# Patent

## Title
Method for implanting an intervertebral disk prosthesis

## Abstract

A cervical intervertebral disk prosthesis has two cover plates, at least one of which is provided with a wedge-shaped connection surface for connection to a vertebral body and which is wider than it is deep. The dorsal edge of the connection surface may be set back from the dorsolateral edge of the cover plate having the connection surface and be connected to the dorsal edge protruding above it via a rounding or bevel.

## Background
REFERENCE TO RELATED APPLICATION
This application is a continuation of Ser. No. 10/407,946, filed Apr. 7, 2003 now U.S. Pat. No. 8,012,212.


BACKGROUND OF THE INVENTION
Endoprostheses for replacement of an intervertebral disk of the cervical spine are known (FR-A-2 718 635, EP-B-699 426) which consist of two cover plates and a joint core. The cover plates, which are arranged approximately parallel on both sides of the core, have connection surfaces which are intended for connection to the adjacent vertebral bodies. The cranial vertebral body cover plates, which are to be connected to a lower prosthesis cover plate, have a roughly rectangular shape. They are approximately flat and are delimited at the sides by edge serrations. The caudal vertebral body cover plates have extensive edge serrations at the ventral edge. These have to be removed before the prosthesis is fitted. It is also expedient for the vertebral body surfaces which are intended to bear on the prosthesis to be worked in order to adapt them to the connection surfaces of the prosthesis.
The connection surfaces of the known prostheses mentioned are circularly delimited. Since the end plates of the vertebral bodies have approximately the shape of a rectangle whose width is substantially greater than its dimension in the anteroposterior direction, they do not exploit the size of the naturally occurring surfaces for force transmission. Accordingly, between the connection surfaces of the prosthesis and the bearing surfaces on the vertebral bodies, greater forces occur than would be the case if the surfaces were better utilized. In the case of intervertebral disk endoprostheses intended for the lumbar spine, the best utilization of space is achieved by using an oval prosthesis contour (WO 0 101 893, EP-B-471 821, EP-A-747 025) or a kidney-shaped configuration (EP-A-747 025), because the cover plates of the vertebral bodies have an oval to kidney-shaped configuration. Rectangular prosthesis shapes are also known (U.S. Pat. No. 5,425,773).
SUMMARY OF THE INVENTION
The object of the invention is to make available an endoprosthesis for replacement of the intervertebral disk in the cervical region of the spine which permits the best possible utilization of space. Since the vertebral body attachment surfaces are approximately rectangular, a similarly approximately rectangular or oval configuration of the connection surfaces of the prosthesis would at first sight seem most appropriate. However, the invention has recognized that better and more reliable results are achieved by using a prosthesis in which at least one of the two connection surfaces, but preferably both connection surfaces, has a configuration in which the connection surface has side edges, a dorsolateral edge and an anteriolateral edge, the side edges inclining toward an imaginary mid-line extending from the ventral edge to the dorsal edge of the cover plate so as to form a wedge shape. The distance from the side edges to their corresponding adjacent dorsal corners of an imaginary rectangle circumscribing a circumferential contour of the cover plate is greater than the distance of the anteriolateral edge from corresponding adjacent ventral corners of the imaginary rectangle.
When shaping the vertebral body bearing surfaces for the prosthesis from the ventral direction, the operating surgeon must keep a safe distance from the spinal canal. This applies in particular when shaping the dorsolateral corners of the bearing surfaces, where visual control is more difficult than in the central dorsal region. This means that in the dorsolateral corners of the vertebral body cover plates bone material may be left which protrudes beyond the worked bearing surface of the vertebral body. If one were to use a rectangular prosthesis, this would not be able to be inserted fully into the intervertebral space because its dorsal corners would strike against the bone material which has been left.
If the prosthesis corners are rounded, the circumstances are not much more favorable. The prosthesis then protrudes ventrally beyond the vertebral bodies and may cause irritation of the esophagus or the large blood vessels located there. The set-back, according to the invention, of the prosthesis connection surfaces spares the dorsolateral corners and thereby avoids this disadvantage. By contrast, the surface area of the connection surfaces in their anterolateral regions remains unchanged.
The measure according to the invention can be best described by reference to the distance of the limit of the connection surface from the corner points of an imaginary rectangle which circumscribes the cover plate. It is assumed here that the sides of the rectangle which are tangential to the circumferential contour of the cover plate extend parallel to the sagittal plane or perpendicular thereto. In this context, only those parts intended for accommodation in the intervertebral space are considered as the cover plate. If, for example, a ventral flange is connected to the cover plates and, in the implanted state, lies in front of the ventral end face of the vertebral body, this is not counted as part of the cover plate in the construction of the imaginary rectangle.
The minimum distance of the limit of the connection surface from the dorsal corners of the imaginary rectangle is preferably at least 1.3 times as great, more preferably at least 1.5 times as great, still more preferably at least twice as great as the minimum distance from the ventral corners. It is preferably assumed here that the width of the cover plates is greater than its anteroposterior dimension, generally by a factor of 1.1 to 1.6 preferably by a factor of 1.2 to 1.4.
In general, the connection surfaces of both prosthesis cover plates are configured in accordance with the invention. There are cases, however, where it is sufficient to do this on one of the two connection surfaces, specifically in particular the lower one.
In a particularly preferred embodiment of the invention, the edge of the prosthesis cover plate extends beyond the dorsolateral limit of the associated connection surface. In this way, the cover plate, the prosthesis core and the connection or slide surfaces interacting on the cover plates and the prosthesis core can have an optimum size despite the set-back nature of the connection surface. These parts can therefore be designed, for example, roughly as a rectangular shape with rounded corners.
The transition between the dorsolateral set-back limit of the connection surface to the farther extended edge takes place in the form of an inclined transition surface. This can directly adjoin the connection surface. The advantage of this is that the transition surface too can if appropriate participate in the transmission of forces, namely in contact with the bone parts which have been left in the dorsolateral region and protrude beyond the worked bearing surface of the vertebral body. The cross section of the transition surface can be straight, convexly rounded or even stepped.
The term dorsolateral designates the transition region from the lateral aspect to the dorsal aspect of the cover plate. The set-back, according to the invention, of the connection surface is accordingly not restricted only to a dorsal region or a lateral region but instead includes portions of both regions. The term set-back relates to a standard contour of the cover plate which to the front and rear is approximately symmetrical to the middle transverse axis. The limit of the connection surface is set back relative to this standard contour. In case of doubt, the standard contour is the anterolateral contour of the cover plate mirrored about the middle transverse axis. If the cover plate has an edge protruding beyond the limit of the connection surface, which edge does not protrude farther than the standard contour, the set-back of the limit of the connection surface can also be related to the contour of this edge.
Viewed from the lateral direction, the portion in which the limit of the connection surface is set back extends generally over at least one third of the antero-posterior dimension of the connection surface. Viewed from the dorsal direction, this portion generally extends over at least approximately one quarter of the width of the connection surface respectively on both sides. It may be expedient if the connection surface, in a central portion of the dorsal plate edge, is not set back in relation to the latter or is set back less than in the dorsolateral region. This middle portion expediently extends over at least one quarter of the width of the connection surface.
In the ventral third of the lateral sides of the cover plate, the limit of the connection surface is preferably not set back. Slight roundings of the edges of the connection surface are not taken into account here. The set-back of the connection surface limit is preferably at its greatest where it is nearest to the dorsal corner of the imaginary circumscribing rectangle. The set-back limit of the connection surface then has an approximately rectilinear course.
At the place where the difference in height between the set-back limit of the connection surface and the edge protruding above it is at its greatest, the difference in height should be at least approximately 1 mm.



BRIEF DESCRIPTION OF THE DRAWINGS
The invention is explained in greater detail below with reference to the drawing which depicts an advantageous illustrative embodiment, and in which:
FIGS. 1 and 2 show perspective views of the whole prosthesis,
FIGS. 3 to 5 show views of the prosthesis from the dorsal, lateral and caudal directions,
FIGS. 6 to 8 show different profiles of the transition surface,
FIG. 9 shows a plan view of an alternative embodiment, and
FIG. 10 shows an enlarged representation of the connection surface and the edge contour.



DETAILED DESCRIPTION OF THE INVENTION
The prosthesis shown in FIGS. 1 to 8 consists of two cover plates 1 and of a prosthesis core 2. The inner face of one of the two cover plates can be provided as a mounting for the prosthesis core 2, while the other cover plate forms, with the prosthesis core, a spherical slide surface 3, for example. At the ventral edge of each cover plate there is a flange 4 whose dorsal face 5 is intended to bear on the ventral face of a vertebral body. The flange can have securing means, for example screw holes 6. Each prosthesis cover plate has a connection surface 10 for bearing on the associated vertebral body cover plate and on the bearing surface created by shaping the vertebral body, said connection surface 10 extending approximately parallel to the main plane of the cover plate. It is substantially flat, but can also have a slight curvature. It is equipped with teeth 13 and/or other means for connecting it securely in position to the bone, for example with a biologically active coating.
Each cover plate is surrounded by a circumferential surface 14 which is approximately perpendicular to the connection surface 10 and which in the present context is designated as an edge. The edge 14 defines the circumferential contour of the cover plate, which has an oblong shape, which can be designated as oval or as rectangular with rounded corners. It is also designated by reference number 14 in FIG. 10. The prosthesis core 2 has the same circumferential contour. The anteroposterior depth dimension 11 of the cover plates 1 is smaller than their width dimension 12, specifically for example in the ratio of three to four. An example which has proven useful has a depth of 15 mm and a width of 20 mm. Its extent is adapted to the vertebral body cover plates and is slightly smaller than these, so that the prosthesis fits into the intervertebral space which is available and has been shaped between the vertebral bodies. If appropriate, it is possible to provide different size categories of prostheses. The cover plates 1 are preferably made of metal, and the core 2 of polyethylene.
The cover plate 1 or the contour of the edge 14 has a ventral face 15, a dorsal face 16 and lateral faces 17 and 18. Between these there extend the anteroposterior depth dimension 11 and the width dimension 12, which in FIG. 10 are indicated as sides of an imaginary rectangle 21 circumscribing and touching the cover plate or the contour 14 of the edge. Only the part of the cover plate 1 lying behind the flange face 5 is taken into consideration here, since it is only the dimension of the part which will lie in the intervertebral space which is relevant here.
On the ventral face 15 and in the ventral half of the lateral faces 17, 18, the limit of the connection surface 10 follows the contour of the edge 14. They do not need to correspond exactly, because slight deviations in the form of roundings or bevels can be present. The width of these is generally less than 3% of the width dimension 12.
In the transition region from the lateral faces 17, 18 to the dorsal face 16 of the edge, which in the present context is designated as the dorsolateral region, a portion 23 of the limit 24 of the connection surface 10 does not follow the contour 14 but is instead set back relative to the latter. The greatest extent of the set-back, in a plan view, lies between approximately 2 and 5 mm, generally of the order of 2.5 to 3.5 mm. The minimum distance 28 from the corner 29 of the circumscribing rectangle 21 is greater than 13% and preferably greater than 15% and preferably greater than 18% of the width dimension 12. In an illustrative embodiment which has proven useful, it is slightly more than 20% of this width.
The set-back of the limit 24 relative to the contour 14 is obtained by providing an oblique transition surface 25 between the limit 24 and the edge. Since the transition surface is raised in relation to the plane of the connection surface, a space is obtained below it for receiving the bone parts which have been left in the dorsolateral region upon shaping of the vertebral body surface. It will be appreciated that this space must have an adequate height for this purpose. It should be at least 1 mm at the place of the maximum height difference between the connection surface and the edge 14. The transition surface 25 can, for example, be convexly rounded (FIG. 6) or have a straight profile (FIG. 7). It can also be cut with a step (FIG. 8).
In a side view of the example illustrated, the portion 23 in which the limit 24 is set back relative to the contour 25 of the edge 14 takes up approximately two thirds of the depth dimension 11 and is preferably not less than one third thereof. In the front third, the contour of the cover plate does not deviate from the limit of the connection surface. Slight roundings of the edges are not taken into consideration here.
Viewed from the dorsal direction (FIG. 3), the set-back of the limit 24 of the connection surface decreases toward the center. In a central portion 22 of the dorsal face 16, the edge 14 in practice does not protrude beyond the limit 24. The length of this central portion is preferably between one tenth and one third of the width dimension 12.
The set-back portion 23 of the limit 24 of the connection surface 10 in the dorsolateral region has an approximately rectilinear extent. If one compares it to a rectilinear course connecting the end points of this portion to one another, it scarcely deviates from this course. Any deviation is well below 10% of the length of this course. The end points of said course lie at those points where the deviation of the limit 24 of the connection surface from the circumferential contour 14 goes beyond the extent of the edge roundings otherwise provided.
The deviation of the limit 24 from the circumferential contour 14 in the dorsolateral region is approximately 10% of the cover plate width 12 and should be not less than 5%.
A set-back of the limit of the connection surface in the dorsolateral region—corresponding to the explanations given above—is also shown in the embodiment according to FIG. 9, which differs from that of FIGS. 1 to 8 in that the edge 14 does not extend beyond the limit of the connection surface. The description of the illustrative embodiment in FIGS. 1 to 8 and FIG. 10 correspondingly applies to this illustrative embodiment, except that the course of the limit of the connection surface in the dorsolateral region is not compared to the circumferential contour 14 but instead to the course 14′, mirrored about the central transverse axis 21, of the anterolateral circumferential contour 14 of the cover plate.
FIG. 10 illustrates the different course of the limit of the connection surface in the anterolateral region and dorsolateral region, by reference to the corners of the imaginary rectangle 21. It will be noted that the minimum distance 28 of the dorsal corner point 29 from the limit line 24 is almost three times as great as the corresponding minimum distance 26 of the front corner point 27. It should normally be at least 1.5 times as great.

## Claims

1. A method of implanting an intervertebral disk prosthesis comprising a first cover plate and a second cover plate, said first and second cover plates each having a dorsal edge, a ventral edge, and lateral edges defining a perimeter of a circumferential edge, and a connection surface extending at least partially between said edges of the circumferential perimeter, said first and second cover plates, at their dorsolateral corners, are configured with a set-back portion having an inclined transition surface that adjoins a plane of the circumferential edge having a height to a plane of the connection surface having a different height, the method comprising:
forming a recess between a first vertebral body and a second vertebral body to receive said intervertebral disk prosthesis by shaping a first vertebral body bearing surface on the first vertebral body, shaping a second vertebral body bearing surface on the second vertebral body, and sparing a bone part of at least one of the first and second vertebral bodies to leave bone material adjacent to at least one of the first and second vertebral body bearing surfaces; and
implanting said intervertebral disk prosthesis into said recess in an anterior to posterior direction of implantation such that said connection surface of said first cover plate is positioned against said first vertebral body bearing surface of said recess, said connection surface of said second cover plate is positioned against said second vertebral body bearing surface of said recess, and said set-back portion is positioned against said spared bone material remaining in said recess.

2. The method of implanting the intervertebral disk prosthesis according to claim 1, wherein the at least one cover plate has a ratio of width to depth that ranges between 1.1:1 and 1.6:1 in a transverse plane relative to an implanted position of the prosthesis.

3. The method of implanting the intervertebral disk prosthesis according to claim 1, wherein the inclined transition surface has a difference in height of at least 1 mm from the plane of the circumferential edge to the plane of the connection surface of the first and second cover plates.

4. The method of implanting the intervertebral disk prosthesis according to claim 1, wherein the set-back portion extends into a dorsal third of an anteroposterior extent of the connection surface.

5. The method of implanting the intervertebral prosthesis disk according to claim 1, wherein the inclined transition surface is at least one of convexly rounded, straight, and stepped.

6. The method of implanting the intervertebral disk prosthesis according to claim 1, wherein the connection surface is configured as a series of longitudinal ridges.

7. The method of implanting the intervertebral disk prosthesis according to claim 1, wherein the set-back portion is configured without ridges on the inclined transition surface.

8. The method of implanting the intervertebral disk prosthesis according to claim 1, wherein the connection surface is equipped with a biologically active coating.

9. The method of implanting the intervertebral disk prosthesis according to claim 1, wherein the first and second cover plates are made of metal.

10. The method of implanting the intervertebral disk prosthesis according to claim 1, wherein the intervertebral disk prosthesis further comprises a prosthesis core mounted on an inner face of one of the first and second cover plates, the prosthesis core forming a slide surface with an inner face of an other of the first and second cover plate.

11. The method of implanting the intervertebral disk prosthesis according to claim 10, wherein the prosthesis core extends to the edges of the circumferential perimeter of at least one of the first cover plate and the second cover plate.

12. The method of implanting the intervertebral disk prosthesis according to claim 10, wherein the prosthesis core is made of polyethylene.

13. A method of implanting an intervertebral disk prosthesis comprising a first cover plate and a second cover plate, said first and second cover plates each having a dorsal edge, a ventral edge, and lateral edges defining a perimeter of a circumferential edge, and a connection surface extending at least partially between said edges of the circumferential perimeter, said first and second cover plates, at their dorsolateral corners, are configured with a set-back portion having an inclined transition surface that adjoins that adjoins a plane of the circumferential edge having a height to a plane of the connection surface having a different height, the method comprising:
forming a recess between a first vertebral body and a second vertebral body to receive said intervertebral disk prosthesis by shaping a first vertebral body bearing surface on the first vertebral body, shaping a second vertebral body bearing surface on the second vertebral body, and sparing a bone part of at least one of the first and second vertebral bodies to leave bone material adjacent to at least one of the first and second vertebral body bearing surfaces; and
implanting said intervertebral disk prosthesis into said recess such that said connection surface of said first cover plate is positioned against said first vertebral body bearing surface of said recess, said connection surface of said second cover plate is positioned against said second vertebral body bearing surface of said recess, and said set-back portion is positioned against said spared bone material remaining in said recess,
wherein the at least one cover plate has a ratio of width to depth that ranges between 1.1:1 and 1.6:1 in a transverse plane relative to an implanted position of the prosthesis.

14. The method of implanting the intervertebral disk prosthesis according to claim 13, wherein the inclined transition surface has a difference in height of at least 1 mm from the plane of the circumferential edge to the plane of the connection surface of first and second cover plates.