted with the driver without the need for additional tools.
- A method according to the invention may also include the steps of inserting the attached driver, guide tool and spinal implant screw into an incision, especially a minimally invasive incision sized to snugly or closely receive the assembled tools and bone screw, and into contact with a vertebra, followed by turning the driver handle. By turning the handle, the driver, the associated tools and the spinal implant screw are rotated as one assemblage or unit, driving the spinal implant screw into the vertebra.
- Further method steps according to the invention include detaching the drivers from the attached guide tool and multi-purpose installation tool, if used, and withdrawing the drivers from the incisions, followed by detaching the multi-purpose installation tools, if used, from the end guide tools and thereby deploying the end tangs. If used, it may also be desirable to detach the multi-purpose installation tools from the intermediate guide tools, if any.
- According to one embodiment of the invention, during rod insertion, a respective multi-purpose installation tool may be utilized for rod reduction and accordingly replaced on each end guide tool with the sleeve opening thereof aligned with the end guide tool flexible wall or tang to allow the tang to remain flexed outward. Then a rod first end may be inserted into an incision through which one of the end guide tools has been inserted, and then guided into a channel of an adjacent end or intermediate guide tool. The rod is then guided into and through all remaining channels with first and second ends of the rod each in contact with a flexible wall or deployed tang of a respective end guide tool with the tangs biasing against the rod ends, and with the rod extending through all associated guide tools. The multi-purpose installation tool sleeve is then utilized as a rod pusher by rotating the nut and sliding the closed end of the sleeve toward the lower guide tool end, the sleeve end contacting the rod and pushing the rod toward the bone screw.
- The attachment structure for joining the guide tool to the bone screw includes radial mating projections and receivers or grooves that allow the guide tool to be twisted on and twisted from the head of the bone screw. For example, an external attachment on the bone screw head can have tapered undercut upper surfaces. Additional attachment structures according to the invention include snap-on/twist off, snap-on/pry-off, slide-on/push-off, snap- or slide-on/slide off, and other combinations. It is foreseen that other attachment structure could be used such as clip-on/clip-off, clip-on/twist-off, snap-on/snap-off, spring-on/spring-off, spring-on/twist-off, set screws, etc. The attachment structure secures the guide tool to the bone screw during insertion of the screw into bone, but allows the tool to release from the bone screw for removal of the tool at the end of the procedure by rotation of the tool about a central axis thereof or by some other mechanism, as described herein.
- Therefore, the objects of the present invention are: to provide a compact tool assembly for supporting and installing bone screws and other implants with minimal surgical invasion to the patient; to provide such an assembly wherein a tool providing support and stabilization for implant engaging members of the assembly during bone screw implantation may also be utilized for deployment of rod containment tangs and as a rod reducer; to further provide a set of tools for implanting a spinal rod for support or alignment along a human spine with minimal surgical invasion of the patient; to provide such a set of tools including a pair of end tool guides for slidably guiding opposed ends of the rod toward end bone screws attached to the end guide tools; to provide such a set of tools including intermediate guide tools for each intermediate bone screw that guide the rod in slots therethrough to respective bone screws; to provide such a set of tools including rod and closure top installation tools for assisting in securing the rod in the bone screws; to provide such a set of tools wherein the guide tools are easily attached to and disengaged from the bone screws; to provide such a set of tools wherein the guide tools, guide tool supports or stabilizers, tang containment and deployment tools, rod reduction tools, bone screw installation tools and closure top installation tools are all easily aligned, positioned, and engaged, if necessary, with respect to the bone screw and are disengaged from the bone screw and other tools in the installation assembly by manual manipulation of the surgeon; to provide a method of implanting a rod into bone screws within a patient with minimal or less surgical invasion of the patient; to provide such a method utilizing the previously described tools for percutaneous implantation of such a rod; and to provide such a set of tools and methods that are easy to use and especially adapted for the intended use thereof and wherein the tools are comparatively inexpensive to produce.
- Other objects and advantages of this invention will become apparent from the following description taken in conjunction with the accompanying drawings wherein are set forth, by way of illustration and example, certain embodiments of this invention.
- The drawings constitute a part of this specification and include exemplary embodiments of the present invention and illustrate various objects and features thereof.
-
FIG. 1 is an exploded front elevational view of a tool assembly according to the present invention showing a driver tool, a multi-purpose installation tool implant engaging member stabilizer sleeve/tang container and deployer/rod pusher and reducer and an end guide tool shown with an attached polyaxial bone screw. -
FIG. 2 is an enlarged front elevational view of an intermediate guide tool of the invention. -
FIG. 3 is an enlarged side elevational view of the intermediate guide tool ofFIG. 2 . -
FIG. 4 is an enlarged rear elevational view of the intermediate guide tool ofFIG. 2 . -
FIG. 5 is an enlarged front elevational view of the end guide tool ofFIG. 1 . -
FIG. 6 is an enlarged side elevational view of the end guide tool ofFIG. 5 . -
FIG. 7 is an enlarged rear elevational view of the end guide tool ofFIG. 5 . -
FIG. 8 is a cross-sectional view of the end guide tool, taken along the line 8-8 ofFIG. 5 . -
FIG. 9 is an enlarged cross-sectional view of the intermediate guide tool, taken along the line 9-9 ofFIG. 2 . -
FIG. 10 is an enlarged cross-sectional view of the intermediate guide tool, taken along the line 10-10 ofFIG. 2 . -
FIG. 11 is an enlarged bottom plan view of the intermediate guide tool ofFIG. 2 . -
FIG. 12 is an enlarged and fragmentary perspective view of a polyaxial bone screw of the invention. -
FIG. 13 is an enlarged and fragmentary front elevational view of the polyaxial bone screw ofFIG. 12 . -
FIG. 14 is an enlarged and fragmentary side elevational view of the polyaxial bone screw ofFIG. 12 . -
FIG. 15 is an enlarged and fragmentary side elevational view of the polyaxial bone screw ofFIG. 12 disposed opposite the side shown inFIG. 14 . -
FIG. 16 is an enlarged top plan view of the polyaxial bone screw ofFIG. 12 . -
FIG. 17 is an enlarged and fragmentary front elevational view of the polyaxial bone screw ofFIG. 12 and the intermediate guide tool ofFIG. 2 , shown at an early stage of a twist-on installation of the intermediate guide tool to the bone screw head. -
FIG. 18 is an enlarged and fragmentary cross-sectional view of the intermediate guide tool and polyaxial bone screw installation, taken along the line 18-18 ofFIG. 17 . -
FIG. 19 is an enlarged and fragmentary cross-sectional view similar toFIG. 18 , showing a later stage of the twist-on installation of the intermediate guide tool to the bone screw head. -
FIG. 20 is an enlarged and fragmentary cross-sectional view similar toFIGS. 18 and 19 , showing the intermediate guide tool installed on the bone screw head. -
FIG. 21 is an enlarged, fragmentary and cross-sectional view, taken along the line 21-21 ofFIG. 20 , showing the intermediate guide tool installed on the bone screw head. -
FIG. 22 is an enlarged front elevational view of the multi-purpose tool shown inFIG. 1 . -
FIG. 23 is a cross-sectional view of the multi-purpose tool taken along the line 23-23 ofFIG. 22 . -
FIG. 24 is an enlarged bottom plan view of the multi-purpose tool ofFIG. 22 . -
FIG. 25 is an enlarged and fragmentary cross-sectional view of a portion of the multi-purpose tool shown inFIG. 23 . -
FIG. 26 is an enlarged and fragmentary side elevational view of the driver shown inFIG. 1 having a handle, a nut fastener and a stem, with the nut fastener being shown in a first, unengaged position. -
FIG. 27 is an enlarged and fragmentary front elevational view of the driver tool similar toFIG. 26 , showing the nut fastener in a second or intermediate position. -
FIG. 28 is an enlarged and fragmentary side elevational view similar toFIG. 27 and further showing a cross-sectional view of the nut fastener, taken along the line 28-28 ofFIG. 27 . -
FIG. 29 is an enlarged cross-sectional view similar toFIG. 23 , showing an early stage of the installation of the multi-purpose tool to the end guide tool (shown in side elevation as inFIG. 6 ). -
FIG. 30 is an enlarged cross-sectional view similar toFIG. 29 , showing the multi-purpose tool installed to the end guide tool (shown in side elevation). -
FIG. 31 is an enlarged cross-sectional view of the multi-purpose tool, taken along the line 31-31 ofFIG. 30 , showing the end guide tool in front elevation. -
FIG. 32 is an enlarged and fragmentary cross-sectional view of the multi-purpose tool similar toFIG. 31 , shown attached to the end guide tool and also showing a sliding engagement stage of attachment to the driver (shown in front elevation). -
FIG. 33 is an enlarged and fragmentary front elevational view similar toFIG. 32 , showing the driver nut fastener in the intermediate position shown inFIG. 27 . -
FIG. 34 is an enlarged and fragmentary front elevational view similar toFIG. 33 , showing the driver in fixed engagement with the guide tool. -
FIG. 35 is an enlarged and fragmentary view similar toFIG. 34 , showing the driver in fixed engagement with the guide tool and with the driver nut fastener shown in cross-section as inFIG. 28 , and the multi-purpose tool shown in cross-section as inFIG. 32 . -
FIG. 36 is a partial and generally schematic cross-sectional view of a patient's spine, showing a thin guide pin installed at a first side thereof and a bone screw tap tool and threaded bore made thereby at a second side thereof. -
FIG. 37 is a partial and generally schematic view of a patient's spine showing a tool assembly according to the invention with attached bone screw being guided toward the threaded bore in a vertebra in an early stage of a process according to the invention. -
FIG. 38 is a partial and generally schematic view of a patient's spine, showing an end guide tool and the multi-purpose tool of the present invention being positioned for use in a process according to the invention. -
FIG. 39 is a partial and generally schematic view of a patient's spine, showing a pair of end tools and a pair of intermediate tools of the present invention being positioned for use in a process according to the invention. -
FIG. 40 is a partial and generally schematic view of a patient's spine, showing a pair of end tools with the flexible tangs containing a rod which has now been inserted and a pair of intermediate tools of the present invention with one of the intermediate tools shown with an attached multi-purpose tool in a rod reduction application and one of the end guide tools shown partially cut-away, illustrating a closure top installation tool disposed within the end tool and cooperating with a bone screw closure member, the tools being utilized in an early stage of rod implantation to guide the rod toward the bone screws. -
FIG. 41 is a partial and generally schematic cross-sectional view of the spine, taken along the line 41-41 ofFIG. 40 , showing an early stage of implanting a rod according to a process of the invention. -
FIG. 42 is a partial and generally schematic view of a patient's spine similar toFIG. 40 , showing cut-away portions of all four tool assemblies, illustrating an intermediate stage of implanting a rod. -
FIG. 43 is a partial and generally schematic view of a patient's spine similar toFIG. 42 , showing cut-away portions of three of the tool assemblies and one assembly without an end tool, illustrating the rod fully installed in all the bone screws. -
FIG. 44 is an exploded front elevational view of an anti-torque tool assembly according to the present invention showing an antitorque tool and a closure top installation tool cooperating with a break-away bone screw closure member. -
FIG. 45 is a bottom plan view of the anti-torque tool shown inFIG. 44 . -
FIG. 46 is a fragmentary and front elevational view of a bone screw with attached break-away closure member and installed rod, and further showing the closure top installation tool ofFIG. 44 with the anti-torque tool. -
FIG. 47 is a fragmentary and front elevational view of a bone screw and anti-torque tool with portions broken away to show a torque driver advancing toward the break-away closure member in a process according to the invention. -
FIG. 48 is a fragmentary and front elevational view of the bone screw and anti-torque tool similar toFIG. 47 , with portions broken away to show a fully installed rod and closure member with the break-away head removed from the top by the torque driver. -
FIG. 49 is an enlarged and fragmentary front elevational view showing an alternative snap- or twist-on and twist-off attachment structure according to the invention on a guide tool and on a cooperating polyaxial bone screw head. -
FIG. 50 is an enlarged and fragmentary front elevational view of the attachment structure shown inFIG. 49 showing the guide tool installed on the bone screw head. -
FIG. 51 is an enlarged and fragmentary view of the attachment structure shown inFIG. 49 with portions removed to show the detail thereof showing an early stage of the snap on installation of the guide tool on the bone screw head. -
FIG. 52 is an enlarged and fragmentary view similar toFIG. 51 showing a later stage of installation of the guide tool on the bone screw head. -
FIG. 53 is an enlarged and fragmentary view similar toFIGS. 51 and 52 showing the guide tool installed on the bone screw head. -
FIG. 54 is an enlarged and fragmentary front elevational view of a polyaxial bone screw shank with a pivotally attached head or receiver and shown with a guide tool, with portions broken away to show the detail thereof, illustrating a second alternative snap-on and pry-off attachment structure according to the invention on a guide tool and on the polyaxial bone screw head, showing and early stage of snap-on installation. -
FIG. 55 is an enlarged and fragmentary view, identical toFIG. 54 with the exception that an intermediate stage of snap-on installation is shown. -
FIG. 56 is an enlarged and fragmentary view, identical toFIG. 54 with the exception that the guide tool is shown fully installed on the bone screw head. -
FIG. 57 is an exploded perspective view of a bone screw having a shank and a head or receiver, the receiver having a third alternative snap-on or slide-on and slide-off or push-off attachment structure according to the invention. -
FIG. 58 is an enlarged front elevational view of the receiver ofFIG. 57 . -
FIG. 59 is an enlarged side elevational view of the receiver and shank ofFIG. 57 shown with a guide tool with cooperating attachment structure. - As required, detailed embodiments of the present invention are disclosed herein; however, it is to be understood that the disclosed embodiments are merely exemplary of the invention, which may be embodied in various forms. Therefore, specific structural and functional details disclosed herein are not to be interpreted as limiting, but merely as a basis for the claims and as a representative basis for teaching one skilled in the art to variously employ the present invention in virtually any appropriately detailed structure.
- With reference to
FIG. 1 , and for example, alsoFIGS. 37 and 40 , reference numeral 1 generally designates a tool assembly according to the present invention andreference numeral 2 generally designates a tool set according to the invention, made up of a number and variety of tool assemblies 1 for use in installing a set ofbone screws 4 into a patient'sspine 6, followed by the installation of an orthopedic spinal rod orlongitudinal member 8 into the bone screws 4 in a process according to the present invention. - The tool embodiment assembly 1 includes an
end guide tool 9 or anintermediate guide tool 10 mated with amulti-purpose installation tool 12 configured to function as a guide tool stabilizer and supporter, a tang container and deployer and a rod pusher and reducer. The tool assembly 1 may further include adriver 14. Aset 2 of the illustrated embodiment includes a pair ofend guide tools 9 and a plurality ofintermediate guide tools 10, which in the illustrated embodiment includes a pair ofintermediate guide tools 10 on each side of a patient'sspine 6, but which can include none, one or manyintermediate guide tools 10 depending upon the particular application, so that oneintermediate guide tool 10 is used for eachintermediate bone screw 4 to which therod 8 is to be attached. - The
driver 14 is used in conjunction with theguide tool 9 and theguide tool 10 to implant bone screws 4 in the patient'sspine 6 and, in particular, invertebrae 16 along thespine 6 as shown inFIG. 37 . Eachend guide tool 9 andintermediate guide tool 10 is configured to cooperate with themulti-purpose installation tool 12 to install therod 8. However, it may be sufficient according to a process of the invention to not utilize themulti-purpose installation tool 12 or to use only onemulti-purpose installation tool 12 in a particular tool set 2, as shown inFIG. 40 .Rods 8 or other longitudinal members are often installed on both sides of thespine 6 during the same procedure. - It is noted that any reference to the words top, bottom, up and down, and the like, in this application refers to the alignment shown in the various drawing figures, as well as the normal connotations applied to such devices, and is not intended to restrict positioning of the assembly 1 or the tool set 2 in actual use.
- The
end guide tool 9 is illustrated inFIG. 1 andFIGS. 5 through 8 . In particular, eachend guide tool 9 has anelongate body 18 that is sized and shaped to be sufficiently long to extend from implantedbone screws 4 through an exterior of a patient'sskin 20 so as to provide an outwardly extending andupper handle portion 22 that allows and provides for gripping by a surgeon during procedures utilizing the tool set 2, with or without an attachedmulti-purpose installation tool 12 and/ordriver 14. - Each of the
end guide tools 9 further includes anintermediate portion 24 and a lowerimplant engaging portion 26 which includes opposed implant engaging members for securing one the implants there between. Eachend guide tool 9 has a substantiallyflat back wall 28 joining a pair of substantially cylindrically shapedside walls back wall 28 provides a flexible holding structure that includes a pair ofparallel slits 34 extending from near thelower handle portion 22 to anend 36 of thetool 9. When pressed upon by arod 8, a flap orflexible tang 38 disposed between theslits 34 in the back wall portion is configured to flex or spring radially outwardly from the bottom and about the top thereof in a deployed position, as is shown inFIG. 6 . The back wall portion flap ortang 38 provides a surgeon with some additional working space and flexibility when working with therod 8 during surgery, so therod 8 can extend beyond the bone screws 4 while remaining under resilient tension produced by outward biasing of the flexible back wall portion so that therod 8 remains in a desired position and under control. Further, the tang orflap 38 also functions to urge therod 8 toward the other tools in the tool set 2, as shown inFIG. 40 and as will be discussed more fully below. - The
upper portion 22 of eachend guide tool 9 includes a laterally or sideways openingchannel 39, forming a U-shaped cross-section, a C-shaped cross-section, a crescent shaped cross-section or the like having a generally elongate and axially extendingopening 40 with a side-to-side width 42. Preferably, thechannel 39 mates with other channel structure described below so as to extend the entire length of theend guide tool 9. Theopening 40 communicates with and forms part of thechannel 39 that opens at anupper end 43 of theguide tool 9 and also opens perpendicularly with respect to a central axis of theguide tool 9 or laterally to one side of theend guide tool 9, thus defining theopening 40. Theopening 40 narrows near theupper end 43 providing aslot 44 having a side-to-side width 45 that is smaller than the side-to-side width 42. Theslot 44 is configured for sliding engagement with arotational locking pin 46 disposed on thedriver 14 and discussed more fully below. Disposed on either side of theslot 44 areco-planar surfaces back wall 28. Thesurfaces back wall 28, provide alignment surfaces when themulti-purpose tool 12 is inserted onto theguide tool 9 discussed more fully below. - The
opening 40 is of substantially constant width through a mid-section 48 of thehandle portion 22, sufficiently wide to receive additional tools and/or a closure top for sideways loading into thechannel 39, as will be discussed below. - The
upper portion 22 also includes an outer helically wound discontinuous guide andadvancement structure 50 disposed on outer surfaces of both of the substantially cylindrically shapedside walls multi-purpose installation tool 12 and thedriver 14, as described more fully below. Theadvancement structure 50 extends from near theintermediate portion 24 to theopen end 43. Theback wall 28 extending between the threadedsides - Extending from the
upper portion 22 and into theintermediate portion 24 of eachend guide tool 9 is an outward facingchannel 51 that has anopening 52 with a side-to-side width 53 that is somewhat smaller than thewidth 42 of theupper handle portion 22, such that thechannel 51 andopening 52 are sized and shaped to receive and allow passage of certain tools and implants, as described below. - Furthermore, a remaining portion of the end guide tool
intermediate portion 24 and thelower portion 26 includes a groove orchannel 55, with an elongate, axially extending and radially outward opening 57, having a side-to-side width 58 that is slightly smaller than thewidth 42 of theopening 40, but larger than theslot width 45 and theopening width 53. Thechannel opening 57 is disposed opposite the flexible tang orflap 38. All of thechannels top end 43 to near the bottom 36 thereof. This passageway provides a continuous open path of non-uniform cross-sectional radius throughout from the top 43 to the bottom 36 thereof that is parallel to an elongate axis A of eachend guide tool 9. As will be discussed more fully below, each end guidetool channel opening 57 is sized and shaped to slidingly receive arespective end 59 of therod 8 therein. It is foreseen that one or all of the channel openings forming the open side that extends from near thetop end 43 to near the bottom 36 of theguide tool 9 may be sized and shaped to receive theend 59 of therod 8. It is also foreseen that therod 8 may be of uniform or non-uniform diameter, regular or uneven surface construction, or smooth or roughened surface finish, and that the channel openings may in turn be sized and shaped to receive such a rod end that may exhibit a greater or smaller width or diameter than at other locations along the rod. - The
slits 34 are spaced in order to have a back wall or flap flex region having a size and shape to allow at least partial passage of arespective end 59 of therod 8 between theside walls rod abutment recess 61 that is sized and shaped for the purpose of bridging therod 8 when theend guide tool 9 is rotated for removal, as described below. However, it is foreseen that other removal means could be used. Theend guide tool 9 also receives aclosure top 62, as will be described below. Still further, near the bottom 36 of each of the end guides 9 on inner surfaces of theside walls advancement structure 64 which may include conventional helically wound V-shaped threads, buttress threads, reverse angle threads, helically wound square threads, or other guide and advancement structure to cooperate with equivalent or mateable structure within the bone screw heads 4 and on theclosure top 62, as also described below. - At the
lower portion 26, the substantiallycylindrical side walls radially extending bevel 66 and substantially cylindricalouter side walls walls respective side walls side walls intermediate portion 24. - As will be discussed more fully below, in addition to increasing the diameter, the
walls facets 70 and co-planar back walls orfacets 71 with thefacets 70 being disposed parallel to thefacets 71, providing for alignment and mating with an interior of themulti-purpose installation tool 12 to ensure that theend guide tool 9 is retained in a selected, non-rotatable position with respect to themulti-purpose installation tool 12 when installed therein. Each of thewalls abutment pin 67 located at an outer surface thereof and near the bottom or end 36. Thepin 67 may serve as a stop for themulti-purpose installation tool 12 as will be described more fully below; however, such a pin stop is not always needed. - Near the end or bottom 36 of each
end guide tool 9, disposed on an inner surface of each of theside walls intermediate guide tool 10 and thebone screw 4. - Each of the
intermediate guide tools 10, specifically illustrated inFIGS. 2 to 4 , have a somewhat similar overall shape when compared to theend guide tools 9 in that both are preferably of the same axial length and width and also have much structure in common; however with certain differences as noted. Eachintermediate guide tool 10 has an overall elongate body 74 with anupper handle portion 76, anintermediate portion 77 and a lowerimplant engaging portion 78 which includes opposed implant engaging members for securing one of the implants there between. In theupper portion 76, the body 74 is generally C-shaped defining a radiallyoutward opening 79 communicating with an elongate and axially extendingchannel 80 defined by arear wall 81 having alower web edge 96 andside walls FIG. 2 , thechannel 80front opening 79 extends parallel to an axis B of the body 74 and has a side-to-side width 85 configured to receive tools and elements described below. - Similar to the
end guide tool 9, theopening 85 narrows near anupper end 87 providing anelongate slot 88 having a side-to-side width 89 that is smaller than thewidth 85. Theslot 88 is configured for sliding engagement with thepin 46 disposed on thedriver 14 and discussed more fully below. Disposed on either side of theslot 88 areco-planar surfaces rear wall 81. Thesurfaces rear wall 81, provide alignment surfaces when themulti-purpose tool 12 is inserted onto theguide tool 10, discussed more fully below. Below theslot 88, the side-to-side opening width 85 is substantially constant through a mid-section 90 of thehandle portion 76, sufficient to receive additional tools and/or a closure top, as will be discussed below. - The upper or handle
portion 76 also includes an outer helically wound discontinuous guide andadvancement structure 93 disposed on outer sides of both of the substantially cylindrically shapedside walls multi-purpose installation tool 12 and thedriver 14 as described more fully below. Theadvancement structure 93 extends from near theintermediate portion 77 to theopen end 87. An outer surface of therear wall 81 extending between the threadedsides - The upper or handle
portion 76 further includes an outward facingchannel 94 communicating with thechannel 80. Thechannel 94 is defined in part by a rear wall orweb 95 having a lower end with theweb edge 96, thewall 95 being integral with thewall 81. Communicating with thechannel 94 is an elongate and axially extendingopening 98 having a side-to-side width 99 that is somewhat smaller than thewidth 85 of theopening 79. Theopening 98 is further defined by thewalls channel 94 andopening 98 are configured to receive, contain and allow translational movement therealong or rotational relative movement of certain tools, as described more fully below. Although not shown in the drawings, it is foreseen that thechannel 94,channel opening 98 and rear wall orweb 95 may extend into theintermediate portion 77 to provide greater strength and stability to thelower portion 78 of theintermediate tool 10, with theopening 98 also extending into thelower portion 78 providing greater retention of small tools or parts being inserted through thechannel 94. - The
intermediate portion 77 of theintermediate tool 10 includes two spaced side walls orlegs side walls legs - Similar to the
end tool 9, at the juncture of theintermediate portion 77 and thelower portion 78, each of thelegs bevel 106 integral with substantially cylindricalouter side walls outer walls lower portion 78 and uniformly increase the thickness of therespective legs lower portion 78 than an outer diameter created by the outer surfaces of thelegs intermediate portion 77. As will be discussed more fully below, in addition to increasing the diameter, thewalls flat surfaces 109 and co-planar rear facets or walls withflat surfaces 110, thefacets 109 disposed parallel to thefacets 110, providing for alignment with an interior of themulti-purpose installation tool 12 to ensure that theintermediate guide tool 10 is properly mated with and retained in a selected, non-rotatable position with respect to themulti-purpose installation tool 12 when installed therein. - Along both the intermediate and
lower portions intermediate tool 10, thelegs passthrough slot 111 sized and shaped to slidingly receive therod 8. The slot or opening extends from the lower edge of theweb end 96 of therear wall 95 to an open end orbottom 112 of thetool 10 configured to secure an open ended spinal surgery implant there between. - Near the
bottom 112 of each implant engagingleg member intermediate guide tool 10 is a helically wound but discontinuoussquare thread 114 and it is foreseen that other type of guide and advancement structure may be utilized such as helically wound flange forms, reverse angle threads, buttress threads, etc. Thethread form 114 cooperates with theclosure top 62, as described below. The lower end of eachleg intermediate guide tool 10 also includes a cutout or rod-abutment recess 116 similar to therecess 61 described with respect to theend tool 9. Each of thewalls abutment pin 118 located at an outer surface thereof and near the bottom or end 112. Thepin 118 may serve as a stop for themulti-purpose installation tool 12 as will be described more fully below. - Also near the end or
bottom 112 of eachleg intermediate guide tool 10, disposed on inner substantiallycylindrical surfaces structure 72 disposed on theend guide tool 9. Thestructure 124 will be described herein in conjunction with thebone screw 4. - With reference to
FIGS. 9-11 , the embodiment shown includes anattachment structure 124 having a first projection, stop orpin 126 in spaced relation with a second smaller projection, stop orpin 127, both pins being disposed on thesurface 120. In the embodiment shown, the structure 123 further includes a cooperating third projection, stop orpin 130 in spaced relation with a fourth smaller projection, stop orpin 131, thepins surface 121. - The larger pins 126 and 130 are substantially configured the same, both being substantially rounded, radially inward projecting nodules, each having a ridge or
lip advancement structure 114 and that preferably follows the curvature of the respective leginner surface - The
lips respective surfaces slots bone screw 4 as will be discussed more fully below. Thepin 126 is configured slightly larger than thepin 130, requiring similar modification in thebone screw 4, resulting in a method of operation wherein thebone screw 4 may only be mated with theguide bone screw 4 and guidetool advancement structure 114 with respect to the installment of theclosure top 62. - Each of the
larger pins end 112 of theguide tool 10 and adjacent a rod-abutment recess 116. Furthermore, each of thelarger pins advancement structure 114. Additionally, in this embodiment thepins FIG. 10 . - The smaller pins 127 and 131 are also substantially configured the same, the
pin 131 being slightly larger than thepin 127, but otherwise bothpins pins FIG. 10 . Each of thepins larger pins guide tool bone screw 4 from a single direction, resulting in a desired alignment between thebone screw 4 guide andadvancement structure 114 and the closure top 62 guide and advancement structure. - The
pins bone screw 4, at a receiver portion, generally identified by thereference numeral 145, of ahead 146 thereof. With reference toFIGS. 12-15 , each of the bone screws 4 further includes a threadedshank 148 attached to thehead 146, theshank 148 for screwing into and seating in avertebra 16 that is part of thehuman spine 6. Thehead 146 includes first andsecond arms rod receiving channel 153 passing therethrough. Each of thebone screw shanks 148 includes anupper portion 154 that extends into thehead 146 and is operationally secured therein, so that thehead 146 is rotatable on theshank 148 until locked in position through engagement with therod 8 under pressure. - The
receiver portion 145 is disposed on outer surfaces of thearms receiver portion 145 ofarm 150 includes a slot or groove 158 communicating with arecess 159 defined in part by aflange 160. Thegroove 158 andrecess 159 open at afront surface 162 of thearm 150 and extend across afacet 163 and into aside surface 164 thereof. With reference toFIG. 21 , thegroove 158 is configured to mate with thelarge pin 126 with thelip 132 extending into therecess 159 and theflange 160 disposed in theslot 134 when theguide tool 10 is attached to thebone screw head 146. The width of theslot 134 is sized to prevent passage therethrough of thepin 126 except by twisting or rotational relative movement therebetween. Thereceiver portion 145 of thearm 150 further includes arounded aperture 165 disposed substantially centrally on a face orfacet 167 of thearm 150, thefacet 167 disposed adjacent to theside surface 163. Theaperture 165 is configured to mate with thesmall pin 127. - Similar to the
arm 150, thereceiver portion 145 of thearm 151 defines agroove 168 communicating with arecess 169 defined in part by aflange 170. Thegroove 168 andrecess 169 open at aback surface 172 of thearm 151 and extend across afacet 173 into aside surface 174 thereof. - Similar to what is shown in
FIG. 21 with respect to thearm 150, thegroove 168 is configured to mate with thelarge pin 130 with thelip 133 extending into therecess 169 and theflange 170 disposed in theslot 135 when theguide tool 10 is attached to thebone screw head 146. Thereceiver portion 145 of thearm 151 further includes arounded aperture 175 disposed substantially centrally on a face orfacet 177 of thearm 151, thefacet 177 disposed adjacent to theside surface 173. Theaperture 175 is configured to mate with thesmall pin 131. - In the embodiment shown, to attach the
bone screw head 146 to theguide tool 10, theguide tool 10 is rotated about its axis B such that thelegs FIGS. 17 and 18 , with thefacets head 146 disposed between theguide tool legs facet 167 adjacent theleg 102 and thefacet 177 adjacent theleg 103, thereby aligning thegroove 158 with thelarge pin 126 and thegroove 168 with thelarge pin 130. Thehead 146 may then be twisted into place as shown by the arrow T inFIGS. 18, 19 and 20 . Thelegs - In order to disengage the
guide tool 9 or theguide tool 10 from thebone screw 4, theguide tool lips recesses end guide tools 9 andintermediate guide tools 10 that have previously twisted on, now twist off of respective bone screws 4. - While a preferred embodiment of the invention has the respective pins of the attachment structure on the guide tools and the grooves on the bone screw heads, it is foreseen that these elements could be reversed in total or part in accordance with the invention. Also, other suitable attachment structure could be used, such as sloped or tapered undercut surfaces on the screw heads that overlap, mate and interlock with radially or linearly projecting structure on or near the ends of the guide tools. Such projecting structure can be snapped on or clipped on and translated up to provide for anti-splay overlapping surfaces. In addition, a groove could be put in the outer surface of the screw head and a fin on the guide tool could snap or slide into the groove.
- In the embodiment shown, the
recesses respective guide tools rod 8 is located in the bone screws 4, theguide tools recess respective guide tool rod 8, thereby allowing theguide tool bone screw 4 and free theattachment structures receiver portion 145 of thebone screw 4 and thereafter be removed after all procedures are complete, as described below. - The
closure top 62 closes between the spaced bone screwarms rod 8 in thechannel 153. The closure top 62 can be any of many different plug type closures. With reference toFIGS. 46-48 , preferably theclosure top 62 has acylindrical body 180 that has a helically wound mating guide andadvancement structure 181. The guide andadvancement structure 181 can be of any type, including V-type threads, buttress threads, reverse angle threads, or square threads. Preferably the guide andadvancement structure 181 is a helically wound flange form that interlocks with a reciprocal flange form as part of a guide andadvancement structure 183 on the interior of the bone screwarms - A suitable locking guide and advancement structure of this type is disclosed in U.S. Pat. No. 6,726,689 from Ser. No. 10/236,123 which is incorporated herein by reference. The helically wound guide and
advancement structures respective guide tools advancement structure 181 of theclosure top 62 and align with the guide andadvancement structure 183 of thebone screw 4 to form a generally continuous helically wound pathway, but does not require locking between theclosure top 62 and thetools closure top 62. - The
guides rod 8, while still outside or partially outside thebone screw 4, toward and into thebone screw head 146. This is especially helpful where therod 8 is bent relative to the location of the vertebra 16 (which is sometimes the case) to which therod 8 is to attach and is not easily placed in thebone screw head 146 without force and the mechanical advantage provided by theguides advancement structures respective tools advancement structure 183 on the insides of the bone screwarms FIG. 42 and pass the closure top 62 therebetween while allowing the closure top 62 to continue to rotate and to continuously apply force to therod 8, so as to aid in seating therod 8 in thebone screw head 146. - Each closure top 62 also preferably includes a break-off
head 186 that breaks from thecylindrical body 180 in a break-offregion 187 upon the application of a preselected torque, such as 95 to 120 inch-pounds. The break-offhead 186 preferably has a hexagonal cross section faceted exterior that is configured to mate with a similarly shaped socket of a final closure driving or torquingtool 190 described below. It is foreseen that different driving heads or other methods of driving the closure top 62 can be utilized with certain embodiments of the invention, such as non-break-off closure top designs. - The present invention is not intended to be restricted to a particular type of bone screw, bone screw closure mechanism, or bone screw and guide tool attachment mechanism. In the present embodiment, a polyaxial
type bone screw 4 is utilized wherein theshank 148 is locked in position by direct contact with therod 8. It is foreseen that the tool set 2 of the present invention can be used with virtually any type of bone screw, including fixed monoaxial and polyaxial bone screws of many different types wherein the head is locked relative to the shank by structure other than in the manner described in the illustrated embodiment. It is also foreseen that the screws could be cannulated. - With reference to
FIGS. 22-25 , themulti-purpose installation tool 12 of the tool assembly 1 of the invention includes anupper translation nut 202 rotatably and free wheelingably attached to a lower guide tool stabilizer orsupport sleeve 204. Thesleeve 204 has an inner substantiallycylindrical surface 205 defining a substantiallyhollow passageway 206 sized and shaped to slidingly receive anend tool 9 or anintermediate tool 10 therein. Alternatively, is foreseen that the sleeve could have an inner and outer planar surface. Thesleeve 204 is elongate and includes a receivingend 207, a substantially cylindricalouter body 208 and a translation nutattachment end portion 210 disposed opposite the receivingend 207. The receivingend 207 not only functions to receive theguide tool sleeve 204, but also as apressing block 218 for contacting the flexible flap orspring tang 38 and as apressing end 207 for contacting therod 8 and translating therod 8 toward thebone screw head 146 when themulti-purpose installation tool 12 is installed on theguide tool - The
cylindrical body 208 further defines a slotted U-shaped or C-shapedchannel 212 that opens radially at anopening 213 and also opens at the receivingend 207 and extends substantially along a length of thebody 208 to alocation 214 spaced from the nutattachment end portion 210. The channel opening has a side-to-side width 216 sized to receive the back wall tang portion orflexible flap 38 of theend guide tool 9 therethrough, when aligned therewith. For example, with reference toFIG. 38 , themulti-purpose installation tool 12 is shown partially removed from anend guide tool 9 and deploying thetang 38 after the bone screw has been inserted. Because of the substantial length of thechannel 212 as defined by thelocation 214 and because of thechannel width 216, themulti-purpose installation tool 12 can be removed, turned 180° and reattached to theend guide tool 9 thereby providing access through thechannel opening 213 for protrusion of the back wall tang portion orflap 38 of theend guide tool 9. Theflap 38 is thus not encumbered or restricted by thetool 12 during the rod pushing application and theflap 38 can be flexed outwardly by a rod 8 (not shown) or other forces, when the devices are assembled in this configuration. - Disposed flush to the
lower sleeve end 207 and rigidly attached to the innercylindrical surface 205 is the solid guide tool alignment and tang/rod pressing block 218. Theblock 218 has a substantially smooth, planar andrectangular surface 220 facing inwardly radially from theinner surface 205. Theblock 218 also follows the curve of thecylindrical surface 220 at asurface 222 thereof. Thus, as shown inFIG. 24 , theblock 218 has a segment shape when observed from a bottom plan view. The term segment used herein is defined as the part of a circular area bounded by a chord and an arc of a circle cut off by the chord. This segment shape of theblock 218 provides a mechanical advantage for compressing theflexible flap 38 flush with theend guide tool 9 and for advancing therod 8 into thebone screw 4 with themulti-purpose installation tool 12 which will be discussed more fully below. - The flat,
rectangular surface 220 provides structure for installing theguide tool multi-purpose installation tool 12. For example, with respect to theguide tool 10, a preferred alignment is that therear wall 81 of thetool 10 be disposed adjacent to thesurface 220 when inserting thetool 10 into themulti-purpose installation tool 12. Then, thetool 10 is slid into themulti-purpose tool sleeve 204, with theblock 218 preventing axial rotation of thetool 10 with respect to thesleeve 204, and resulting in the preferred alignment of theopening 79 and the pass-through slot 11 of thetool 10 and theU-shaped channel 212 of the multi-purpose tool in this application. - With respect to the
end guide tool 9, theblock 218 with theplanar surface 220 provides for the insertion of thetool 9 in a first, installation tang containing position or a second, rod pushing position. When utilizing the assembly 1 of the invention to install abone screw 4, it is advantageous for the flexible back wall portion ortang 38 of thetool 9 to be fully restrained by themulti-purpose installation tool 12 and for thewalls multi-purpose installation tool 12 is inserted onto thetool 9 with theback wall 28 of thetool 9 disposed adjacent to thesleeve surface 220. Then, thetool 9 and thesleeve 204 are attached with theblock 218 preventing axial rotation of thetool 9 with respect to themulti-purpose installation tool 12. This results in the preferred alignment wherein the flexible back wall portion ortang 38 is disposed adjacent to themulti-purpose tool sleeve 204 and contained and disposed opposite theU-shaped channel 212. After thebone screw 4 is installed and it is desired to install therod 8 in two ormore bone screws 4, themulti-purpose installation tool 12 is removed from theend guide tool 9 and replaced thereon with theslot 44 andchannel openings alignment block 218. - The
translation nut 202 of themulti-purpose installation tool 12 is substantially cylindrical in shape and is shown withouter grooves 223 to aid a surgeon in handling themulti-purpose installation tool 12 and rotating thenut 202. Thenut 202 further includes an innercylindrical surface 224 defining an inner substantiallycylindrical passage 226 communicating with thepassage 206 of thesleeve 204. Theinner surface 224 further includes a helical guide and advancement structure as shown by a V-shapedthread 228 that is configured to mate with the guide andadvancement structure 50 of theend guide tool 9 or the guide andadvancement structure 93 of theintermediate guide tool 10. - With reference to
FIG. 25 , the innercylindrical surface 224 extends from an upperopen end 230 of thetranslation nut 202 to anannular seating surface 232 extending radially outwardly and perpendicular to thecylindrical surface 224. As will be discussed more fully below, thesurface 224 with associatedthread 228 is of a length that provides an equivalent translation distance of themulti-purpose installation tool 12, and in particular the tang/rod pressing block 218, with respect to theguide tool pressing block 218 can be used to gradually push therod 8 toward thebone screw 4 for the entire translation distance by rotating thenut 202 which can be continued until the rod is fully seated in the head of the bone screw. - Also with reference to
FIG. 25 , at theannular seating surface 232, thesleeve 204 is in sliding contact with thenut 202. Alower portion 234 of thenut 202 further defines a second innercylindrical surface 236 of greater diameter than thesurface 224. Thesurface 236 has a diameter slightly greater than a diameter of thesleeve 204 and is configured to slidingly receive thesleeve 204 into thenut 202 along thesurface 236. Thenut 202 further defines an annular recess or groove 238 configured to receive apin 240 rigidly fixed to thesleeve 204. Thepin 240 may be accessed for attachment and removal from thesleeve 204 through anaperture 242 disposed in thetranslation nut 202. Thepin 240 slidingly mates with thenut 202 within therecess 238, keeping thenut 202 andsleeve 204 in an attached but freely rotatable relation. - With reference to
FIGS. 26-28 , thedriver 14 of an assembly 1 according to the invention includes ahandle 250, a guide tool fastener ornut 252, and an elongate cylindrical stem orshaft 254 having a lowercylindrical portion 255 integral with a bone screw engager shown as asocket 256. Thesocket 256 is configured to mate with the upper part of thebone screw shank 154. Theshaft 254 with attachedsocket 256 is receivable in and passes through the interior of theguides channel 80 of theguide tool 10. Thelower portion 255 has a slightly smaller diameter than a diameter of the remainder of theshaft 254, this smaller diameter provides for adequate clearance of theportion 254 from the guide andadvancement structures shaft 254 is installed within the interior of therespective guide tools shaft 254 is rigidly attached to thehandle 250 and coaxial therewith. Both thehandle 250 and theguide tool fastener 252 includeouter grooves - The
guide tool fastener 252 is a substantially hollow cylinder disposed in coaxial relationship with thehandle 250 and theshaft 254. The fastener has a threaded innercylindrical surface 262 disposed at alower portion 263 thereof, the threadedsurface 262 configured to mate with the guide andadvancement structure 50 of theend guide tool 9 or the guide andadvancement structure 93 of theintermediate guide tool 10. Thefastener 252 is disposed on thedriver 14 between anannular surface 264 of thehandle 250 and thepin 46 that is fixed to theshaft 254 and extends laterally therefrom. - The
driver 12 further includes alateral pin 266 projecting radially outwardly from acylindrical surface 268 adjacent thehandle 250. In the embodiment shown, thecylindrical surface 268 is integral with thehandle 250 and fixedly attached to theshaft 254. Thepin 266 is disposed within anannular recess 270 defined by thecylindrical surface 268, and surfaces of thefastener 252, including anupper seating surface 272, alower seating surface 274 and an innercylindrical surface 276. Thepin 266 disposed in therecess 270 allows for both rotational and axial or vertical translational movements of thefastener 252 with respect to theshaft 254. Thus, as shown inFIG. 26 , thefastener 252 is rotatable about an axis C. Furthermore, the fastener is slidable along the axis C between theannular surface 264 and thepin 46, withFIG. 26 showing a first or unattached position with thefastener 252 in contact with theannular surface 264 andFIGS. 27 and 28 showing a second, engagement position, with thefastener 252 partially covering, but not contacting thepin 46, with thepin 266 abutting theupper seating surface 272 prohibiting further downward or vertical (axial) translational movement of thefastener 252 with respect to theshaft 254. - As stated previously herein, the
pin 46 is configured for sliding engagement with both theslot 44 of theguide tool 9 and theslot 88 of theguide tool 10 when thedriver shaft 254 is disposed in an interior of theguide tool pin 46 is received in theslot 44 or theslot 88, any relative rotational movement between theguide tool driver 14 is prevented, but the driver is free to slide axially with respect to theguide tool nut 252 is slid into the second position shown inFIGS. 27 and 28 and the fastener is mated with the guide andadvancement structure 50 of theend guide tool 9 or the guide andadvancement structure 93 of theintermediate guide tool 10 by rotating thefastener 252 to a location adjacent to thepin 46, with thepin 266 in contact with theupper seating surface 272, relative axial movement between thedriver 14 and theguide tool - With reference to
FIGS. 1 and 29-35 , a three-component assembly 1 according to the invention including theguide tool 9, themulti-purpose installation tool 12 and thedriver 14 may be assembled as follows: Theguide tool 9 shown with attachedbone screw 4 is inserted into themulti-purpose installation tool 12 with theupper end 43 being inserted into the receivingend 207 of themulti-purpose installation tool 12. With respect to the assembly shown inFIGS. 29-31 , illustrated is a particular assembly wherein themulti-purpose installation tool 12 is being utilized as a support or stabilizer for theend guide tool 9 during installation of thebone screw 4 into thevertebra 16, specifically, to contain and compress thetang 38 and to provide extra support to the walls, such aswalls tool 9. Thus, theguide tool 9 is received into themulti-purpose installation tool 12 with therear wall 28 facing thealignment block 218 as shown inFIG. 29 . - As the
guide tool 9 is received into themulti-purpose installation tool 12, rotational movement is prevented by thealignment block 218 in sliding contact with theflat surfaces 28 of theguide tool 9. Thetranslation nut 202 is then rotated clock-wise as viewed from thetop end 230 and shown by the arrow X, with thethread 50 of theguide tool 9 mating with thethread 228 disposed on theinner surface 224 of thetranslation nut 202. Thetranslation nut 202 is preferably rotated until theupper end 43 of theguide tool 9 is positioned outside of the body of thenut 202 with a few of thethreads 50 exposed as shown inFIGS. 30 and 31 . Furthermore, thesleeve 204 cannot be translated beyond thepin 67 that stops the sleeve near therod abutment recess 61 disposed near the end of theguide tool 9. During rotation of thetranslation nut 202, theguide tool 9 is held in a preferred bone screw installation position and any rotational movement of thetool 9 is prevented by thealignment block 218 in contact with the co-planar back walls orfacets 71 of theguide tool 9 as well as the planar back surface of thetang 38. As illustrated inFIGS. 30 and 31 , when theguide tool 9 is fully installed in themulti-purpose installation tool 12 in this first or bone screw installation position, the flexible back wall portion orflap 38 is compressed and retained in place between theside walls alignment block 218. - When the
multi-purpose installation tool 12 is used as a rod pusher with theguide tool 9 as shown inFIGS. 38 and 41 , themulti-purpose installation tool 12 is preferably used first as an end guide tool stabilizer andtang 38 container, as already described herein, and thus must first be removed by rotating thetranslation nut 202 counter-clockwise until themulti-purpose installation tool 12 is disengaged from theend tool guide 9 thereby deploying thetang 38. Thereafter, themulti-purpose installation tool 12 is removed and replaced on theguide tool 9 with theslot 44 andchannel openings alignment block 218. As themulti-purpose installation tool 12 reinserted onto theguide tool 9, rotational movement is prevented by thealignment block 218 in sliding contact with theflat surfaces guide tool 9. Thetranslation nut 202 is then rotated clock-wise as shown by the arrow X (FIG. 29 ), with thethread 50 of theguide tool 9 mating with thethread 228 disposed on theinner surface 224 of thetranslation nut 202. Similar to what is shown inFIGS. 30 and 31 , thetranslation nut 202 is rotated clockwise as shown by the arrow X, until theupper end 43 of theguide tool 9 is positioned outside of the body of thenut 202 with some of thethreads 50 exposed. During rotation of thetranslation nut 202, theguide tool 9 is held in position and any rotational movement of thetool 9 is prevented by thealignment block 218 in contact with the co-planar front walls orfacets 70 of theguide tool 9. When themulti-purpose installation tool 12 is used in this second or rod pushing position, the flexible back wall tang portion orflap 38 is not obstructed by thesleeve 204 of themulti-purpose installation tool 12 and may spring out or be further pushed out through theopening 213 of theU-shaped channel 212. - An assembly 1 according to the invention may also include the
intermediate guide tool 10 in the place of theguide tool 9 as shown inFIGS. 40-42 . Because theintermediate guide tool 10 includes a pass-throughslot 111 rather than a flexible backwall tang portion 38, the alignment between themulti-purpose installation tool 12 and theguide tool 10 may be the same during bone screw installation as for the pushing of therod 8. Therefore, thetool guide 10 may be inserted into themulti-purpose installation tool 12 with either therear wall 81 or theslot 88 adjacent to and facing thealignment block 218. - Similar to the discussion herein with respect to the
guide tool 9, as theguide tool 10 is inserted into themulti-purpose installation tool 12, rotational movement is prohibited by thealignment block 218 in sliding contact with either therear wall 81 or thecoplanar surfaces guide tool 10. Thetranslation nut 202 is then rotated clock-wise as viewed looking toward the top 87 of thetool 10, with thethread 93 of theguide tool 10 mating with thethread 228 disposed on theinner surface 224 of the translation nut. Similar to what is shown inFIGS. 30 and 31 , thetranslation nut 202 is rotated until theupper end 87 of theguide tool 10 is positioned outside of the body of thenut 202 with some of thethreads 93 exposed. During rotation of thetranslation nut 202, theguide tool 10 is held in position, with rotational movement of thetool 10 being prevented by thealignment block 218 in contact with the co-planar front walls orfacets 109 or the co-planar rear walls orfacets 110 of theguide tool 10. - Further discussion of the assembly 1 in this application will be directed toward the
end guide tool 9 shown in the drawings. Unless specifically stated otherwise, theintermediate guide tool 10 can be utilized in similar fashion to what is being described herein with respect to theend guide tool 9. - With reference to
FIGS. 1 and 32-35 , after installation of themulti-purpose installation tool 12 to theguide tool 9, thedriver 14 is inserted into theguide tool 9/multi-purpose installation tool 12 combination by inserting thesocket end 256 into theend 43 of theguide tool 9 and sliding theshaft 254 into the interior of theguide tool 9 until thesocket end 256 contacts and surrounds the upper part of theshank 154 of thebone screw 4 as shown inFIG. 35 . As theshaft 254 is being inserted into theguide tool 9, thepin 46 on theshaft 254 of thedriver 14 is aligned with and slid into theslot 44 of theguide tool 9. In order to more easily view the pin alignment process, theguide tool fastener 252 is placed in the first or unattached position with thefastener 252 in contact with theannular surface 264 as shown inFIG. 32 . Also as shown inFIG. 32 , preferably, thepin 46 is slid to a position disposed substantially within theslot 44 when thesocket end 256 engages theshank 154 of thebone screw 4. The guide tool fastener ornut 252 is then rotated clockwise as viewed from the handle and illustrated by the arrow Y inFIG. 33 , from the first unattached position toward the second engaged position, mating thethread 50 located near theend 43 of theguide tool 9 with the inner threadedsurface 262 of thenut 252 of thedriver 14. If, after thefastener 252 is rotated to a hand-tightened position, and a gap or space remains between thefastener 252 and thetranslation nut 202, as shown inFIG. 33 , thetranslation nut 202 may then be rotated counter-clockwise as shown by an arrow Z inFIG. 33 , and hand-tightened until thetranslation nut 202 abuts against thefastener 252, as shown inFIG. 34 . The assembly 1 is then fully assembled and may be used to install thebone screw 4 into thevertebra 16 as will be described more fully below. Thereafter, thedriver 14 may be removed by rotating thefastener 252 in a counter-clockwise direction (arrow Z) and sliding theshaft 254 out of themulti-purpose installation tool 12 through theopen end 230. - Another tool used in implanting a
spinal rod 8 is anantitorque tool 300 illustrated inFIGS. 44 and 45 and further shown inFIG. 44 with a closuretop installation tool 302 engaging the break-awayportion 186 of theclosure top 62. The closuretop installation tool 302 includes anupper handle portion 303 and a lower, closuretop engagement portion 304 configured to mate with and rotate theclosure top 62. - The
antitorque tool 300 is also preferably used with a closuretop torquing tool 305, shown inFIGS. 47 and 48 . Thetool 305 is used to torque and set theclosure top 62, so it is snug against therod 8, and thereafter break away the break-offhead 186 in the manner shown inFIG. 48 . Thetorquing tool 305 is preferably in the form of a socket as shown in the drawings to allow for adequate tightening of theclosure top 62 and also ease in removal of the break-offhead 186 as shown inFIG. 48 . - The
antitorque tool 300 includes a tubularhollow shaft 306 that is sized and shaped to be slidably received over theinstallation tool 302 and also thetorquing tool 305. Theshaft 306 has alower end portion 308 that has a pair of diametrically spaced, curved bridges 310. Each of thebridges 310 is sized and shaped to fit over therod 8, shown inFIGS. 47 and 48 . When in place, as illustrated inFIG. 47 , theantitorque tool 300 allows a surgeon to counter torque applied by thetorquing tool 305, when applying torque to and breaking away the break-offhead 186. Theantitorque tool 300 also has anupper handle 316 disposed perpendicular to theshaft 306 and having anopening 318 through which theinstallation tool 302 and thetorquing tool 305 passes in the manner suggested byFIGS. 46-48 . - In use, the previously described tools are utilized to attach one or
more rods 8 to the humanspinal column 6. The procedure is begun by selection of abone screw 4 in accordance with the size of the patient'svertebra 16 and the requirements of the spinal support needed. Bone screws 4 having a rotatable orpolyaxial head 146 are preferred but not required for the procedure, as such allow relatively easy adjustment of therod 8 in thetools tools bone screw 4 is also preferably cannulated so as to be receivable over and guided by aguide pin 355 as discussed more fully below. - A relatively small incision, such as an
incision 350 in theskin 20 is then made for eachbone screw 4 to be used. Preferably, the incisions are sized so as to snugly receive the tools of the invention. Theincisions 350 are stretched into a round shape with a circumference equal to or just slightly larger than themulti-purpose installation tool 12. Theskin 20 is relatively flexible and allows the surgeon to move theincision 350 around relative to thespine 6 to manipulate the various tools and implants, as required. In some cases, two screws can be inserted through one or the same incision. - With reference to
FIG. 36 , a drill (not shown) is utilized to form a first guide bore 366 in avertebra 16 under guidance of non invasive imaging techniques, which procedure is well known and established. The thin pin orguide wire 355 is then inserted in the first guide bore 366. This first guide bore 366 and associatedthin pin 355 function to minimize stressing thevertebra 16 and provide an eventual guide for the placement and angle of thebone screw shank 148 with respect to thevertebra 16. - The guide bore 366 is enlarged utilizing a cannulated drilling tool or tap 360 having an integral or otherwise attached cannulated and threaded
bit 362 with an outer surface sized and shaped to correspond to the size and shape of the chosen threadedbone screw 4. Thedrilling tool 360 cooperates with a cylindrical holder orsleeve 368 having an inner surface in slidable mating arrangement with thetool 360 and being held in a position substantially coaxial therewith. Theholder 368 is sized and shaped to fit within theincision 350 and prevents soft tissues from being rolled up in the threadedbit 362 as it is rotated. Thetool 360 further includes ahandle 370 fixedly attached to thetool 360 located at anend portion 372 thereof and of a size and shape for rotating thebit 362 along thepin 355 and into thefirst bore 366. - With the
pin 355 still in place, the enlargement of the guide bore 366 begins by threading thethin pin 355 through the end of the tap and inserting theholder 368 into the incision until the holder comes into contact with thevertebra 16. Thedrill bit 362 is advanced downward along thepin 355 until thedrill bit 362 comes into contact with thevertebra 16. Thetool 360 is then rotated within theholder 368 using thehandle 370, driving thebit 362 along thepin 355 until a fullsized bore 380 is drilled to a depth desired by the surgeon. During drilling, theholder 368 remains stationary, shielding the surrounding tissue from the rotational movement of thebit 362 andtool 360. - The
tool 360 is then removed by rotating thebit 362 in reverse until thebit 362 is outside thebore 380. Thetool 360 is then removed from theholder 368, followed by the removal of theholder 368 through theincision 350. - Before placing the
bone screw 4 in thevertebra 16, thebone screw 4 is preferably joined to an associatedguide tool multi-purpose installation tool 12, and an associateddriver 14. It is foreseen that the driver can also be cannulated. It is possible, but typically not desirable, to join aguide tool bone screw 4 after the installation of thebone screw 4 to thevertebra 16. There also may be instances wherein it is desirable to join thebone screw 4 to an associatedguide tool installation tool support 12 or thedriver 14 until after thebone screw 4 is installed in thevertebra 16, if at all. Furthermore, it is understood that thedriver 14, cannulated or not, may be used with aguide tool multi-purpose installation tool 12. However, it may be preferable to utilize themulti-purpose installation tool 12 during installation of abone screw 4 into thevertebra 16 as thetool 12 provides some mechanical advantage and aids in preventing inadvertent splaying ofside walls end guide tool 9 andlegs intermediate guide tool 10. - The
attachment structure 124 of theintermediate guide tool 10 is joined to abone screw 4 by first rotating thetool 10 relative to thebone screw 4 so that thelegs FIGS. 17 and 18 , with thefacets head 146 disposed between theguide tool legs facet 167 adjacent theleg 102 and thefacet 177 adjacent theleg 103, thereby aligning thegroove 158 with thelarge pin 126 and thegroove 168 with thelarge pin 130. A slight splaying of thelegs head arms - The
head 146 is then twisted into place by rotating thetool 10 axially in a clockwise direction as shown by the arrow T inFIGS. 18 and 19 . - The twist-on procedure described herein with respect to the
attachment structure 124 of theintermediate tool 10 is also followed with respect to theend guide tool 9attachment structure 72. As previously stated herein, theattachment structure 72 is substantially similar to theattachment structure 124 of theintermediate tool 10, with the only difference being that theend guide tool 9 includes a flexible backwall tang portion 38 rather than the pass-throughslot 111 of theintermediate guide tool 10. - After the bone screws 4 have been attached to the
guide tools multi-purpose installation tool 12 can be attached to each of theguide tools intermediate guide tools 10, themulti-purpose installation tool 12 is preferably installed as follows: Therear wall 81 of thetool 10 is positioned adjacent to thesurface 220 and thetool 10 is inserted into thehollow passage 206 and slid into therod pusher sleeve 204 until theend 87 contacts thetranslation nut 210, with theblock 218 preventing axial rotation of theguide tool 10 with respect to themulti-purpose installation tool 12, and resulting in the preferred alignment of the sleeve slot 11 and theopening 79 of thetool 10 with theU-shaped channel 212 of themulti-purpose installation tool 12. However, because the slot 11 is a pass-through slot, the alignment of theguide tool 10 with respect to themulti-purpose installation tool 12 is not critical to processes according to the invention. Therefore, in most instances therear wall 81 of thetool 10 may also be positioned opposite thesurface 220 upon entry into themulti-purpose installation tool 12. - The
translation nut 202 is then rotated with thethread 228 of thenut 202 mating with thethread 93 of thetool 10. Thenut 202 is rotated in a clockwise direction as illustrated by the arrow X inFIG. 29 until theend 87 is disposed outside of thenut 202 and positioned similar to what is shown with respect to themulti-purpose installation tool 12 andend guide tool 9 assembly shown inFIGS. 30 and 31 . Theabutment pin 118 prevents further rotation of thenut 202 and advancement of thesleeve 204 beyond thepin 118. - As shown in
FIGS. 29-31 , theend guide tools 9 are similarly equipped withmulti-purpose installation tools 12. In order to compress thetang 38 during installation of abone screw 4 into avertebra 16, thetool 9 is received into themulti-purpose installation tool 12 with theback wall 28 of thetool 9 disposed adjacent to thesurface 220. Then themulti-purpose installation tool 12 is slid onto thetool 9 until theend 43 contacts thetranslation nut 202, with theblock 218 preventing axial rotation of thetool 9 with respect to themulti-purpose installation tool 12, and resulting in the preferred alignment wherein the flexible back wall tang portion orflap 38 is disposed adjacent to theguide tool sleeve 204 disposed opposite theU-shaped channel 212. Thetranslation nut 202 is then rotated with thethread 228 of thenut 202 mating with thethread 50 of theend guide tool 9. Thenut 202 is rotated in a clockwise direction as illustrated by the arrow X inFIG. 29 until theend 43 is disposed outside of thenut 202 and positioned as shown inFIGS. 30 and 31 , but not beyond thepin 67. - The
driver 14 is then installed into theguide tool 9 as shown inFIGS. 32-35 and as follows: Thedriver 14 is first prepared for ease of insertion by placing theguide tool fastener 252 in the first or unattached position with thefastener 252 in contact with theannular surface 264 of thedriver 14 as shown inFIG. 32 . Then, thedriver end 256 is inserted into theguide tool 9 at theend 43 with thestem 254 being slid into theguide tool 9 with thepin 46 aligned with thechannel 39 until coming to a stop with thepin 46 disposed in theslot 44 and thebone screw engager 256 in contact with the bone screwupper shank 154. A slight rotation or jiggling of thebone screw shank 148 may be required for the hex socket of thebone screw engager 256 to become positioned in operational engagement with the hex shapedupper shank 154. The guide tool fastener ornut 252 is then moved downward and toward theend 43 and then rotated clockwise as viewed from thehandle 250 and illustrated by the arrow Y inFIG. 33 , mating thethread 50 disposed near theend 43 of theguide tool 9 with the inner threadedsurface 262 of thenut 252 of thedriver 14. Thenut 252 is rotated in this clock-wise fashion and hand-tightened until further translation of thenut 252 along theguide tool 9 is prevented by thepin 266 abutting theupper seating surface 272. - If, after the
fastener 252 is rotated to a hand-tightened position, and a gap or space remains between thefastener 252 and thetranslation nut 202 as shown inFIG. 33 , thetranslation nut 202 is rotated counter-clockwise as shown by the arrow Z inFIG. 33 , and hand-tightened until thetranslation nut 202 abuts against thefastener 252 as shown inFIG. 34 . The assembly 1 is now ready for bone screw installation into thevertebra 16. - The
driver 14 is installed into theintermediate guide tool 10 andmulti-purpose installation tool 12 assembly in steps similar to that described above with respect to theend guide tool 9. - A series of
bone screws 4 are installed in eachvertebra 16 to be attached to therod 8 by inserting each of the assemblies 1 through theskin incision 350 as shown inFIG. 37 . Thescrew 4 is then rotated and driven into the tapped bore 380 with the surgeon holding and rotating the assembly 1 with thedriver handle 250, thereby rotating the entire assembly 1 as one unit until theshank 148 is disposed at a desired depth in the tapped bore 380 of therespective vertebra 16. Preferably, theshank 148, along with thescrew driver 14 are also cannulated to receive thepin 355, providing additional guidance for installation of thebone screw 4 into thevertebra 16. - After a
specific bone screw 4 is installed, thedriver 14 is removed from either theguide tool fastener 252 in a counter-clockwise direction (illustrated by the arrow Z inFIG. 33 ) and sliding theshaft 254 towards theopen end 230 of themulti-purpose installation tool 12, if used, and pulling thedriver 14 out of the assembly 1 by thehandle 250. - With respect to the
end guide tools 9, themulti-purpose installation tool 12, if used, is then removed by rotating thetranslation nut 202 counter-clockwise until thethread 228 disposed on theinner surface 224 of thetranslation nut 202 is disengaged from thethread 50 of thetool 9. Themulti-purpose installation tool 12 is then slid off of thetool 9 deploying theflexible flap 38, as shown inFIG. 38 . If desired at this junction of a process according to the invention, themulti-purpose installation tool 12 many then be rotated 180 degrees and replaced on thetool 9 with theslot 44 and thechannel openings alignment block 218 of themulti-purpose installation tool 12 for a rod pushing application. Thetranslation nut 202 is then rotated clockwise as illustrated by the arrow X inFIG. 29 . In this rod pushing position, theflexible tang 38 is extendible into theU-shaped channel 212 of themulti-purpose installation tool 12. - For each
bone screw 4, an associatedguide tool skin 14, as illustrated inFIG. 39 . Anend guide tool 9 is located at each end of the series ofbone screws 4 and anintermediate guide tool 10 is located on eachintermediate bone screw 4. - In order to install a
rod 8 in two ormore bone screws 4, it may not be necessary to equip eachguide tool multi-purpose installation tool 12. For example, with reference toFIG. 40 , for a particular procedure, it may be desirable to utilize only onemulti-purpose installation tool 12 with a tool set 2 according to the invention. In the process illustrated by theFIG. 40 , themulti-purpose installation tools 12 have been removed from both of theend guide tools 9 and both of theintermediate guide tools 10 after which arod 8 has been inserted and amulti-purpose tool 12 reattached to onetool 10. Some pushing of the rod may be accomplished by just extending a rod or tool down the central channel of theguide tools rod 8. As required by the surgeon, one or moremulti-purpose installation tools 12 may be added or removed at any time during the course of the rod pushing or reducing procedure. - With reference to
FIG. 39 , prior to installation of therod 8, theend guide tools 9 are turned or rotated so thechannels 55 therein face one another and theintermediate guide tools 10 are aligned so the pass-throughslots 111 align with thechannels 55. - With reference to
FIG. 40 , therod 8 has been inserted diagonally through one of theend skin incisions 350 with theadjacent end guide 9 pushed to the side, so that one of the rod ends 59 first passes through theslots 111 in theintermediate guide tools 10 and then into thechannel 55 of one of theguide tools 9. Back muscle tissue separates easily here to allow the upper insertion of therod 8 and can be further separated by finger separation or cutting through one of theincisions 350, if required. - After initial insertion, the remaining
opposed end 59 of therod 8 is positioned in thechannel 55 of theend guide tool 9 that is located next to the insertion point of therod 8. Manipulation of therod 8 in thechannels 55 is aided by the back wall tang portions orflexible flaps 38 of theguide tools 9 which may also be moved like a joy-stick toward or away from each other by the surgeon. Furthermore, once therod 8 is disposed within thechannels rod 8 in place between theend guide tools 9 of thetool set 2. The reason that thetangs 38 are needed is that therod 8 extends beyond the end bone screws 4 and theend guide tool 9 are located on the end bone screws 4. Also, the rod may tend to slip out of one end screw head. When the rod is spaced above the bone screws 4, theguide tools 9 can be manipulated to be spaced farther apart to receive therod 8 therebetween, but as therod 8 nears the bone screws 4, theguide tools 9 can not be manipulated enough to compensate so therod 8 must extend beyond the bodies of theguide tool 9. Therefore, thetangs 38 allow therod 8 to be controlled and positioned outwardly of the end bone screws 8. Moreover, the position of therod 8 is controlled by equal pressure applied by thetangs 38 so that therod 8 extends past the bone screws 4 approximately an equal amount on each side. - Also with reference to
FIGS. 40 and 41 , once therod 8 is positioned in theguide tools multi-purpose installation tool 12 may be utilized to push therod 8 toward thebone screw 4, normally when mechanical advantage is needed to seat therod 8 in the bone screws 4. This is accomplished by rotating thetranslation nut 202 in a clockwise direction (as viewed from above the skin 20), thereby translating thesleeve 204 in a downward direction toward thebone screw 4, with the guidetool alignment block 218 abutting and pushing against therod 8. It is also possible to reduce or realign vertebral bodies by this maneuver. - As shown in
FIG. 40 , it may also be desirable to simultaneously or thereafter push therod 8 toward thescrew 4 of one ormore guide tools top installation tool 302 pushing against a closure top 62 that in turn pushes against therod 8. In particular, aclosure top 62 is placed in the elongate top to bottom channel associated with theguide tools channel opening 40 of theguide tool 9 or alternatively into thechannel 39 through thetop end 43 of theguide tool 9. If theguide tool multi-purpose installation tool 12 attached, the closure top 62 can be placed into the guide tool by side insertion into theU-shaped channel 212. The closuretop installation tool 302 is then inserted into thetop end 43 and through the channels disposed within theguide tool 9, until theengagement portion 304 mates with a cooperating aperture disposed in the break-offhead 186. Theclosure top 62 is then driven or pushed under manual control of the surgeon by use of theinstallation tool 145 toward therod 4. - With reference to
FIG. 42 , near the bottom of theguide tools end 112 of theintermediate tool 10 and the bottom 36 of theback wall 28 ofend guide tool 9, theclosure top 62 engages the helically wound guide andadvancement structures respective guide tools tools 302 and mated closure tops 62 are then rotated, mating the closure tops 62 with associatedguide tools rod 8 and to urge therod 8 downward into thebone screw channel 153. Preferably, thetranslation nut 202 of themulti-purpose installation tool 12 is rotated in a clockwise direction, translating thesleeve 204 and block 218 downwardly slightly in advance or substantially concurrent with the advancement of the closure tops 62, providing additional mechanical advantage for the blockflat surface 222 against therod 8. - With reference to
FIG. 43 , at the bottom of theguide tool top mating structure 181 engages and begins to mate with the guide andadvancement structure 183 on therespective bone screw 4 and continued rotation of thetool 302 drives therod 8 downward and into engagement with the upper part of thebone screw shank 154, so as to snug against and frictionally lock theshank 148 in position relative to thebone screw head 146. - Once all of the closure tops 62 are in final seated position in
respective bone screws 4 and the surgeon is satisfied with the position of all of the elements, such as is illustrated inFIG. 43 , any and allmulti-purpose installation tools 12 are removed by rotating thenut 202 counter-clockwise followed by sliding thesleeve 204 off of theguide tool incision 350. Thereafter, each of theguide tools guide tools recesses 116 straddle therod 8 to allow theattachment structure receiver portion 145 on thebone screw 4. Theguide tool bone screw 4, along thetool 302 and then out of theincision 350. - The
antitorque tool 300 is mounted over each closuretop installation tool 302, utilizing thetool 302 as a guide for re-entry through theincision 350. Theantitorque tool 300 is slid along thetool 302 until thebridges 310 straddle therod 8, preventing axial rotation of thetool 300. As shown inFIG. 46 , the closuretop installation tool 302 is then pulled axially upward away from thebone screw 4 and out of theincision 350. - With reference to
FIG. 47 , the closuretop torquing tool 305 is then inserted into theantitorque tool 300 and engaged with the break-offhead 186. By cooperative use of thetools 300 and 305 a preselected torque is manually applied to the break-offhead 186 which breaks from the closure top 62 as illustrated inFIG. 48 and is thereafter removed, followed by removal of theantitorque tool 300, after which theincision 165 is closed. - With reference to
FIGS. 49-53 , an alternative attachment structure, generally 401, is illustrated. A portion of thestructure 401 is located on a polyaxial bone screw head orreceiver 406 that is pivotally attached to ashank 407. Shown in phantom in the illustrated embodiment, the threadedshank 407 is cannulated, having a smallcentral bore 408 extending an entire length of the shank body. Thebore 408 provides a passage through the shank interior for a length of wire or pin inserted into a vertebra prior to the insertion of the threadedshank body 407, the wire or pin providing a guide for insertion of theshank 407 into the vertebra. - The
attachment structure 401 for holding cooperation between the polyaxial bone screw head orreceiver 406 and aguide tool 410 is also located at alower end portion 411 of theguide tool 410. Thelower end portion 411 has acutout 412 and aninner attachment ledge 413. Theattachment ledge 413 has abody 414 with an upperwardly extending, projection, flange orhook member 415 that follows an inner curvature of theguide tool 410. Thebody 414 extends radially inwardly and is sized and shaped to mate with and set within a tool receiving recess or groove 418 formed on thebone screw head 406. Therecess 418 is sufficiently wide to simultaneously receive both thebody 414 and thehook member 415 in a radially inward direction, as is shown inFIG. 52 . Theattachment 413 is then set by axially raising theguide tool 410 relative to thebone screw 406 so at least part of thehook member 415 is located in an upperhidden recess 420, thereby securing theguide tool 410 to arespective bone screw 406, as shown inFIG. 53 . This locks theguide tool 410 to arespective bone screw 406 and prevents outward splaying of theguide tool 410. This is a snap-on type installation or assembly as seen inFIG. 49 where theleg 411 splays outward during initial placement of theguide tool 410 over thebone screw 406 and then returns to an unsplayed position when theinner attachment structure 413 seats in the receivingrecess 418, as shown inFIG. 52 . - Alternatively, the
guide tool 410 can be rotated approximately 90° about a rotational axis thereof prior to joining with arespective bone screw 406, theattachment structure 413 lowered through the opening between bone screwarms tool receiving recess 418, after which theguide tool 410 is rotated back to the first position shown inFIG. 53 in a twist on type assembly. In some instances theguide tool 410 is rotated somewhat more or less than ninety degrees to make the necessary alignment for removal which depends on the specific construction of the parts. - To remove the
guide tool 410 from thebone screw receiver 406, theguide tool 410 is rotated ninety degrees to align theinner attachment ledge 413 with the opening between bone screwarms attachment structure 413 to disengage from therecess 418. Theguide tool 410 is then pulled axially upward away from thebone screw 406. - With reference to
FIGS. 54-56 , a second alternative attachment structure, generally 430, for holding attachment of a bone attachment structure and a guide tool is illustrated. A polyaxial bone screw head orreceiver 434 with a pivotally attachedbone screw shank 435 is shown cooperating with aguide tool 436 having alower end portion 438 thereof. On thebone screw receiver 434, theattachment structure 430 includestool engaging apertures 440 formed on outer surfaces ofarms receiver 434 during procedures such as bone screw assembly, implantation of theshank 435 into a vertebra, and subsequent procedures, such as rod reduction and closure top installation. The illustratedapertures 440 are substantially circular in cross-section and are disposed opposite one another, each including an upwardly projecting, hiddeninner recess 448 for cooperating with complimentary bone screw holding components of theguide tool 436, discussed more fully below. It is noted that theapertures 440 and the cooperating guide tool holding components may be configured to be of a variety of sizes and locations for attachment to the guide tool along any of the surfaces of thearms - On the
guide tool 436, theattachment structure 430 is disposed at thelower portion 438 and on inner slightly recessedsurfaces surfaces attachment structure 430 includes diametrically opposed projections or pins 460 and 462, extending radially inwardly from thesurfaces pins lip 464 projecting upwardly and away from abottom surface lip 464 partially defines agroove 470 for receiving thebone screw receiver 434. Thegroove 470 is further defined by abase surface 472 and awall 474 that faces theinner surface upper wall 476 is substantially parallel to the base orbottom surface - The
pins opposed apertures 440 of the bone screw head orreceiver 434 with thelip 464 extending into theinner recess 448, when theguide tool 436 is fully installed on thebone screw head 434 as shown inFIG. 56 and described more fully below. While a preferred embodiment of the invention haspins implant engaging structure 430 on theguide tool 436, andapertures 440 on thebone screw head 434, it is foreseen that these elements could be reversed in total or part in accordance with the invention. - In use, before implanting the
bone screw shank 435 in a vertebra, the bone screw head orreceiver 434 is preferably joined to theguide tool 436. It is also possible to join theguide tool 436 to thebone screw receiver 434 after the installation of the bone screw to the vertebra. The cooperatingimplant engaging structure 430 disposed on theguide tool 436 and the head orreceiver 434 is joined by first manually spreading thelegs guide tool 436 onto thebone screw head 434 as illustrated inFIG. 54 . The inwardly projectingpins apertures 440 and the tool is slid downwardly along thehead 434 surface until thepins apertures 440 as shown inFIG. 55 . With reference toFIG. 56 , theguide tool 435 is then pulled upwardly and away from thebone screw head 434, causing thelips 464 to enter therecesses 448. Engagement between thelips 464 and the structure defining therecesses 448 result in a firm attachment that also resists any attempt to spread or splay thelegs - To remove the
guide tool 436 from thebone screw head 434, downward force is first placed on theguide tool 436 by the surgeon to move thelips 464 of the guide toolimplant engaging structure 430 out of theinner recesses 448 of thebone screw head 434. Then a prying tool may be inserted between thelegs legs guide tool 436 to allow the guide tool to slide upwardly along the bone screw head 434 (as illustrated in reverse byFIGS. 56, 55 and 54 ). Theguide tool 436 is then pulled axially upwardly away from thebone screw head 434. - With reference to
FIGS. 57-59 , a third alternative attachment structure, generally 480, for holding a bone attachment, such as the bone screw, generally 482, to a guide or holdingtool 484 is illustrated. The illustratedbone screw 482 includes a head orreceiver 486 hingedly attached to abone screw shank 487. With reference toFIG. 57 , theshank 487 is bottom loaded into thereceiver 486 and then rotated ninety degrees to seat anupper portion 489 of theshank 487 within thereceiver 486 as shown inFIG. 59 . First andsecond arms receiver 486 each include outer substantiallyplanar surfaces 494. Eachouter surface 494 of eacharm top surface 498, the undercut 496 extending along and throughend surfaces 497 of thereceiver 486 and sized and shaped for cooperating with complimentary bone screw holding components of theguide tool 484. The under cut 496 includes a planar surface 500 disposed at an acute angle with respect to asecond surface 501, thesurface 501 being perpendicular to thetop surface 498. - On the
guide tool 484, theattachment structure 480 includes diametrically opposed projections in the form of straight, hook-like ledges 502 extending along inner surfaces of thetool 484 and projecting inwardly and upwardly (operably in a direction away from thebone screw 482 and toward a remainder of the tool 484). The hook-like ledges 502 are sized and shaped to be received in the undercut 496 and be in frictional engagement with the angled surfaces 500. First andsecond set screws 504 rotatably attached to theguide tool 484 are sized and shaped for frictional engagement with thetop surface 498 of thereceiver arms ledges 502 within the undercut 496. - In use, before implanting the
bone screw shank 487 in a vertebra, the bone screw head orreceiver 486 is preferably joined to theguide tool 484. It is also possible to join theguide tool 484 to thebone screw receiver 486 after the installation of the bone screw to the vertebra. The cooperatingimplant engaging structure 480 disposed on theguide tool 484 and the head orreceiver 486 may be joined in more than one way. One option is to manually spread opposed legs orportions 506 and insert theguide tool 484 onto thebone screw receiver 486outer arm surface 494 at a location spaced from thetop surfaces 498, thereby snapping theguide tool 484 onto thereceiver 486 and thereafter pulling theguide tool 484 upwardly and away from thereceiver 486, theguide tool 484 sliding upwardly along an inwardly slopingsurface 507 leading up to the undercut 496 until theledges 502 are received in the undercut 496. Engagement between theledges 502 and the sloped surfaces 500 result in a firm attachment that also resists any attempt to spread or splay thelegs 506. Theset screws 504 may then be rotated and thereby moved into frictional engagement with the top surfaces 498. - Alternatively, the
implant engaging structure 480 on theguide tool 484 may be aligned with the undercut 496 on thereceiver 486, thetool 484 disposed laterally of thebone screw receiver 486. Then thetool 484 may be slid onto thebone screw receiver 486 with theledges 502 in sliding engagement in the surfaces 500 of theundercuts 496 until theledges 502 are fully received in theundercuts 496. To fully engage theledges 502 with the surfaces 500, theguide tool 484 is pulled upwardly and away from thereceiver 486. Theset screws 504 may then be rotated and placed in frictional engagement with the top surfaces 498. - To remove the
guide tool 484 from thebone screw head 434, theset screws 504 are first rotated until thescrews 504 are spaced from the top surfaces 498. Downward force is then placed on theguide tool 484 by the surgeon to move theledges 502 of the guide toolimplant engaging structure 480 slightly out of the undercut 496. Then theguide tool 484 is slid in a lateral direction, out of the undercut 496. - It is to be understood that while certain forms of the present invention have been illustrated and described herein, it is not to be limited to the specific forms or arrangement of parts described and shown. For example, it is foreseen that more than one tool could be used to provide the described functions for the
multi-purpose installation tool 12. It is also possible to use the invention in an open surgical wound. Different types of screw drivers, both cannulated and non-cannulated, can be used with the invention.
Claims (8)
1. A receiver of a pivotal bone anchor assembly that includes at least a shank and a closure top, the receiver being configured to accept a rod that is locked in the receiver via the closure top, the receiver comprising:
a receiver body having a center longitudinal axis, a base, and a pair of upstanding arms extending upwardly from the base to define an open channel for receiving the rod, the open channel opening through front and back outer faces of the receiver body and having lowermost rod seating surfaces defining the bottoms of the arms, the upstanding arms having opposed interior surfaces mateable with the closure top to securely lock the rod within the open channel, side outer faces opposite the interior surfaces, and top side surfaces defining a top of the receiver body;
a first substantially planar outwardly-facing surface formed on both the front and back outer faces of the receiver body; and
a second substantially planar outwardly-facing surface formed into both side outer faces of the upstanding arms,
wherein the second substantially planar outwardly-facing surfaces are perpendicular to the first substantially planar outwardly-facing surfaces and extend upwardly from the bottoms to the top side surfaces of the upstanding arms to form an outer arm periphery defined by at least three planar surfaces.
2. The receiver of claim 1 , wherein the first substantially planar outwardly-facing surfaces extend below the lowermost rod seating surface toward a bottom of the receiver body.
3. The receiver of claim 1 , wherein the first substantially planar outwardly-facing surfaces are parallel with respect to each other and to the center longitudinal axis.
4. The receiver of claim 1 , wherein the second substantially planar outwardly-facing surfaces are parallel with respect to each other and to the center longitudinal axis.
5. The receiver of claim 1 , wherein the top side surfaces remain uncovered when the rod is locked in the open channel by the closure top.
6. The receiver of claim 1 , further comprising a substantially planar facet surface extending between the first substantially planar outwardly-facing surfaces and the second substantially planar outwardly-facing surfaces and from at least the bottoms to the top side surfaces of the upstanding arms to form an outer arm periphery defined by at least five planar surfaces.
7. A pivotal bone anchor assembly comprising the receiver of claim 1 and further comprising the shank extending downward from the receiver body or configured to extend downward from the receiver body.
8. The pivotal bone anchor assembly of claim 7 , wherein the shank further comprises a shank body with a helically wound bone implantable thread.
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US15/868,978 US20180132910A1 (en) | 2004-02-27 | 2018-01-11 | Bone anchor receiver with upstanding planar arms |
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US10/789,149 US7160300B2 (en) | 2004-02-27 | 2004-02-27 | Orthopedic implant rod reduction tool set and method |
US63053604P | 2004-11-23 | 2004-11-23 | |
US10/996,289 US8152810B2 (en) | 2004-11-23 | 2004-11-23 | Spinal fixation tool set and method |
US11/272,508 US9050148B2 (en) | 2004-02-27 | 2005-11-10 | Spinal fixation tool attachment structure |
US13/815,933 US9050139B2 (en) | 2004-02-27 | 2013-03-15 | Orthopedic implant rod reduction tool set and method |
US14/733,222 US9636151B2 (en) | 2004-02-27 | 2015-06-08 | Orthopedic implant rod reduction tool set and method |
US15/481,192 US9924982B2 (en) | 2004-02-27 | 2017-04-06 | Orthopedic implant rod reduction tool set and method |
US15/868,978 US20180132910A1 (en) | 2004-02-27 | 2018-01-11 | Bone anchor receiver with upstanding planar arms |
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US15/867,281 Abandoned US20180146991A1 (en) | 2004-02-27 | 2018-01-10 | Spinal fixation tool attachment structure |
US15/868,978 Abandoned US20180132910A1 (en) | 2004-02-27 | 2018-01-11 | Bone anchor receiver with upstanding planar arms |
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US15/867,281 Abandoned US20180146991A1 (en) | 2004-02-27 | 2018-01-10 | Spinal fixation tool attachment structure |
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US10485588B2 (en) | 2004-02-27 | 2019-11-26 | Nuvasive, Inc. | Spinal fixation tool attachment structure |
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Also Published As
Publication number | Publication date |
---|---|
US20180146991A1 (en) | 2018-05-31 |
US9050148B2 (en) | 2015-06-09 |
US20150142060A1 (en) | 2015-05-21 |
WO2006057837A1 (en) | 2006-06-01 |
US10485588B2 (en) | 2019-11-26 |
US20060069391A1 (en) | 2006-03-30 |
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Legal Events
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