Abstract:
A method of determining the size and/or placement of a prosthetic disc in a disc space between adjacent endplates of two vertebrae in a selected spinal area, comprising: using a computer to identify the disc space parameters of height, width, depth and lordosis between the adjacent vertebral endplates; using a computer to create an artificial volume corresponding to an actual prosthetic disc that can be positioned in the disc space in accordance with a manufacturer&#39;s size and lordosis specifications for prosthesis; using a computer to determine the center of the disc space and the center of rotation of the prosthetic disc volume; using a computer to position the prosthetic disc volume in the disc space such that the center of rotation of the prosthetic disc volume is positioned posterior to the center of the disc space; and using a computer to determine the prosthetic disc volume that fits within the disc space in accordance with a surgeon&#39;s or manufacturer&#39;s specification for prosthesis.

Description:
CROSS REFERENCE TO RELATED APPLICATION  
       [0001]     This application claims the benefit of U.S. Provisional Patent Application No. 60/816,882 filed on Jun. 28, 2006. 
     
    
     BACKGROUND OF THE INVENTION  
       [0002]     1. Field of the Invention  
         [0003]     The present invention relates to the templating and placement of prosthetic intervertebral discs and, more particularly, to new and improved apparatus and methods for enabling a physician to select the optimal size of a prosthetic disc and to position it accurately between vertebrae to optimize its dynamic function.  
         [0004]     2. Description of the Background Art  
         [0005]     The degeneration of human intervertebral discs is increasingly being treated with prosthetic intervertebral discs. The critical parameters for a successful surgical outcome are appropriate templating and placement of the prosthetic disc during artificial disc replacement spine surgery. For templating, the critical parameters are height, width, depth and lordosis. For placement, there are different approaches of placing these artificial discs. Specifically, they can be placed anteriorly, laterally or posteriorly. The most common of these approaches is the anterior approach. A critical component of positioning of the prosthetic disc is the anterior-posterior position as this determines the center of rotation through the prosthesis and hence its dynamic function. If the prosthesis is placed anterior to the center of the disc space then the prosthesis will essentially function as a rigid device. Ideal placement of the prosthesis requires its instantaneous center of rotation to be in the posterior one-third of the disc space posterior to the center of the actual disc space. Templating of appropriate artificial disc implant size selection is often finalized at time of surgery. Subsequent placement of the prosthetic disc is aided by fluoroscopic or other image guidance.  
         [0006]     To date many of the proprietary templating and placement systems and methods are manually determined by the surgeon at the time of surgery. As of yet, no apparatus or system is available which will automatically determine the ideal height, width, depth and lordosis or actual placement of an artificial intervertebral disc prosthesis.  
       BRIEF SUMMARY OF THE INVENTION  
       [0007]     The present invention will automatically generate a table providing the height, width, depth and lordosis of both the actual disc space and an individual prosthetic or artificial disc, and will also generate a schematic diagram illustrating this data for individual intervertebral disc spaces, This method in effect establishes two dimensionally true different volumes. Specifically, it creates the actual volume of the disc space and then also incorporates the volume created by the prosthetic disc. The volumes are displayed individually and merged together to allow the surgeon to determine ideal prosthetic disc selection. A key feature of the merged volume image is center of rotation coordinates within these volumes to assure ideal prosthetic implant size and position to optimize dynamic function through the prosthetic disc range of motion. This data can then be utilized by the surgeon for actual prosthetic disc replacement by one of four methods: 1. Method A: manual artificial disc placement by the surgeon&#39;s preferred method; 2. Method B: utilize pedicle base circumference outline method combined with intraoperative fluoroscopy; 3. Method C: automated prosthetic disc placement using a two ring aligning apparatus and drill guide method; and 4. Method D: with any commercially available registration software (e.g., computed tomography/fluoroscopy, etc). These methods are embodied in the present invention.  
     
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0008]      FIGS. 1   a  and  1   b  are three dimensional computer images of the side and back, respectively, of the bony spine made from CT, MRI or other studies of the spine area of interest;  
         [0009]      FIG. 2  illustrates three dimensional computer images of individual vertebra undergoing a manual eggshell corpectomy from the spine area shown in  FIG. 1   a  and  FIG. 1   b;    
         [0010]      FIG. 3  is a schematic coronal elevational view of two adjacent vertebrae and the disc space therebetween.  
         [0011]      FIG. 4  is a schematic sagittal elevational view of the vertebrae shown in  FIG. 3 ;  
         [0012]      FIG. 5  is a schematic transverse plan view of the upper vertebra shown in  FIGS. 3 and 4 ;  
         [0013]      FIG. 6  is a schematic perspective view of a prosthetic disc positioned within the disc volume between the adjacent vertebrae shown in  FIGS. 3, 4  and  5 ;  
         [0014]      FIG. 7  is a schematic coronal elevational view of the vertebrae shown in  FIGS. 3-5  with the prosthetic disc of  FIG. 6  positioned therebetween;  
         [0015]      FIG. 8  is a schematic sagittal elevational view of the vertebrae and prosthetic disc shown in  FIG. 7 ;  
         [0016]      FIG. 9  is a schematic transverse plan view of the vertebrae and prosthetic disc shown in  FIGS. 7 and 8 ;  
         [0017]      FIG. 10  is a coronal view similar to  FIG. 7  showing the center of rotation of the prosthetic disc and the center of the disc space between the vertebrae;  
         [0018]      FIG. 11  is a sagittal view similar to  FIG. 8  showing the center of the rotation of the prosthetic disc and the center of the disc space between the vertebrae;  
         [0019]      FIG. 12  is a transverse view similar to  FIG. 9  showing the center of rotation of the prosthetic disc and the center of the disc space between the vertebrae;  
         [0020]      FIG. 13  is a schematic sagittal view of a vertebra showing the medial center of the pedicle base circumference;  
         [0021]      FIG. 14  is a schematic transverse view of the vertebra shown in  FIG. 13  showing the medial centers of the pedicle base circumferences and the isthmus of a pedicle;  
         [0022]      FIG. 15  is a schematic coronal view of the vertebra shown in  FIGS. 13 and 14  showing the medial centers of the pedicle base circumferences;  
         [0023]      FIG. 16  is a sagittal view of a vertebra showing the medial center of the pedicle base circumference and the anterior and posterior points through the sagittal center of the endplate;  
         [0024]      FIG. 17  is a schematic transverse view of the vertebra shown in  FIG. 16 ;  
         [0025]      FIG. 18  is a schematic coronal view of the vertebra shown in  FIGS. 16 and 17 ;  
         [0026]      FIG. 19  is a portion of a schematic volume table that is generated to show the positioning of the prosthetic disc relative to the disc space between vertebrae in the coronal, sagittal and transaxial (or transverse)planes;  
         [0027]      FIG. 20  is a table showing maximum size parameters for the intervertebral disc space that may be generated in accordance with the present invention;  
         [0028]      FIG. 21  is a schematic sagittal view in elevation of adjacent vertebrae showing the medial centers of the pedicle base circumferences and a prosthetic disc positioned in the space between the vertebrae;  
         [0029]      FIG. 22  is a schematic coronal view in elevation of the vertebrae shown in  FIG. 21 ;  
         [0030]      FIG. 23  is a schematic transverse view of the vertebrae shown in  FIGS. 21 and 22  and includes pedicle base circumferences with posterolateral corners seen on a coronal view;  
         [0031]      FIG. 24  is a schematic perspective view of a prosthetic disc volume in which center lines are present for the alignment and positioning of the prosthetic disc;  
         [0032]      FIG. 25  is a schematic view showing adjacent vertebrae in the coronal plane and the steps of positioning a prosthetic disc therebetween in accordance with one of the methods of the present invention;  
         [0033]      FIG. 26  is a perspective view similar to  FIG. 24  showing a prosthetic disc volume for positioning in accordance with a two ring aligning apparatus;  
         [0034]      FIG. 27  is a schematic view generated by a computer of a prosthetic disc volume having a central line and a surrounding alignment ring;  
         [0035]      FIGS. 28   a  and  28   b  are side and front elevational views of the end portion of a first embodiment of a drilling cannula member for the dual ring aligning apparatus shown in  FIG. 26 ;  
         [0036]      FIGS. 29   a  and  29   b  are side and front elevational views of the end portion of a second embodiment of a drilling cannula member for the dual ring aligning apparatus shown in  FIG. 26 ; and  
         [0037]      FIG. 30  is a schematic view similar to  FIG. 27  showing a slotted outer cannula surrounding one of the ring members shown in  FIG. 26 . 
     
    
     DESCRIPTION OF THE PREFERRED EMBODIMENTS  
       [0038]     The methods and apparatus of templating and placement of prosthetic intervertebral discs in accordance with the present invention are set forth in more detail hereinafter.  
         [0000]     Step 1  
         [0039]     A computed tomography scan (CT), magnetic resonance image (MRI), CT capable fluoroscopy or similar two-dimensional imaging study of the spine area of interest may first be obtained. Thin cut sections are preferable to increase accuracy and detail.  
         [0000]     Step 2  
         [0040]     A dimensionally true three dimensional computer image of the bony spine is made from the CT, MRI or other studies or in any other suitable manner, as shown in  FIGS. 1   a  and  1   b.    
         [0000]     Step 3  
         [0041]     The three dimensional individual vertebra as shown in  FIGS. 2-5  are utilized to determine the intervertebral disc space volume parameters of height H, width W, depth D and lordosis θ between adjacent vertebral endplates E. B represents the pedicle base circumference and X represents the pedicle isthmus in  FIG. 4 .  
         [0000]     Step 4  
         [0042]     As shown in  FIGS. 6-9 , the computer then automatically determines the maximum allowable disc prosthesis to be placed by creating an artificial volume  2  corresponding to an actual prosthetic disc which is positioned according to a manufacturer&#39;s size and lordosis recommendations for its prosthesis. For example, one manufacturer&#39;s prosthesis may require a two millimeter anterior inset, whereas another manufacturer&#39;s prosthesis may require a three millimeter anterior inset. The manufacturers&#39; recommendations vary from one prosthesis to another and apply to all four parameters of height, width, depth and lordosis. In addition, to assure the prosthetic disc is not oversized, the maximum artificial disc volume  2  is constrained such that its center of rotation  6  must lie posterior to the center  8  of the disc space  4 , ideally in the posterior one-third, when the prosthesis is fully seated. As shown in  FIGS. 10-12 , this center of disc space  4  distance is defined by utilizing a pedicle base circumference method, described more fully hereinafter. The artificial prosthetic disc volume  2  will fit within the actual intervertebral disc space volume  4  except for specified height or lordosis alterations desired by the surgeon. Artificial discs are of two major designs, either as a single integrated unit or of multiple components.  
         [0000]     Step 5  
         [0043]     The pedicle base circumference outline method as shown in  FIGS. 13-18  utilizes a computer generated image which demonstrates the pedicle base circumference B defined as the cortical junction between the pedicle walls and its transition into the vertebral body. Radiographically this is identified intraoperatively on both plain x-rays and fluoroscopic images as the circular-like cortical outline commonly seen in an anteroposterior direction at the superior lateral aspect of the vertebral body. By using the medial center of each pedicle base circumference B to its vertebral body as a reference point PB 1  or PB 2 , a line can then be drawn to connect these two points PB 1 -PB 2 . From this line, a sagittal plane SP is made perpendicular to the PB 1  -PB 2  line. The intersection of the sagittal plane SP with the respective vertebral endplates E defines the anterior point A and posterior point P which is the distance through the sagittal center of the endplate E. One-half of this distance from A-P (½ A-P) is the center of the vertebral endplate, point C. This center point C is depicted on the actual disc space volume for individual and merged volume image analysis.  
         [0000]     Step 6  
         [0044]     For those disc spaces in which the surgeon desires to restore lost disc height or lordosis secondary to disc degeneration, the computer can modify the artificial disc space volume to incorporate these desired changes and include them in the idealized schematic volume table.  
         [0000]     Step 7  
         [0045]     The computer then provides a data summary table, (See e.g.,  FIGS. 19 and 20 ) which displays the ideal prosthetic disc height, width, depth and lordosis for each intervertebral disc space and also provides an idealized schematic drawing of the actual disc space volume and the prosthetic disc space volume individually and merged together. These volumes will include the center points for visualization. Individual vertebra are labeled by having the surgeon identify any specific vertebra and then the computer automatically labeling the remaining vertebral bodies and the surgeon confirming accurate vertebral labeling.  
         [0000]     Step 8—Method A: Manual Artificial Disc Placement  
         [0046]     The surgeon utilizes the idealized schematic diagram and summary data for prosthetic disc placement by a manual preferred method.  
         [0000]     Step 9—Method B: Pedicle Base Circumference Outline Method  
         [0047]     This method utilizes a computer generated image which demonstrates the pedicle circumference B defined as the cortical junction between the pedicle wall and its transition into the vertebral body. Radiographically this is identified intraoperatively on both plain x-rays and fluoroscopic images as the circular-like cortical outline commonly seen in an anteroposterior direction at the superior lateral aspect of the vertebral body.  
         [0048]     This is a consistent radiographic landmark which can be utilized for artificial disc placement. The fluoroscopic or image guidance image is aligned to be parallel to the caudad superior endplate. Furthermore, the vertebral body is centered by having its center equidistant from each pedicle base circumference within the fluoroscopic AP image and with its superior endplate visualized usually by symmetric disc space with the cephalad vertebral body.  
         [0049]     Insertion of the prosthetic disc can be undertaken in anterior, lateral or posterior approaches. The posterior most aspect of the prosthetic disc will lie in nearly the same plane as the pedicle base circumference line connecting the medical centers PB 1 -PB 2  of the pedicle base circumferences. Thus, the superior and inferior posterolateral corners PLC of the prosthetic disc  2  can be labeled to identify this radiographically for positioning with respect to the pedicle base circumferences on the AP view and confirmed on the lateral view. This is shown in  FIGS. 21-23 .  
         [0000]     Step 10—Method C: Dual Ring Apparatus and Drill Guide  
         [0050]     For automated intraoperative prosthetic disc placement, the dimensionally true three dimensional spine model with computer automated prosthetic disc space volumes can be utilized. In addition, a line L is drawn from the center point C of the prosthetic disc volume  2  to the center of the face, point F, of the disc from the approach it will be inserted to create a prosthetic disc volume which now has a line exiting out of the prosthetic disc volume at the anterior face FA, the posterior face FP or the lateral face FL, as shown in  FIG. 24 .  
         [0000]     Step 11  
         [0051]     Referring to  FIG. 25 , real time intraoperative fluoroscopy is utilized for accurate registration with the there dimensional model on an individual vertebral basis. This fluoroscopic vertebral body image is centered on the monitor and identified by the surgeon for its specific vertebral body identifier (i.e., L 4 , L 5  etc.). The corresponding dimensionally true three dimensional individual vertebral models are registered to this fluoroscopic image. This can be performed on either surgically exposed spines or percutaneously.  
         [0000]     Step 12  
         [0052]     The registration occurs by utilizing internal vertebral body landmarks. These landmarks are the pedicle base circumferences B seen on the fluoroscopic image which arise from the confluence of the pedicle cortical walls joining the vertebral body. These pedicle base circumferences B form either circular or elliptical shapes which can change configuration and square area based on vertebral body rotation with respect to fluoroscopic imaging.  
         [0000]     Step 13  
         [0053]     The intraoperative fluoroscopic and computer spine generated pedicle base circumference outlines are then registered. Precision of registration is obtained by assuring outlines are superimposed and measured square areas are equal; and by assuring distance between pedicles is equal. This method of registration eliminates the requirement of having a radiographic marker anchored to the patient&#39;s skeleton. This method also allows for free independent movement of one vertebral body to another demonstrating compliance of this computer generated model, which is particularly useful in spines with instability. The surgeon confirms adequacy of registration of pedicle circumferences intraoperatively in order to proceed with prosthetic disc placement. This method allows for magnification or reduction of the computer generated model to match the intraoperative fluoroscopic image.  
         [0000]     Step 14  
         [0054]     Referring to  FIGS. 26 and 27 , the three full dimensional image which now includes the computer generated pedicle base circumference and prosthetic disc volume  2  and central line L is then projected superimposed on the intraoperative fluoroscopic image. The computer prosthetic disc volume  2  is then projected out of the patient&#39;s body through the disc space and is intercepted by two separate and collinear rings R 1  and R 2 . These rings are mounted on a device (not shown) anchored to the patient&#39;s bed and are oversized to allow interception of the computer volume image and to allow placement of drilling cannulas. The first ring R 1  intercepts the computer prosthetic disc volume  2  near the disc space cortical region and the second ring R 2  intercepts the computer prosthetic disc volume at any desired distance from the first ring R 1 . The longer the distance between the two rings, the greater the accuracy of prosthetic disc placement. The interception of the computer prosthetic volume by the rings is manually performed which is displayed real-time on the computer monitor which demonstrates movement of the rings with respect to the computer prosthetic volume.  
         [0000]     Step 15  
         [0055]     Interception of the prosthetic disc volume occurs on two levels. The computer prosthetic volumes are comprised of a central line L with surrounding volume. First, the rings R 1  and R 2  need to be centered to both the central line L and surrounding volume. Second, the rings are registered to the body so their movements can be followed on the computer monitor probably through LED, EMF or other devices. Third, the rings are designed to have inner sizes to allow matching of the sizes of the computer generated prosthetic disc volumes. A variety of fixed ring sizes are available to allow utilization of any artificial disc system desired by the surgeon or the rings can be designed to have apertures allowing for variable sizes to allow matching of sizes corresponding to the sizes of the computer generated prosthetic disc volumes. Registration of the rings with the computer prosthetic disc volume is identified and confirmed on the computer monitor.  
         [0000]     Step 16  
         [0056]     The two co-aligned rings R 1  and R 2  now form the conduit in which to place a cannula  10 . This cannula is also secured rigidly to the device anchored to the patient&#39;s bed. Inside this drilling cannula is placed either a solid drilling cannula  12  or a specialized inner cannula  14  which has multiple narrow metal parallel pins  16  contained within the cannula and centrally is clear to allow for drill placement. The multiple pins  16  allow for the inner cannula to rest evenly on an uneven surface. This feature provides additional stability at curved cortical surface drilling areas to avoid toggling of the drill bit. Additionally, this specialized inner cannula allows for retraction of the multiple parallel pins to allow fluoroscopic visualization of drilling within the disc space. Either method may be chosen by the surgeon. For use of the variable aperture diameter ring method, a solid cannula which contains two separate variable apertures can be utilized.  
         [0000]     Step 17  
         [0057]     The disc space is drilled to the desired precalibrated depth and not exceeding the predetermined artificial disc depth.  
         [0000]     Step 18  
         [0058]     The disc space is sounded to assure osseous integrity.  
         [0000]     Step 19  
         [0059]     For actual prosthetic disc placement a specialized slotted outer cannula  18  is placed collinear and onto the co-aligned two rings R 1  and R 2 , as shown in  FIG. 30 . This specialized cannula  18  is also rigidly secured to the anchoring device. The rings R 1  and R 2  are then removed by withdrawing them from the cannula  18 . The inner size of the cannula  18  is sufficient to accommodate any prosthetic disc size. The appropriate prosthetic disc is placed into its holding screwdriver (not shown), placed into the slotted cannula  18  and then placed into its respective disc space. For the variable aperture rings, the apertures are opened fully to allow placement of the screwdriver holding the appropriate prosthetic disc.  
         [0000]     Step 20  
         [0060]     The process is repeated for all desired disc spaces.  
         [0000]     Step 21  
         [0061]     There are currently commercially available software packages capable of producing intraoperative registration of intraoperative fluoroscopy images with preoperative three dimensional images of a patients&#39; spine. Those capabilities an be integrated with the present invention to provide summary numerical data and idealized illustrated diagrams. The latter information will provide the basis for actual prosthetic disc placement as described in this invention or by a surgeon&#39;s preferred choice.  
         [0062]     While the invention has been described in connection with what is presently considered to be the most practical and preferred embodiments, it is to be understood that the invention is not to be limited to the disclosed embodiments, but on the contrary, is intended to cover various modifications and equivalent arrangements included within the spirit and scope of the appended claims.