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Publication numberWO1995002372 A2
Publication typeApplication
Application numberPCT/US1994/007791
Publication date26 Jan 1995
Filing date11 Jul 1994
Priority date9 Jul 1993
Also published asUS5584831, US5984922, US6468276, WO1995002372A3
Publication numberPCT/1994/7791, PCT/US/1994/007791, PCT/US/1994/07791, PCT/US/94/007791, PCT/US/94/07791, PCT/US1994/007791, PCT/US1994/07791, PCT/US1994007791, PCT/US199407791, PCT/US94/007791, PCT/US94/07791, PCT/US94007791, PCT/US9407791, WO 1995/002372 A2, WO 1995002372 A2, WO 1995002372A2, WO 9502372 A2, WO 9502372A2, WO-A2-1995002372, WO-A2-9502372, WO1995/002372A2, WO1995002372 A2, WO1995002372A2, WO9502372 A2, WO9502372A2
InventorsDouglas W. Mckay
ApplicantSeptember 28, Inc.
Export CitationBiBTeX, EndNote, RefMan
External Links: Patentscope, Espacenet
Spinal fixation device and method
WO 1995002372 A2
Abstract
A spinal column fixation device is disclosed. Generally, the device contains a pedicle screw (36) that has a first and second end. The first end of the screw has a threaded portion (40) and the second end has a spherical handle (48). Also included will be a clamping apparatus (16) that will clamp onto the spherical handle ends as well as having a receiving portion for placement of interconnecting rods. A novel intra-vertebral body wedge (180) is also included. Further, a method of stabilizing motion of a plurality of involved spinal diseased vertebrae with the spinal column fixation device and wedge, has been claimed.
Claims  (OCR text may contain errors)
I claim:
1. A spinal column fixation device comprising:
- a pedicle screw having a first end and a second end; - clamping means for securing to the second end of said pedicle screw.
2. The device of claim 1 wherein said first end of said screw has a threaded portion, and said second end contains a ball portion, with a nut portion.
3. The device of claim 2, wherein said clamping means comprises:
- a cap portion having an aperture therein; - a bottom portion having an aperture therein;
- a bolt fitted dirough the aperture of the cap and bottom portion;
- and wherein the cap portion contains a cavity portion for receiving said ball portion, and wherein said bottom portion contains a cavity portion.
4. An apparatus for stabilizing the spinal column of a person's back, the spinal column containing a plurality of involved diseased vertebrae and a sacrum, said apparatus comprising: a first sacrum clamping means for clamping to an implanted first sacrum screw in the alae of the person's sacrum, said first sacrum clamping means containing a stabilizing rod; a second sacrum clamping means for clamping to an implanted second sacrum screw in the alae of the person's sacrum, said second sacrum clamping means containing a stabilizing rod; a first vertebrae clamping means for clamping to an implanted first vertebrae screw in the pedicle of an involved vertebrae, said first vertebrae clamping means receiving said stabilizing rod of said first sacrum clamping means; a second vertebrae clamping means for clamping to an implanted second vertebrae screw in the pedicle of an involved vertebrae, said second vertebrae clamping means receiving said stabilizing rod of said second sacrum clamping means.
5. The apparatus of claim 4 wherein said first vertebrae clamping means further contains a stabilizing rod, and wherein said second vertebrae clamping means contains a stabilizing rod, and the apparatus further comprising: a third vertebrae clamping means for clamping to an implanted diird vertebrae screw in the pedicle of an involved vertebrae, said diird vertebrae clamping means receiving said stabilizing rods of said first vertebrae securing means; and a fourth vertebrae clamping means for clamping to an implanted fourth vertebrae screw in the pedicle of an involved vertebrae, said fourth vertebrae clamping means receiving said stabilizing rods of said second vertebrae clamping means.
6. The apparatus of claim 5 wherein said fourth vertebrae clamping means further contains a stabilizing rod, and the apparatus further comprising: a first interconnecting means for interconnecting the stabilizing rod of die fourth and second vertebra clamping means.
7. The apparatus of claim 6 wherein said diird vertebrae clamping means contains a receiving portion, and wherein said apparatus further contains a second interconnecting means for interconnecting the stabilizing rod of d e first and third clamping means.
8. The apparatus of claim 5 wherein said implanted screws contain a first end and a second end, and wherein said first end contains external thread means for threading said implanted screws into the spinal column of the person, and wherein said second end contains a multi-sided member, and wherein said multi-sided nut member has attached thereto a spherical handle end.
9. The apparams of claim 8 wherein said first and second sacrum clamping means, and said first, second, third and fourth vertebrae clamping means comprises:
a cap portion having an aperture therein, and wherein said cap portion has a first and second cavity formed tiierein, said first cavity being formed for receiving said spherical handle ends of said pedicle screws and said second cavity being formed for receiving said stabilizing rods;
a base portion having an aperture therein, and wherein said base portion has a first and second cavity formed tiierein, said first cavity being formed for receiving said spherical handle ends of said pedicle screws and said second cavity being formed for receiving said stabilizing rod;
a bolting member fitted dirough die aperture of said base and said cap, and cooperating with said base and said cap so that said spherical handle end and stabilizing rods are adapted to be received witiiin the mating cavities.
10. The apparams of claim 9 further comprising a third sacrum clamping means for clamping to an implanted third sacrum screw in the pedicle of the person's sacrum, said third sacrum clamping means containing a stabilizing rod; and, a fourth sacrum clamping means for clamping to an implanted fourth screw in the pedicle of die person's sacrum, said fourth sacrum clamping means containing a stabilizing rod.
11. The apparatus of claim 10 wherein said stabilizing rod extending from said third sacrum and fourth sacrum clamping means has a spherical handle end, and wherein said third sacrum and fourth sacrum clamping means comprises: a cap portion having an aperture therein, and wherein said cap portion has a first and second cavity formed therein, said first cavity being to receive said spherical handle end of said pedicle screws and said second cavity being formed for receiving the spherical end of said stabilizing rod;
a base portion having an aperture therein, and wherein said base portion has a first and second cavity formed therein, said first cavity receiving said spherical handle end of said pedicle screws and said second cavity being formed for receiving the spherical end of said stabilizing rod;
a bolting member fitted through the aperture of the cap and base, and cooperating with said cap and base so that said spherical handle end of said pedicle screw and stabilizing rod are adapted to be received witiiin the mating cavities. 12. The apparams of claim 11 further comprising an intra-vertebral body wedge, said wedge containing: a first end having a tapered end increasing in size; a second end having a tapered end increasing in size; and wherein said first end taper and said second end taper meet at a point which forms the greatest widtii of said wedge.
13. The apparams of claim 12 wherein said wedge member contains an opening therein for placement of a bone so that a bone graft may be performed.
14. The apparatus of claim 13 wherein said second end of said wedge contains a threaded aperture for placement of an inserter means for inserting the wedge between the involved vertebrae.
15. A method of stabilizing motion of a plurality of involved spinal diseased vertebrae with a spinal fixation device, die spinal fixation device containing a plurality of pedicle screws, the pedicle screws containing a first and second end, die first end containing thread means and the second end containing a spherical handle end and a multi-sided fastening member, die spinal fixation device further containing a plurality of spherical clamp means for securing onto the spherical handle ends, a plurality of interconnecting rods for interconnecting the ball clamp means, and a wedge member, die metiiod comprising the steps of: a. performing two posterior lateral incisions or one posterior incision on the back of the patient to the area of the involved spinal diseased segments; b. exposing the transverse process of the involved spinal diseased segments; c. dissecting between and lateral to the transverse process of the involved spinal diseased vertebrae so that the nerve roots and die annulus fibrosis are exposed; d. placing a cruciate incision in the annulus fibrosis posterior laterally near the intervertebral foramen; e. removing the gelatinous disc material and cartilage end plate of the involved spinal diseased vertebrae; e. determining die proper size and length of the intra-pedicle screws; f. placing the drill point on the vertebral body at die pedicle starting at the base of the transverse process; g. drilling a bore hole in die pedicle of die involved spinal diseased vertebrae for placement of die pedicle screw; h. rotating the pedicle screw into die bored openings of die involved spinal diseased vertebrae with the wrench; and i. applying a spreader to die pedicle screws so that the disc is opened for discectomy and placement of the wedge member.
16. The method of claim 15, further comprising the steps of: j. selecting the proper length, height, and angle of the wedge member; k. placing a bone in small pieces into the inter-discal space of die involved spinal diseased vertebrae, and in the fenestration of the wedge for intervertebral fusion;
1. inserting the wedge 180 into the inter discal space of the involved spinal diseased vertebrae bilaterally; m. releasing the spreader from die intra-pedicle screws which had been keeping the involved spinal diseased vertebrae separated so that the elasticity of the annulus fibrosis and adjacent tissue lock the wedge between the involved spinal diseased vertebrae.
17. The method of claim 16 further comprising the steps of: n. examining the position of the intra-pedicle screws with an image intensifier; o. placing the spherical clamp means about the spherical handles of die pedicle screws; p. tightening the fastening member so that the spherical clamp means will not slip off the spherical handle of die pedicle screw; q. determine the particular structure arrangement of the interconnecting stabilizing rods; r. cutting the interconnecting stabilizing rods, witii or without spherical balls on the end, to die proper lengtii; s. placing the interconnecting rods into the ball clamp means so that the ball clamp means are linked; and t. tightening the ball clamp means so that the ball clamp means envelopes the spherical handle end and die interconnecting rods.
18. The method of claim 17 wherein the step of placing the drill point on the involved spinal diseased vertebral bodies and drilling a bore hole in die involved spinal diseased vertebral bodies includes: u. placing the drill point on a first and second site of the pedicle of die sacrum; v. placing the drill point on a first and second site of the ala of the sacrum and drilling a bore hole to the first and second site on the ala of the sacrum; w. placing the drill point on a first and second site of the pedicle of die L5 involved spinal diseased vertebral body and drilling a bore hole to the first and second site of the L5 involved spinal diseased vertebral body; x. and, placing the drill point on a first and second site of die pedicle of die second involved spinal diseased vertebral body and drilling a bore hole to the first and second site of die L4 involved spinal diseased vertebral body.
Description  (OCR text may contain errors)

DESCRIPTION SPINAL FIXATION DEVICE AND METHOD

TECHNICAL FIELD

This invention relates to an apparatus for spinal column fixation. More particularly, but not by way of limitation, this invention relates to a mechanical device used to obtain a rigid posterior spinal column fixation in order to obtain a rigid posterior spinal column bony fusion for disabling back and leg pain.

BACKGROUND ART

In one embodiment, the apparatus includes a posterior fixation device which is attached to the involved vertebral bodies. The attachment is made by pedicle screws penetrating into the vertebral body with rigid attachment to ball-and-socket clamps and rods.

The invention also may include a pair of intervertebral metallic or radiolucent wedges inserted into the disc space of the involved vertebrae to increase the stability of the spinal column anteriorly and to avoid breakage of the pedicle screw. Additionally, die application also discloses a method of placing the fixation and wedge device in a posterior lateral approach.

Posterior spinal fusions have been performed on millions of people since at least the early 1900' s. The principle of bony fusion has been and still is stabilization or prevention of motion between two adjacent vertebral bodies.

The most recent attempt to stop motion of the spinal column in order to obtain spinal fusion is internal fixation. One design consist of a series of hooks, rods, screws and wires attached to the lamina or spinous processes to correct deformity or to stabilize the spine.

Another design utilizes screws inserted posteriorly through the pedicle into the vertebral body connecting to plates, rods and clamps to stabilize the two adjacent segments.

The prior art pedicle screw devices have different functions. One function includes the correction of the degenerative curve of the lumbar spine between L3 and SI or traumatic deformities. These devices have the internal purpose of this device is correction of a deformity through two vertebra such as seen in U.S. Patent 4,987,892 to Martin H. Krag, and in U.S.

Patent 5,047,029 to Max Aebi and Robert Mathys, Jr.

Another function includes rigidly fixing the spinal column using a combination of intra- vertebral screws, plates, rods and clamps. In general, see U.S. Patents 4,615,681, 4,648388,

4,655,199 to Steffie; 4,754,326, to Burton; 4,950,269 to Gaines; 4,653,481 to Howland; 4,913,134 to Luque; 4,836,196 to Parke and Weinstein; 4,946,458 to Harms; 5,030,220 to Howland; 4,887,595 to Heinig; and 5,042,982 to Harms.

Another function includes flexible or semi-rigid fixation shown in U.S. Patents 4,913,134 to Luque; and, 4,743,260 to Buttem. The present invention utilizes the rigid posterior fixation device which is attached to the involved vertebral bodies through pedicle screws connected with a series of operably associated ball-and-socket clamps and rods. One such device using a ball connector is seen in U.S. Patent 4,946,458 to Harms. However, the prior art devices include several disadvantages. For instance, many devices were susceptible to breakage, and once breakage occurs, the devices are very difficult to retrieve. Also, the mechanism of clamps and rods is very complicated and difficult for the surgeon to install.

Furthermore, in both the rigid and flexible type of devices, the pedicle screw developed excessive motion and toggle. This in turn would cause the plate to become loose thereby allowing the plate to slide back and forth causing irritation, lack of fixation, and thus failure of fusion. The rigid devices without inter-body fusion or rigid spacer will result in breakage in the screw because of mechanical factors. The greatest portion of the weight of the individual is taken through the vertebral body and disc. The center of motion of the vertebral segments is located in the posterior aspect of the disc. In the lower lumbar spine the greatest amount of motion is flexion and extension of the trunk, therefore, the intervertebral segment motion is mainly to the anterior frontal or posterior backward movement. Rigid posterior fixation is at a mechanical disadvantage because d e forces of weight and motion are anterior to the rigid posterior fixation device. With repetitive motion the device either breaks or becomes loosened. Widi loosening or breakage, the motion will increase leading to more pain and failure.

Sciatica is pain which shoots down the posterior lateral aspect of the leg. Sciatica is caused by impingement or encroachment on the neural elements in the lumbar spine. Recent studies indicate d at intervertebral body fusion is the most effective relief of sciatica. This is because the intervertebral disc is die mechanical center of motion between the intervertebral bodies, and die majority of the body weight of die individual is taken through the vertebral bodies.

Prior art devices are designed and placed in the intervertebral disc comprise several concepts. One is to replace me disc which has been removed with an artificial disc material which can function and behave biomechanically similar to the normal intervertebral disc when inserted in the space. A second includes maintaining the disc height widi no attempt at inter-body fusion. A spacer is placed in after removal of the intervertebral disc.

A diird involves maintaining height and obtaining a fusion with a fenestrated spacer that will contain a bone graft. The fenestrated spacer is placed in directly posteriorly under die neural elements.

This invention solves these problem by combining the wedge insert anteriorly and the rigid posterior fixation device allowing the patient to obtain a solid, rigid fixation. The purpose of the wedge is to obtain anterior stabilization, restoration of intervertebral disc height, normal physiological lumbar lordosis, and intervertebral body bony fusion in the human spinal column. The posterior device stabilizes the mechanical dynamics associated witii posterior forces, and the wedge compensates die forces associated witii the anterior forces.

DISCLOSURE OF THE INVENTION

The invention includes both apparatus and mediod claims to a spinal column fixation device that includes multiple clamping means for clamping onto an implanted screw in the sacrum and involved vertebrae of a patient. The clamping means will also contain a stabilizing rod and a portion to receive a receptacle stabilizing rod from a complementary clamping means. In one embodiment, the invention comprises a first sacrum clamping means for clamping to an implanted first sacrum screw in the pedicle of die person's sacrum, said first sacrum clamping means containing a stabilizing rod. The apparatus will also contain a second sacrum clamping means for clamping to an implanted second sacrum screw in d e pedicle of d e person's sacrum, me second sacrum clamping means containing a stabilizing rod.

The invention will contain a first vertebrae clamping means for clamping to an implanted first vertebrae screw in the pedicle of an involved vertebrae, with the first vertebrae clamping means receiving the stabilizing rod of said first =acrum clamping means. A second vertebrae clamping means for clamping to an implanted second vertebrae screw in die pedicle of an involved vertebrae is also provided, widi the second vertebrae clamping means receiving the stabilizing rod of d e second sacrum clamping means.

In one embodiment, me first vertebrae clamping means further contains a stabilizing rod, and wherein said second vertebrae clamping means contains a stabilizing rod, and die apparatus further comprises a diird vertebrae clamping means for clamping to an implanted diird vertebrae screw in die pedicle of an involved vertebrae, widi die third vertebrae clamping means receiving said stabilizing rods of said diird securing means. Also, a fourth vertebrae clamping means for clamping to an implanted fourth vertebrae screw in die pedicle of an involved vertebrae is furnished, widi the fourth vertebrae clamping means receiving die stabilizing rods of said second vertebrae clamping means.

In one embodiment, me fourth vertebrae clamping means further contains a stabilizing rod, and the apparatus further comprises a first interconnecting means for interconnecting me stabilizing rod of die fourth and second clamping means. The third vertebrae clamping means contains a receiving portion, and die apparatus further contains a second interconnecting means for interconnecting the stabilizing rod of die first and diird clamping means.

The implanted screws contain a first end and a second end, and wherein said first end contains external thread means for threading die implanted screws into die spinal column of the person, and more particularly into die pedicle of die involved vertebra, and sacrum. The second end contains a multi-sided, generally a hexagon, shaped nut member. Further, die hexagon shaped nut member has attached thereto a spherical handle end.

The first, second, diird and fourth sacrum, as well as the first, second, and fifth vertebrae clamping means comprises a cap portion having an aperture therein, and wherein the cap portion has a first and second cavity formed tiierein, the first cavity being formed for receiving the spherical handle ends of die pedicle screws and die second cavity being formed for receiving die stabilizing rods. Also included is a base portion having an aperture therein, and wherein said base portion has a first and second cavity formed tiierein, the first cavity being formed for receiving die spherical handle ends of die pedicle screws and die second cavity being formed for receiving said stabilizing rod. Next, a bolting member fitted dirough the aperture of the base and die cap is included and cooperating with the base and d e cap so that the spherical handle end and stabilizing rods are adapted to be received within the mating cavities.

The stabilizing rod may extend from die third and fourth sacrum clamping means and has a spherical handle end, and die third vertebrae and fourth vertebrae clamping means will comprise a cap portion having an aperture tiierein, and wherein die cap portion has a first and second cavity formed therein, the first cavity being to receive said spherical handle end of die pedicle screws and die second cavity being formed for receiving the spherical end of the stabilizing rod, a base portion having an aperture therein, and wherein the base portion has a first and second cavity formed tiierein, with die first cavity receiving the spherical handle end of die pedicle screws and die second cavity being formed for receiving die spherical end of die stabilizing rod. Also included will be a bolting member fitted dirough die aperture of die cap and base, and cooperating with said cap and base so that the spherical handle end of the implanted screw and stabilizing rod are adapted to be received witiiin the mating cavities.

In the preferred embodiment, die apparatus may further comprise an intra-vertebral body wedge. The wedge will contain a first end having a tapered end increasing in size; a second end having a tapered end increasing in size; and wherein the first end taper and the second end taper converge at a point which forms the greatest widtii of the wedge. The wedge member will contain an opening tiierein for placement of a bone so that a bone graft may be performed. Further, the wedge may contain a threaded aperture for placement of bolting means for placement of an inserter to secure the wedge member for insertion into the discal space in a sagittal plane. The application also discloses a method of stabilizing motion of involved spinal diseased vertebrae with a spinal fixation device, the spinal fixation device containing a plurality of implanted screws, the implanted screws containing a first and second end, die first end containing thread means and die second end containing a spherical handle end, die spinal fixation device further containing a plurality of spherical clamp means for securing onto the spherical handle ends. The device also contains a plurality of interconnecting rods for interconnecting the ball clamp means. Finally, a wedge member is provided for insertion into inter-discal space.

Generally, the metiiod comprises the steps of performing two posterior lateral incisions or alternatively, one posterior incision on the back of the patient to the area of the involved spinal diseased segments. Next, the metiiod will expose die transverse process (Fig. 19, 224) of the involved spinal diseased segments; then, dissecting between and lateral to die transverse process of the involved spinal diseased vertebrae is performed so tiiat the nerve roots (Fig. 19, 216) and die annulus fibrosis (Fig. 18, 210) are exposed. Subsequently, a cruciate incision is placed in the annulus fibrosis (Fig. 18, 210) posterior laterally near the intervertebral foramen; then, the surgeon removes the gelatinous disc material and cartilage end plate of the involved spinal diseased vertebrae. The surgeon then determines die proper size and lengtii of the intra-pedicle screws and die drill point of the drill is placed on die vertebral body at die pedicle starting at the base of the transverse process. A bore hole is then drilled in the pedicle of d e involved spinal diseased vertebrae or sacrum for placement of the pedicle screw. The pedicle screw is tiien rotated into the bored openings of the involved spinal diseased vertebrae witii the wrench; and, d e surgeon applies a spreader to the pedicle screws so tiiat the disc is opened for placement of die wedge member. The metiiod may also include die steps of selecting the proper length, height, angle of the wedge member, and then placing a bone in small pieces into the inter-discal space of die involved spinal diseased segments, and in the fenestration of the wedge for intervertebral fusion prior to insertion of the wedge 180. In selecting the proper wedge member, a test wedge may be first employed on a trial basis in order to insure selection of the correct size, length and angle of the wedge.

Following tiiis step, die wedge is inserted (Figs. 16 and 17A-E) into the inter discal space of die involved spinal diseased vertebrae bilaterally, and die spreader is released which had been keeping the intra-pedicle screws separated tiiereby allowing the elasticity of the annulus fibrosis and adjacent tissue to lock the wedge in inter-discal space.

Subsequent to this step, the position of the intra-pedicle screws is examined with an image intensifier, and die ball clamp means is placed about the spherical handles of die implanted screws. The fastener member (nut) is tightened so that the ball clamp means will not slip off the spherical handle of die implanted screw. The surgeon will then determine die particular structural arrangement of the interconnecting stabilizing rods.

Next, the cutting of the interconnecting stabilizing rods is performed, widi or witiiout spherical balls on the end, to die proper length, and the interconnecting rods are placed into the ball clamp means so that the ball clamp means are linked; and tightening of the ball clamp means is executed so that the ball clamp means encases the spherical handle end and die interconnecting rods. Because of the curved contour of the spinal column, some bending and shaping of the rods may be necessary.

The application also includes a step wherein die process of placing the drill point on the involved spinal diseased vertebral bodies and drilling a bore hole in the involved spinal diseased vertebral bodies includes: placing the drill point on a first and second site of die pedicle of die sacrum; then, placing the drill point on a first and second site of the ala of die sacrum and drilling a bore hole to the first and second site on the ala of the sacrum; then, placing the drill point on a first and second site of the pedicle of die L5 involved spinal diseased vertebral body and drilling a bore hole to the first and second site of die L5 involved spinal diseased vertebral body; and, placing the drill point on a first and second site of die pedicle of die second involved spinal diseased vertebral body and drilling a bore hole to die first and second site of die L4 involved spinal diseased vertebral body.

At this point, completion of the application of the posterior intra-pedicle spinal fixation device is completed. The particular structure arrangement will vary on a case-by-case basis. Thus, the figures of this application show one possible sequence; however, other arrangements will depend on die particular circumstances so that the connections and cross connections can be many different arrangements.

A feature of the present invention includes die ability of using one or two screws on each side of die sacrum. Another feature includes use of triangular cross fixation rods to increase posterior stability. Yet another feature is that when combined with the wedge of die present invention, the device increases stability of the spinal column anteriorly and to avoid breakage of the implanted screws, die wedge creates support in the inter-discal space as well as creating the normal lordosis and increasing stability. Another feature includes fewer moving parts which allows for the clamps to be mechanically cross connected. Another feature consist of the ball in the socket concept which allows for connecting two clamps at variable angles in both a horizontal and vertical plane, depending on die circumstances of each individual patient. The interconnecting stabilizing rods widi a spherical handle end can rotate while in place in the clamping means up and down, as well as laterally relative to the implanted screw.

Still another feature includes die capability of measuring the length of the stabilizing rods during the procedure and cutting the rods to die appropriate length in order to conform to the particular circumstances of the patient. Still yet another feature consist of having less fiddle factor. Another feature consist of having the stem as the weakest point of the implanted screw member which allows for easy removal of me screw if breakage occurs. Put another way, the screw can easily be extracted because the nut and die penettated portion of the screw is still intact.

An advantage of die present invention includes tiiat the device is easy to insert. Another advantage is that the device allows for adjustable tightness of the various securing means. Yet another advantage includes avoiding breakage of screws. Another advantage is tiiat multiple clamps connecting to individually associated intra- pedicle screws allows for variations in the number of connecting rods and the variations in the pattern of interconnection. Still another advantage includes that the lamina and die spinous process are not disturbed which leaves a large area for bone grafting. Yet another advantage of the procedure allows for ease of facet joint fusion. Still anodier advantage consist of the anterior and die posterior rigid fixation and the large bone grafting area achieved by this invention which leads to solid bony fusion. BRIEF DESCRIPTION OF THE DRAWINGS

Figure 1 is an illustration of the spinal column bony elements viewed from the posterior of the human.

Figure 2 is a cross-sectional view of the intra-pedicle screw. Figure 3A is a cross-sectional view of die wrench of die present invention.

Figure 3B is a bottom view of the wrench seen in fig. 3 A.

Figure 4A is an illustration of the main connector clamp of the invention secured to die ball of d e intra-pedicle screw.

Figure 4B is a cross-sectional view of the main connector clamp seen in fig. 4A. Figure 5 is a front view of the main connector clamp.

Figure 6 is a rear view of the main connector clamp.

Figure 7 is a top view of the main connector clamp as seen from the posterior during application.

Figure 8 is a bottom view of the main connector clamp. Figure 9 is an illustration of a modified main connector clamp secured to die ball of the intra-pedicle screw as well as die ball of die connecting rod.

Figure 10 is an illustration of another modified main connector clamp when the invention requires three units connected to one clamp.

Figure 11 is an illustration of a cross connecting clamp. Figure 12 is a cross-sectional view of the cross connecting clamp of figure 11.

Figure 13 is an illustration of a modified cross connecting clamp.

Figure 14 is an illustration of another modified cross connecting clamp.

Figure 15 is a cross-sectional view of the modified cross connecting clamp of figure 14.

Figure 16 is a three dimensional illustration of the intra- vertebral wedge. Figure 17A is an illustration of the top of the wedge seen in figure 16.

Figure 17B is an illustration of one side of die wedge seen in figure 16.

Figure 17C is an illustration of the lateral view of the wedge seen in figure 16.

Figure 17D is an illustration of the second end of die wedge seen in figure 16.

Figure 17E is a cross-sectional view of the wedge seen in figure 16. Figure 18 is a three dimensional illustration of the spinal column depicting two vertebra.

Figure 19 a cross sectional view through the spinal column taken along line A-A.

Figure 20 is an illustration of the wedge inserter device. Figures 21A, 21B, and 21C illustrate the spreader device. Figures 22 A, 22B, and 21C illustrate the compressor device.

BEST MODE OF CARRYING OUT THE INVENTION

Like numbers in the various figures refer to like components throughout the application. Referring to Fig. 1, the spinal column bony elements are depicted. Generally, die sacrum 2 is shown that will have the first sacrum clamping means 4 for clamping to an implanted pedicle screw in die alae of die sacrum 2. The pedicle screw will be described in greater detail later in the application. It should also be noted that the sequence of interconnection of the various clamping means may be adjusted on a case-by-case basis, and as such, Fig. 1 depicts one possible arrangement. Other arrangements of the clamping means is possible.

A stabilizing rod 6 will extend from the clamping means 4. A second sacrum clamping means 8 for clamping to an implanted pedicle screw to d e opposite side, in the alae, of the sacrum may also be provided. The clamping means 8 will have a stabilizing rod 10 extending therefrom. A first vertebrae clamping means 12 for clamping to an implanted pedicle screw to the involved vertebra, which in Fig. 1 is the fifth lumbar vertebra, may also be provided. The first vertebrae clamping means will have connected thereto the stabilizing rod 6, as well as having a stabilizing rod 14 extending therefrom.

A second vertebrae clamping means 16 will be attached to die involved vertebra by means of me pedicle screw, which in Fig. 1 is the fifth lumbar vertebra. The second vertebrae clamping means 16 will have connected thereto the stabilizing rod 10, as well as having stabilizing rod 18 extending therefrom.

A third vertebrae clamping means 20 for clamping to an implanted diird vertebrae screw in the pedicled of an involved vertebra, which in Fig. 1 is the fourth lumbar vertebra. The clamping means 20 will have connected thereto the stabilizing rod 14, as well as having cross stabilizing rod 22 extending tiierefrom. It should be noted tiiat other vertebrae clamping means (not shown) for clamping to other implanted vertebrae screws in the pedicle of otiier involved vertebrae may be provided as deemed necessary by die surgeon. The various clamping means will be interconnected by stabilizing rods. A first interconnecting (or cross-connecting) means 24 for interconnecting the stabilizing rods from me clamping means 16 may also be provided. The first interconnecting means 24 will have connected thereto the stabilizing rod 18, as well as having stabilizing rod 26 and cross stabilizing rod 28 extending therefrom.

The invention will also contain a third vertebrae clamping means 30 for clamping to an implanted third pedicle screw (not shown). The clamping means 30 will be cross attached with die interconnecting means 24 by means of the stabilizing rod 26. This structural connection aids in balancing the distribution of stabilizing forces.

A third and fourth sacrum clamping means 32, 34 for clamping to an implanted third and fourth sacrum alae screw to die sacrum 2 may also be included. The clamping means 32, 34 will be cross attached with the clamping means 20, 24 by means of the cross stabilizing rods 22, 28 respectfully. This cross structural connection aids in balancing the distribution of stabilizing forces.

Referring now to Fig. 2, the screw 36, used in the pedicle of the involved vertebra, sacrum as well as the ala of the sacrum, will now be described. It should be noted tiiat through out the application, the terms screw and intra-pedicle screw will be used interchangeably. The screw 36 will have a first cylindrical end 38 tiiat will have contained tiiereon external thread means 40 for boring into the involved sacrum and vertebra. The thread means will be of standard course thread for cancellus bone.

The thread means 40 extend to d e smooth cylindrical surface 42, that in turn extends to die multi-sided (usually six) nut member 44, which may vary from 3 to 6 millimeters in widtii W. The nut member 44 will then conclude at die stem 46. In the preferred embodiment, the stem 46 will have the smallest outer diameter of die intra-pedicle screw 36 so tiiat the stem will be the weakest point of the screw 36, and therefore, the stem will be the first to break. Also, the stem 46 increases the distance from the clamp to the bone for ease of bone grafting.

The stem 46 extends to the spherical handle end 48 which in the preferred embodiment will be excoriated on its surface and d e actual size of the ball portion will vary between 6 and 12 millimeters.

Referring to Fig. 3A, the wrench 50 of the present invention is illustrated. The wrench 50 will generally comprise a receiving segment 52 that will reciprocally receive the hexagon nut member 44. The wrench 50 will also contain a cavity 54 that is a recess for receiving the spherical handle end 48. The actual wrench handle means 56 for allowing the surgeon to fastened die nut member 44 will be connected to the receiving segment 52. Fig. 3B depicts die bottom view of the wrench 50. Turning now to Fig. 4A, a typical main connector clamp depicted as die vertebrae clamping means 16, which also is seen in the vertebrae clamping means 30, is shown and will be explained in greater detail. The main connector clamp will have cap portion 62 that will have a first end 64 and a second end 66, and wherein the first end 64 has a generally spherical configuration tiiat forms a cavity 68, as better seen in Fig. 4B, that receives the spherical handle end 48.

The second end 66 of die main connector clamp 16 will contain a second cavity 70 that is shaped so as to receive a stabilizing rod 72. The stabilizing rods of this invention can be round, as shown, square or some other configuration. The stabilizing rods may be manufactured out of stainless steel, titanium, or plastic. The cap portion 62 will also contain an aperture 74, as better seen in Fig. 4B, that will receive a bolting member 76, that may have a hexagon nut head 78 and a threaded end portion 80.

The base portion 82 will have a first end 84 and a second end 86, widi die first end 84 having a cavity 88 that will have fitted tiierein a segment of the spherical handle end 48. The second end will also have a cavity 90 that will have a segment of the stabilizing rod 72 fitted therein, as well as an aperture 92 that will have the bolting member 76 fitted therein, as seen in Fig. 4B. The bolting member 76, cap 62 and base 82 cooperate with one another so that the spherical handle end 48 and stabilizing rods are adapted to be received within the mating cavities 68, 88 and 70, 90 and secured together as the bolting member 76,80 threadedly attaches the cap and base together (which can also be seen in Fig. 8). A lock washer, though not shown, may also be employed in order to lock the bolting member in place.

The main connector clamp 16 may have the cap 62 and base portion 82 manufactured generally from steel, but titanium, and/or plastic can also be used.

Referring now to Fig. 5, the front view of the main clamp 16 is depicted. This view depicts die first end 64 of die cap portion 62 and die base portion 82 engaged witii the spherical handle end 48 of the pedicle screw 36, as well as the stabilizing rod 72 which exits from both sides of die main connector clamp 60.

Turning to Fig. 6, the rear view of the main connector clamp 16 is illustrated. This view shows the second end 66 of the cap 62, as well as the second end 86 of die base 82, witii the threaded end 80 of the bolting member 76. It should be noted tiiat the void (widtii) W2 is in place after securing the base 82 and cap 62 together to ease placing the rod 72 in die cavities without difficulties. Turning now to Fig. 7, the top view of the main connector clamp 16, as seen from posterior during application, is illustrated. This figure shows the stabilizing rods 72 operatively attached to die main connector clamp 60. Also, the first end of die cap portion 64 is shown, as well as the second end of die cap 66. Also, die hex nut head 78 is shown. In Fig. 8, the bottom view of the main connector clamp 16 is illustrated. In this figure, the stabilizing rod 72 is shown, as well as the second end 86 of die base portion 82. A cross- section of the intra-pedicle screw stem 46.

The first end of die plate 84 surrounds half of die spherical handle 48 witii a recess around the stem. Thus, because of the contour of the cavity 88 which surrounds the perimeter of the spherical handle 48, when die hex head nut 78 is tightened, the threaded portion 80 will lock the base and cap portion together and beginning moving the base 82 and cap 62 together, which in turn effectively clamps die spherical handle end 48 and stabilizing rod 72 in the respective cavities of the base 82 and cap portions 62. The cavities can be excoriated in order to more easily obtain the proper amount of friction between the cavities and the stabilizing rod 72 and/or spherical handle 48.

Referring to Fig. 9, a modified main connecting clamp 4, which in Fig. 1 is the first sacrum clamping means, is illustrated. The modified clamp 4 will have a cap portion 98 and a base portion 100. The cap 98 will have a first end 102 and a second end 104. The first end will be of general spherical construction and contain an inner cavity 106 (not shown) that is adapted to receive the spherical handle end 48 of die intra-pedicle screw 36. A second cavity 107 is also provided to receive the spherical end 108 of a stabilizing rod 109.

The base portion 100 will also contain a first end 110 and a second end 111 tiiat will have first cavity 112 that will receive the bottom portion of spherical handle end 48. A second cavity 114 is also formed thereon, which will receive the spherical end of a stabilizing rod. The modified clamp 4 connects the ball of the intra-pedicle screw to the connecting rod which in this case has a ball, or spherical handle end. The modified clamp 96 is best utilized in the sacrum as seen in Fig. 1, securing means 4 and 8, but also can be used on die upper vertebral connections if deemed appropriate by die surgeon.

The cap 98 and base portion 100 will be secured togedier by means of the bolting member 116, with the bolting member containing a hexagon head 118 similar to the hex head nut 78. The bolt member 116 will also contain thread means 120. The cap 98 and base portion 100 will contain apertures 122 and 124 respectfully, that will receive the bolt, and aperture 124 will contain internal thread means that will cooperate with the thread means 120 so that as the bolt 116 is threaded into the aperture 124, the base and cap 98 will be joined togedier and will lock the spherical handles 48 and 108. When the hexagon head 118 is tightened, die two halves cover approximately two-thirds of the diameter of the ball 108 of the connecting rod 109 which in the preferred embodiment is excoriated and locks the ball 108 rigidly. Referring now to Fig. 10, an interconnecting type of main connector 24, such as the first interconnecting means 24 of Figure 1, is shown. This type of inter-connector may be utilized when die system of connectors chosen by the surgeon requires three clamp means connected at a particular location. The inter-connector 24 will have the stabilizing rods 18 and 26 connected thereto. Also, the cross-stabilizing rod 28 will be connected, witii the spherical handle end 48 being disposed within the connector 24. The spherical handle 48 and stabilizing rods 18 and 26 will be disposed within the connector 24 by means of the cap portion 126 and the base portion (not shown) being fastened together by the bolting member 128, as previously described.

Fig. 11 depicts another cross connecting clamp 130 that is not necessarily shown in Fig. 1. The cross connecting clamp 130 is utilized to connect a connecting rod to a cross connecting rod. The cross connecting clamp 130 can be at 90 degrees from one cross connecting rod to die otiier. While only the 90 degree situation has been shown, other clamps can be at angles that range from 0 to 90 degrees, with the angles shown in Fig. 1 being 30 degrees and 45 degrees.

In Fig. 11, the stabilizing rod 132 is inserted between the cap portion 134 and the base portion 136. A bolting member 138, with lock waisher 139 and thread means 140, is provided in order to fasten the cap 134 and base 136 togedier as previously described.

A connecting, or stabilizing, rod 142 witii the attached spherical end 144 having been encircled within a first cavity 144 located witiiin the cap, and a second cavity 146 located within the base 136, as depicted in Fig. 12 which is a cross-sectional view of Fig. 11. It should be noted that other rods may have attached thereto, if desired, a spherical end similar to that shown in Figs. 11, 12. The cap will also have a cavity 148 for placement of the stabilizing rod 132, as well as mating cavity 150.

In the embodiment shown in Figs. 11 and 12, when the cap 134 and base 136 are tightened, die cap 134 and base 136 will generally cover two-thirds of the diameter of the ball, and widi die tightening of the bolting member 138, the clamp becomes as rigid as preferred by the surgeon. Due to the posterior application of these devices, die bolting member 138 is tightened from the back of the patient (i.e. the spinal column) which makes for easy application.

Fig. 13 is another alternate cross-connecting clamp 152 which can be used to connect a connecting rod 154 to a second connecting rod 156. Like die otiier clamps previously discussed, the clamp 152 will have a cap portion 156 and a base portion 158, with the cap 156 having a first cavity (not shown) for placement of the rod 154, and a second cavity 160 for placement of the rod 156. The base will likewise contain a cavity (not shown) for placement of the rod 154, and a second cavity 162 for placement of the rod 156.

The bolting member 164 with lock washer (not shown) will be placed dirough apertures in the cap 156 and base portions 158, with the member 164 having thread means 166. The bolting member 164 will have hexagon head 168, as seen in Fig. 14. The cap 156 and base 158 will be attached to one another by means of the bolting member 164 as previously described which will effectively lock the rods 154 and 156 in place.

Turning now to Fig. 15, a cross-sectional view of die alternate cross-connecting clamp 152 taken along line A-A is illustrated. As shown, the rod 154 is continuous therethrough; however, the rod 156 terminates at rod end 170. It should be noted tiiat the embodiments depicted in Figs. 13-15 can be made at 90 degrees as illustrated from one connecting rod to me other or it can be at 45 or 30 degrees, depending on the circumstances and die discretion of the surgeon.

With reference to Fig. 16, a three dimensional view of the intervertebral body wedge 180 is shown. The wedge 180 is generally a rectangidar shaped device made from either stainless steel, titanium, fiberglass, or other suitable material. The height of the device can vary from 6 to 16 millimeters. The widtii of the device can vary from 8 to 16 millimeters. The device is wedged shaped witii varying degrees of taper, from 4 to 20 degrees. All of these various measurements may vary, depending on die needs of die intra- vertebral space. The wedge 180 will comprise a first side 182, second side 184, a top side 186, and a bottom side 188. The top side 186 contains a first angled surface 190 that concludes at second angled surface 192. The bottom side 188 will contain a first angled surface 194 that terminates at the second angled surface 196. The angled surfaces of the top 186 and bottom 188 sides provides for a wedged device. The wedge 180 also contains a first end 198 and a second end 200.

Figs. 17A-17E depicts various views of the wedge 180 which will now be discussed. Fig. 17A is a top view of the wedge 180. As can be seen, the top side 186 contains an opening 202. The opening 202 (also known as the fenestration) is for application of bone grafting, as well as for locking purposes since the bone would sink into die opening 202. Fig. 17B depicts die first end 198 of die wedge 180. The first end 198 will have contained tiiereon a threaded aperture 204. In the preferred embodiment, the first end 198 would be directed posterior in the patient or towards the back of the patient. The threaded aperture 204 is necessary for the application of die inserter means for inserting the device into the intra-vertebral space. In Fig. 17C, the first side 182 is shown. This view depicts die angled surfaces 190 and 194 increasing d e width of the device until die angled surfaces 192 and 196 are intersected thereby creating a tapered end which leads to second end 200. The point at which the sides 190, 192, 194 and 196 intersect represent die greatest thickness of wedge 180. Fig. 17D is die second end 200 of die wedge. As seen, the angled surfaces 192 and 196 causes a tapered effect of the wedge at die second end 200. In Fig. 17E, a cross-sectional view taken along line A-A is illustrated. Thus, the first end 198 contains the threaded aperture 204, while the wedge 180 contains the opening 202. The second end is represented at 202.

Turning now to Fig. 18, a three dimensional view of the spinal column depicting two vertebra is illustrated. The Fig. 18 depicts die position of the intra-vertebral wedge 180 in position in the spinal column. The wedge 180 is in place between a first anterior vertebral body 206 and a second anterior vertebral body 208. Also depicted is the posterior longitudinal ligament and annulus fibrosis 210, the pars intra-articularis, part of the lamina, which is a bone extending from one vertebra and connects one vertebrae bone to the next 212, and the intra-vertebral foramen 214 which is the hole between each segment of the spine or vertebra that allows for the passage of the nerve roots and die presence of arteries, veins, and fat.

In Fig. 19, a horizontal view through the spinal column at the level of the intra-vertebral disc, generally at line B-B of Fig. 18, is shown. The purpose is to show the position of the wedges 180 (as seen here, two wedges have been employed) in the disc in a horizontal view of the intra-vertebral view. The wedges 180 converge anteriorly, but do not touch one another. The wedges 180 diverge posterior so that the wedges 180 can be inserted lateral to the nerve roots 216.

The lamina 218, die spinous process 220 which projects posterior of the vertebral column, the spinal cord 222, die transverse process 224, and die nerve root 216 passing out through the intra-vertebral foramen and it progresses anteriorly and inferiorly in front from the spinal column.

Referring to Fig. 20, wedge inserter 240 is shown. The inserter 240 has a generally cylindrical surface 242 tiiat terminates at the radial collar surface 244, with the surface 244 extending to second cylindrical surface 246 tiiat in turn will terminate at radial collar surface 248.

The collar surface will have attached tiiereto die external thread means 250; the thread means 250 will mate and cooperate with die threaded aperture 204. The inserter 240 also has handle means

252 that extends from die cylindrical surface 242.

The spreader device 254 is shown in Figs. 21A, 21B and 21C. The spreader device has a first prong 256 and second prong 258, with prongs 256 and 258 having generally curved surfaces tiiat extend to aperture 260 tiiat has fitted tiierein a connector pin 262. The prongs will have at one end jaw means 264 and 266, respectively, as seen in Fig. 21B. The jaw means will contain a notched groove 268 and 270 tiiat will be sized so tiiat the notched grooves 268 and 270 fit and cooperate with the stem 46 of the screw 36.

As seen in Fig. 21A, the spreader device has a threaded separating screw 272 that will have contained thereon an external thread. The separating screw 272 fits through a slotted opening 274 in the prong 256. A fastening nut 276 will be provided so that when the spreader device 254 is in use, the nut keeps a constant force applied to die jaw means 264 and 266. Thus, when the correct amount of spreading force has been applied, die fastening nut can be applied in order to fix the jaw means 266, 264 in a static position. Also, as seen in Fig. 21C, a lateral view of the prong 256 depicts die jaw means 264 along with pin 262 and die opening 274 for placement of the separating screw 272.

In Fig. 22A, a compressor device 278 is depicted. The compressor device 278 will contain a first prong 280 and a second prong 282 that will contain jaw means 284 and 286, widi the jaw means 284 and 286 containing notched grooves 288 and 290, respectively, (as seen in Fig. 22B) that will engage and cooperate with the stem 46 of the screw 36 in a manner similar to the spreader device 254, except jaw means 284 and 286 will apply a compressive force relative to two implanted screws 36. The compressor device 278 will contain a torsion spring 292 that will have fitted therein a stem 294 that will be attached to the prong 280, and the stem will be fitted dirough the slotted opening 296. A fastening nut 298 will be provided such tiiat the surgeon may set the desired force that jaw means 284 and 286 will be urged together by the torsion spring 292. Fig. 22C shows the lateral view of prong 280 which depicts die curved end 300 as well as the jaw means 284.

OPERATION:

The surgical procedure is done bilaterally through two posterior lateral incisions or one posterior incision, exposure is carried out to the transverse process (Fig. 19, 224) of the spinal diseased segments. Gentle dissection between and lateral to the transverse process exposing the nerve roots (Fig. 19, 216) and die annulus fibrosis (Fig. 18, 210) is carried out in order to expose and visualize the nerve root, disc, vessels and intervertebral foramen.

The intervertebral foramen is enlarged, if necessary (Fig. 18, 214) by cutting away bone of the superior facet of the lower vertebra increasing the space and soft tissue around the nerve roots. A small cruciate incision is made in the annulus fibrosis (Fig. 18, 210) posterior laterally near the intervertebral foramen. The gelatinous disc material and cartilage end plate is removed (discectomy) to die vertebral bodies witii a pituitary rongeur and a bone burr. This procedure is performed bilaterally down to firm bone but does not cut dirough the surface of the vertebral body.

At this point in the procedure the intra-pedicle screws are placed in posteriorly for posterior stabilization. The pedicle screws are applied under image intensifier control. The drill point is placed into the vertebral body dirough die pedicle starting at the base of the transverse process. The proper size and length of the intra-pedicle screws are then determined.

Next, the pedicle screw is rotated into the bored opening with the wrench. The pedicle screws are placed in the lumbar vertebral bodies bilaterally which needed fixation, which generally is either the pedicle of die fourth, fifth or first sacral vertebra. Two to four screws are placed into the sacrum at the discretion of die surgeon. A spreader is applied to the intra-pedicle screws and the disc is opened to the limits of strong annulus fibrous. 14. The wedge 180 is pre- measured for length, height, and angle of the wedge. Bone is taken in small pieces and placed into inter-discal space prior to insertion of the wedge 180. Small pieces of the bone are placed in the fenestration of the wedge for intervertebral fusion. The pre-measured wedge 180 (Figs. 16 and 17A-E) is inserted bilaterally as seen in Figs.

18 and 19. As noted earlier, a temporary wedge may be placed witiiin the discal space in order to aid in determining die exact size needed.

The distraction (spreader) on die intra-pedicle screws is released and die elasticity of the annulus fibrosis and adjacent tissue lock the wedge in solidly. The angled shape of the wedge 180 prevents retropulsion which is dangerous to the neural elements. Anterior extrusion of the wedge is prevented by the annulus fibrosis, anterior longitudinal ligament and die locking effect of the compression on the fenestrated wedge.

After the intra-pedicle screws are in place, the position is checked witii the image intensifier and a direct visual check. Next, the ball clamp is placed about the spherical handles of the pedicle screw. The fastening member (nut) is tightened so tiiat the ball clamp will not slip off the ball of the pedicle screw.

The particular structure arrangement will vary on a case-by-case basis. Thus, the figures of this application show one possible sequence; however, other arrangements will depend on die particular circumstances so that the connections and cross connections can be many different arrangements.

Once the plan is decided upon, the stabilizing rods, widi or without spherical balls on the end, are cut to die proper length. Next, the rods are slipped into the clamps. Then, the compressor device 278 is applied to die intra-pedicle screws of two adjacent vertebra, and die screws are thereafter compressed witii device 278. Next, die nuts of die clamping devices are tightened. At this point, completion of die application of the posterior intra-pedicle spinal fixation device is completed.

Changes and modifications in the specifically described embodiments can be carried out without departing from the scope of the invention which is intended to be limited only by the scope of the appended claims.

Patent Citations
Cited PatentFiling datePublication dateApplicantTitle
US5030220 *29 Mar 19909 Jul 1991Advanced Spine Fixation Systems IncorporatedSpine fixation system
US5084049 *8 Feb 198928 Jan 1992Acromed CorporationTransverse connector for spinal column corrective devices
US5196013 *2 Nov 199023 Mar 1993Harms JuergenPedicel screw and correcting and supporting apparatus comprising such screw
Referenced by
Citing PatentFiling datePublication dateApplicantTitle
WO1998044859A13 Apr 199815 Oct 1998Stryker France SaDevice for backbone osteosynthesis with offset intervertebral fixing rod
US646827610 Sep 199922 Oct 2002Mckay Douglas WilliamSpinal fixation device and method
US790985726 Mar 200822 Mar 2011Warsaw Orthopedic, Inc.Devices and methods for correcting spinal deformities
US90114981 Feb 201121 Apr 2015Warsaw Orthopedic, Inc.Devices and methods for correcting spinal deformities
US901738814 Sep 200628 Apr 2015Warsaw Orthopedic, Inc.Methods for correcting spinal deformities
Classifications
International ClassificationA61B17/86, A61B17/70, A61B17/88
Cooperative ClassificationA61B17/7005, Y10S606/90, A61B17/7037, A61B17/7077, A61B17/7041, A61B17/7055, A61B17/86
European ClassificationA61B17/88S, A61B17/70B1C2, A61B17/70G, A61B17/70B5B, A61B17/70T2B
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