# Patent

## Title
Systems and methods for performing spine surgery

## Abstract

A method is provided for correcting a curvature or deformity in a patient's spine based on the digitized locations of implanted screws and tracking the placement of the rod as it is placed in a minimally invasive fashion. The method is implemented by a control unit through a GUI to digitize screw locations, accept one or more correction outputs, and generate one or more rod solution outputs shaped to fit at locations distinct from the implanted screw locations.

## Background
CROSS-REFERENCE TO RELATED APPLICATIONS
This application is a U.S. patent application claiming the benefit of priority from commonly owned and U.S. Provisional Application Ser. No. 61/888,990 filed on Oct. 9, 2013 and entitled “Systems and Methods for Performing Spine Surgery”, the complete disclosure of which is hereby expressly incorporated by reference into this application as if set forth in its entirety herein.


FIELD
The present application pertains to spine surgery. More particularly, the present application pertains to systems and methods related to the planning, design, formation, and implantation of spinal implants.
BACKGROUND
The spinal column is a highly complex system of bones and connective tissues that provide support for the body and protect the delicate spinal cord and nerves. The spinal column includes a series of vertebral bodies stacked atop one another, each vertebral body including an inner or central portion of relatively weak cancellous bone and an outer portion of relatively strong cortical bone. Situated between each vertebral body is an intervertebral disc that cushions and dampens compressive forces exerted upon the spinal column. A vertebral canal containing the spinal cord is located behind the vertebral bodies. The spine has a natural curvature (i.e., lordosis in the lumbar and cervical regions and kyphosis in the thoracic region) such that the endplates of the upper and lower vertebrae are inclined towards one another.
There are many types of spinal column disorders including scoliosis (abnormal lateral curvature of the spine), excess kyphosis (abnormal forward curvature of the spine), excess lordosis (abnormal backward curvature of the spine), spondylolisthesis (forward displacement of one vertebra over another), and other disorders caused by abnormalities, disease, or trauma (such as ruptured or slipped discs, degenerative disc disease, fractured vertebrae, and the like). Patients that suffer from such conditions often experience extreme and debilitating pain, as well as diminished nerve function. Posterior fixation for spinal fusions, decompression, deformity, and other reconstructions are performed to treat these patients. The aim of posterior fixation in lumbar, thoracic, and cervical procedures is to stabilize the spinal segments, correct multi-axis alignment, and aid in optimizing the long-term health of the spinal cord and nerves.
Screws, hooks, and rods are devices used to stabilize the spine during a spinal fixation procedure. Such procedures often require the instrumentation of many bony elements. The devices, for example rods, can be extremely challenging to design and implant into the patient. Spinal rods are usually formed of stainless steel, titanium, cobalt chrome, or other similarly hard metal, and as such are difficult to bend without some sort of leverage-based bender. Moreover, a spinal rod needs to be oriented in six degrees of freedom to compensate for the anatomical structure of a patient's spine as well as the attachment points (screws, hooks) for securing the rod to the vertebrae. Additionally, the physiological problem being treated as well as the physician's preferences will determine the exact configuration necessary. Accordingly, the size, length, and particular bends of the spinal rod depends on the size, number, and position of each vertebrae to be constrained, the spatial relationship amongst vertebrae, as well as the screws and hooks used to hold the rods attached to the vertebrae.
The bending of a spinal rod can be accomplished by a number of methods. The most widely used method is a three-point bender called a French Bender. The French bender is a pliers-like device that is manually operated to place one or more bends in a rod. The French bender requires both handles to operate and provides leverage based on the length of the handle. The use of the French bender requires a high degree of physician skill because the determination of the location, angle, and rotation of bends is often subjective and can be difficult to correlate to a patient's anatomy. Other methods of bending a rod to fit a screw and/or hook construct include the use of an in-situ rod bender and a keyhole bender. However, all of these methods can be subjective, iterative, and are often referred to as an “art.” As such, rod bending and reduction activities can be a time consuming and potentially frustrating step in the finalization of a complex and/or long spinal construct. Increased time in the operating room to achieve optimum bending can be costly to the patient and increase the chance of the morbidity. When rod bending is performed poorly, the rod can preload the construct and increase the chance of failure of the fixation system. The bending and re-bending involved can also promote metal fatigue and the creation of stress risers in the rod.
Efforts directed to computer-aided design or shaping of spinal rods have been largely unsuccessful due to the lack of bending devices as well as lack of understanding of all of the issues involved in bending surgical devices. U.S. Pat. No. 7,957,831, issued Jun. 7, 2011 to Isaacs, describes a rod bending system which includes a spatial measurement sub-system with a digitizer to obtain the three dimensional location of surgical implants (screws, hooks), software to convert the implant locations to a series of bend instructions, and a mechanical rod bender used to execute the bend instructions such that the rod will be bent precisely to custom fit within each of the screws. This is advantageous because it provides quantifiable rod bending steps that are customized to each patient's anatomy enabling surgeons to create custom-fit rods on the first pass, thereby increasing the speed and efficiency of rod bending, particularly in complex cases. This, in turn, reduces the morbidity and cost associated with such procedures. However, a need still exists for improved rod bending systems that allow for curvature and deformity correction in fixation procedures, provide the user with more rod bending options, and accommodate more of the user's clinical preferences including the ability to determine the spatial orientation of the tip of the rod and the tip of the rod pusher relative to one another.
SUMMARY
The present invention includes a system and methods for rod bending that enable the user (e.g., surgeon) to customize screw-based rod bend instructions to suit the desired correction of a patient's spinal condition. According to a broad aspect, the present invention includes a spatial tracking system for obtaining the three-dimensional position information of surgical implants, a processing system with software to convert the implant locations to a series of bend instructions based on a desired correction, and a mechanical rod bender for bending a surgical linking device to achieve the desired spinal correction.
According to another aspect of the present invention, the spatial tracking system includes an infrared (IR) position sensor and at least one IR-reflective tracking array attached to a digitizer pointer used to digitize the surgical implant location. The spatial tracking system is communicatively linked to the processing system such that the processing system may utilize the spatial position information to generate bend instructions.
According to another aspect of the present invention, the processing system is programmed to generate bend instructions based on one or more surgeon-prescribed clinical objectives. For example, the processing system may be programmed to create a custom bend, adjust one or more points to which the rod will be bent to, suggest a pre-bent rod option, provide spinal correction in the sagittal plane, provide spinal correction in the coronal plane, and provide correction to achieve global spinal balance, and as well as perform a plurality of predetermined functions. The processing system is further configured to preview and display the results of these clinical objectives and/or predetermined functions to the user in a meaningful way.
According to another aspect of the invention, the spatial tracking system is configured to track the three-dimensional position of a spinal rod relative to the implanted surgical implants during rod insertion. For example, the spatial tracking system may include at least one IR-reflective tracking array attached to a rod inserter instrument and another attached to a screw guide rod pusher to continuously digitize the rod location in real time during insertion of the rod. The processing system is programmed to generate and display the real time three-dimensional location of the rod tip relative to the tip of the rod pusher and the implanted surgical implants.
According to another aspect of the invention, one or more surgical procedures may be performed using various embodiments of the system.



BRIEF DESCRIPTION OF THE DRAWINGS
Many advantages of the present invention will be apparent to those skilled in the art with a reading of this specification in conjunction with the attached drawings, wherein like reference numerals are applied to like elements and wherein:
FIG. 1 is a surgical procedure setup depicting the components of a surgical bending system, according to one embodiment;
FIG. 2 is a perspective view of one embodiment of a digitizer array in the closed position comprising part of the system of FIG. 1;
FIG. 3 is an exploded perspective view of the digitizer array of FIG. 2;
FIG. 4 is a perspective view of the digitizer array of FIG. 2 in the open position;
FIG. 5 is a front view of one embodiment of a digitizer pointer assembly comprising part of the system of FIG. 1;
FIG. 6 is a perspective view of various surgical pointers compatible with the digitizer array of FIG. 2;
FIG. 7 is a partial perspective view of the offset pointer of FIG. 6 in a collapsed position;
FIG. 8 is a partial exploded view of the offset pointer of FIG. 6;
FIG. 9 is a partial perspective view of the offset pointer of FIG. 6 in an extended position;
FIG. 10 is a flowchart depicting the steps of the spatial tracking algorithm according to one embodiment;
FIG. 11 is a flowchart depicting the rod bending workflow according to one embodiment;
FIG. 12 is a flowchart depicting the steps in generating a rod solution according to a first embodiment;
FIG. 13 is a flowchart depicting the steps in generating rod solution according to a second embodiment;
FIG. 14 is a flowchart depicting the steps in generating a rod solution according to a third embodiment;
FIG. 15 is a flowchart depicting the steps of the rod bending process according to a first embodiment;
FIG. 16 is a screen shot depicting an example setup screen of the system of FIG. 1;
FIG. 17 is a screen shot depicting an example IR positioning sensor setup screen of the system of FIG. 1;
FIG. 18 is a screen shot depicting an example screw location digitization screen during a first step in the Acquire Screws step of FIG. 15;
FIG. 19 is a screen shot depicting an example screw location digitization screen during a second step in the Acquire Screws step of FIG. 15;
FIG. 20 is a screen shot depicting an example screw digitization screen during a third step in the Acquire Screws step of FIG. 15;
FIG. 21 is a screen shot depicting an example bend instructions screen in the Bend Instructions step of FIG. 15;
FIG. 22 is a flowchart depicting the steps of the rod bending process according to a second embodiment;
FIG. 23 is a screen shot depicting an example Advanced Options menu screen of the system of FIG. 1;
FIG. 24 is a screen shot illustrating a first example screen of an Adjust Points feature according to one embodiment;
FIG. 25 is a screen shot illustrating a second example screen of the Adjust Points feature of FIG. 24;
FIG. 26 is a screen shot illustrating a third example screen of the Adjust Points feature of FIG. 24;
FIG. 27 is a screen shot illustrating a first example screen of a Pre-Bent Preview feature according to one embodiment;
FIG. 28 is a screen shot illustrating a second example screen of the Pre-Bent Preview feature of FIG. 27;
FIG. 29 is a screen shot illustrating a third example screen of the Pre-Bent Preview feature of FIG. 27;
FIG. 30 is a screen shot illustrating a first example screen of a Sagittal Correction feature according to one embodiment;
FIG. 31 is a screen shot illustrating a second example screen of the Sagittal Correction feature according to the first embodiment;
FIG. 32 is a screen shot illustrating a first example screen of the Sagittal Correction feature according to a second embodiment;
FIG. 33 is a screen shot illustrating an additional example screen of the Sagittal Correction feature according to the first and/or second embodiment;
FIG. 34 is a screen shot illustrating a first example screen of the Coronal Correction feature according to a first embodiment;
FIG. 35 is a screen shot illustrating a second example screen of the Coronal Correction feature according to a first embodiment;
FIG. 36 is a screen shot illustrating a third example screen of the Coronal Correction feature according to the first embodiment;
FIG. 37 is a screen shot illustrating a fourth example screen of the Coronal Correction feature according to the first embodiment;
FIG. 38 is a screen shot illustrating a first example screen of the Coronal Correction feature according to a second embodiment;
FIG. 39 is a screen shot illustrating a second example screen of the Coronal Correction feature according to the second embodiment;
FIG. 40 is a screen shot illustrating a third example screen of the Coronal Correction feature according to the second embodiment;
FIG. 41 is a flowchart illustrating the steps of the Global Spinal Balance feature according to one embodiment;
FIG. 42 is a screen shot illustrating a first example screen of the Global Spinal Balance feature in pre-operative mode;
FIG. 43 is a screen shot illustrating a first example screen of the Global Spinal Balance feature in target mode;
FIG. 44 is a screen shot illustrating a second example screen of the Global Spinal Balance feature in target mode;
FIG. 45 is a screen shot illustrating a first example screen of the Global Spinal Balance feature in intraoperative mode;
FIG. 46 is a screen shot illustrating a second example screen of the Global Spinal Balance feature in intraoperative mode;
FIG. 47 is a screen shot illustrating a third example screen of the Global Spinal Balance feature in intraoperative mode;
FIG. 48 is a screen shot illustrating a fourth example screen of the Global Spinal Balance feature in intraoperative mode;
FIG. 49 is a screen shot illustrating a fifth example screen of the Global Spinal Balance feature in intraoperative mode;
FIG. 50 is a perspective view of one embodiment of a mechanical rod bender comprising part of the surgical bending system of FIG. 1;
FIG. 51 is a perspective view of a lumbar spine illustrating example spinal fixation anchors with attached extension guides and an example rod pusher instrument in use during implantation of a two level fixation construct, according to one example;
FIG. 52 is a perspective view of the example rod pusher of FIG. 51;
FIG. 53 is a plan view of an example rod inserter configured for use in the implantation procedure of FIG. 51;
FIG. 54 is a screen shot illustrating a first example screen of the Rod Tracking feature according to one embodiment; and
FIG. 55 is a screen shot illustrating a second example screen of the Rod Tracking feature according to one embodiment.



DESCRIPTION OF THE PREFERRED EMBODIMENT
Illustrative embodiments of the invention are described below. In the interest of clarity, not all features of an actual implementation are described in this specification. It will of course be appreciated that in development of any such actual embodiment, numerous implantation-specific decisions must be made to achieve the developers' specific goals such as compliance with system-related and business-related constraints, which will vary from one implementation to another. Moreover, it will be appreciated that such a development effort might be complex and time-consuming, but would nevertheless be a routine undertaking for those of ordinary skill in the art having the benefit of this disclosure. The systems and methods disclosed herein boast a variety of inventive features and components that warrant patent protection, both individually and in combination.
With reference now to FIG. 1, there is shown, by way of example, one embodiment of a surgical bending system 10 including a spatial tracking system 12 to obtain the location of one or more surgical implants 14, a control unit 16 containing software to convert the implant locations to a series of bend instructions, and a bending device 18 to execute the bend instructions.
Preferably, the spatial tracking system 12 includes an IR sensor 20, a digitizer pointer 23, as well as other components including Host USB converter 21. The spatial tracking system 12 is in communication with control unit 16. The control unit 16 has spatial relation software and is communicatively linked to the display 32 so that information relevant to the surgical procedure may be conveyed to the user in a meaningful manner. By way of example, the relevant information includes, but is not limited to, spatial positioning data (e.g., translational data in the x, y, and z axes and orientation/rotational data Rx, Ry, and Rz) acquired by the IR sensor 20. According to one or more embodiments, the system 10 comprises a neuromonitoring system communicatively linked to the spatial tracking system 12 via the control unit 16. By way of example only, the neuromonitoring system may be the neuromonitoring system shown and described in U.S. Pat. No. 8,255,045, entitled “Neurophysiologic Monitoring System” and filed on Apr. 3, 2008, the entire contents of which are hereby incorporated by reference as if set forth fully herein.
FIGS. 2-9 depict the various components of one or more digitizer pointers 23 for use with the present invention. FIGS. 2-4 detail an example IR-reflective tracking array 22 component of the digitizer pointer 23. Array 22 includes a housing 34, bilateral shutters 36, and a plurality of IR-reflective spheres 38 arranged in a calculated manner at various locations on the array 22 such that their position information is selectively detectable by the IR sensor 20. Housing 34 comprises a top housing 40, bottom housing 42, and a distal threaded aperture 56 configured to threadably receive the threaded end 78 of a stylus (e.g., stylus 24, 26, 28, and/or 30). Top housing portion 40 is further comprised of upper portion 44, underside 46, and sides 48. A plurality of sphere apertures 52 extend between upper portion 44 and underside 46 and are sized and dimensioned to receive reflective spheres 38 within recessed pockets 54. Each side 48 includes cutout 50 sized and dimensioned to receive tongue 70. Bottom housing 42 is comprised of a first face 58 and a second face 60. The first face 58 includes nesting platforms 62 and bullet posts 64. Each shutter 36 includes handle portion 66, cover portion 68, tongue 70, interdigitating gear teeth 72, and channel 74 for receiving bullet posts 64. A spring 76 extends between the two shutters 36 and is held in place via spring posts 71.
In an assembled state, each IR-reflective sphere 38 is nested on a platform 62. Top housing 40 is placed over bottom housing 42 in a snap fit configuration such that each IR-reflective sphere 38 fits within a recessed pocket 54 within its respective sphere aperture 52. According to one implementation, bilateral shutters 36 are positioned over the housing 34 with tongues 70 sliding into cutouts 50 such that each shutter cover 68 obscures exactly one half of the IR-reflective sphere 38 (for example, the middle IR-reflective sphere 38) as depicted in FIG. 2.
As depicted in FIG. 5, the IR-reflective tracking array 22 mates with one or more surgical objects (for example styluses 24, 26, 28, 30). Each stylus 24, 26, 28, 30 includes a threaded proximal end 78 for mating with the threaded distal aperture 56 of the IR-reflective tracking array 22, elongate shaft 80, and shaped distal tip 82. Shaped distal tip 82 may be any shape that is complimentary to, and fits securely within, the shape of a particular screw head. For example, FIG. 6 shows styluses 24, 26, 28, and 30 each with a different shaped distal tip designed to mate with different open screw systems, minimally-invasive screw systems, and closed tulip, iliac, and offset connector systems. The distal tip 82 is preferably inserted into each screw while orienting the digitizer pointer coaxial to that screw (or other fixation device).
According to some implementations (for example, the implementations shown with respect to styluses 24, 26, and 28), the length of the elongate shaft 80 is fixed relative to the array 22 such that all digitized points are a consistent length from the geometry of the IR-reflective markers 38 and position information may be obtained from this relationship. According to other implementations (for example, the implementation shown with respect to offset pointer 30), the length of the elongate shaft 80 is adjustable relative to the array 22 such as that shown with stylus 30, effectively elongating the distance from the digitized point and the IR-reflective markers. This longer distance translates to digitization of a point above the actual screw head based on the distance the user adjusted the elongate shaft 80. As will be appreciated in conjunction with the discussion below, the resulting bend instructions would shape a rod that traverses that point above the screw allowing the user to reduce the screw to the rod.
As shown in FIGS. 6-8, offset pointer 30 includes an elongate tubular member 84 and an inner piston 86. Elongate tubular member 84 is comprised of a milled helical slot 104 and a plurality of offset depth slots 106 located around the helix that correspond to a plurality of offset distances as will be described below. Inner piston 86 includes shaft 88, T-shaped cap 92, springs 94, and bushing 96. The T-shaped cap 92 is positioned over the proximal end of the shaft 88 and is preferably welded to the proximal end 105 of the elongate tubular member 84. Springs 94 are slideably positioned along the length of the shaft 88 between the distal end 93 of the T-shaped cap 92 and bushing 96. Bushing 96 is positioned over the distal end of the shaft 88. Pin 100 is travels through, and protrudes laterally from, slots 90, 98 on the inner shaft 88 and bushing 96, thereby securing the bushing 96 to the inner shaft 88. The pin 100 is sized and dimensioned such that it travels through the helical slot 104 and be positioned within each of the offset depth slots 106.
The offset pointer 30 gives the user the ability to execute planned screw movement by a specific amount. The user inserts the offset pointer 30 into the screw head. Keeping the distal tip 82 engaged to the screw head, the user then selects an offset amount to be added to the screw and angles the offset pointer 30 in the direction he or she wishes to apply the offset to. To adjust between offset depth slots 106, the shaft 88 is pulled away from the array 22 and twisted until the pin 100 falls into the desired offset slot 106. As the shaft 88 is pulled, it telescopes in and out of the elongate tubular member 84 such that the distance between the shaped distal end 82 and the array 22 is increased. For purposes of illustration, FIG. 8 shows the offset pointer 30 with the pin 100 in the 16 mm offset slot 106 corresponding to a 16 mm offset between the pointer 30 length and the IR-reflective array 22. Offset options may be provided, by way of example only from 0 mm to 16 mm offsets in 2 mm increments. The system 10 will then acquire position information at that
The digitizer pointer 23 may be used to acquire positional information about some or all screw locations. According to a preferred embodiment, the shaped distal tip 82 is coaxially aligned into the screw head and the array 22 is triggered to register the screw point. Screw locations may be digitized in a superior-inferior or inferior-superior direction. According to some implementations, the first screw location digitized correlates to the rod insertion direction component of the bend instructions (described below). Squeezing handles 66 activates the spring mechanism and permits the shutters 36 to open equally via the interdigitating gear teeth 72 (FIG. 4). Opening the shutter covers 68 exposes the middle IR-reflective sphere 38 and allows the IRtracking array 22 to be “seen” by the IR sensor 20 and the position of the digitizer pointer 23 to be digitized. In this way, the IR sensor 20 only recognizes the digitizer pointer 23 once the middle sphere 38 is exposed which allows for point-by-point tracking and obviates the sensing and digitization of one or more unnecessary data points which may occur with prior art systems that continually track surgical objects. Further, use of the gear mechanism allows the passive IR-reflective sphere 38 to be “seen” symmetrically by the IR sensor 20, thereby enabling a more accurate calculation of position information by the system 10. According to some implementations, the control unit 16 emits an audible sound to notify the user that the middle sphere 38 is recognized by the IR sensor 20 and the screw point is acquired. Once a point has been registered, the shutter handles 66 may be released, thereby closing the bilateral shutters 36. This process is then repeated for all screw locations to be digitized.
In accordance with the present invention, there are provided a plurality of algorithms for achieving rod bends. The surgical bending algorithms may be divided into two smaller sub-systems: (1) the spatial location algorithms that acquire, collect, and digitize points in space and (2) the bending algorithms that analyze the points and calculate the bend instructions and rod length needed to bend a rod with the mechanical bending device 18.
As set forth above, the spatial tracking system 12 measures the six degrees of freedom (6 DOF) information for the tracked IR-reflective spheres 38. These data provide the full pose (position and orientation) of each screw of interest which may then be made available to the algorithm library to calculate the bend instructions. FIG. 10 is a flow chart indicating the steps of the spatial location data acquisition process according to one embodiment. The system 10 initializes the sensor objects from configuration to connect to, control, and read data from the IR sensor 20 (step 140). The system 10 then inspects all devices connected to it and finds the device with a device ID that corresponds to the IR sensor 20 (step 141). At step 142, if an IR sensor 20 is found at step 141, the system 10 continues to establish a connection with the IR sensor 20 (step 143). However, if not the system 10 continues to search. After the system 10 connects to the IR sensor 20, it then loads a tool file that defines the array 22 (step 144). After initialization and tool file loading, the IR sensor 20 must prepare for taking data. At step 145, the IR sensor 20 is enabled and ready to generate positional data but is left idle until tracking is enabled. By way of example and as described with reference to FIG. 17, selecting the position of the IR sensor 20 with respect to the patient's body causes the control unit 16 to send the IR sensor 20 a command to begin tracking. With tracking enabled (step 146), the IR sensor 20 may be polled to for data (step 147). Preferably, new data is requested twenty times per second from the IR sensor 20. At step 148, the data generated from polling the IR sensor 20 is checked to ensure that it is reporting valid data. The data may be considered valid if all of the IR-reflective spheres 38 are visible to the IR sensor 20, the digitizer pointer 23 is fully inside the IR sensor's 20 working volume, there is no interference between the IR sensor 20 and the digitizer pointer 23, and both the location and rotation information reported are not null. At step 149, if the data is not deemed valid, then the digitized point is not used by the system 10 and polling is resumed. If the fifth IR-reflective sphere 38 (i.e. the middle sphere) is visible on the digitizer pointer 23 (step 150), the process of collecting positional data for the bend algorithm commences. If the middle sphere 38 is not visible, then the data is available to the system 10 only to show proximity of the IR sensor 20 and IR-reflective tracking array 22 (step 151). Points used by the bend algorithm are preferably an average of several raw elements (step 152). Normally, five points are collected at this step before the points are processed and made available to the bend algorithm. The position data is averaged using a mean calculation. The directions are averaged in the quaternion representation (raw form) then converted to a unit direction vector. The data is rotated from the spatial tracking system 12 coordinate from into the system 10 coordinate frame using a rotation matrix. At step 153, after all processing, the data is available for the bend algorithm to collect and process further as will be described in greater detail below.
The surgical bending software takes the location and direction data of the screw locations as described above and uses one or more geometry-based algorithms to convert these relative screw locations into a series of bend instructions. FIG. 11 is a flow chart indicating the steps of the surgical bending process according to a first embodiment. At the input validation step 154, the system 10 may validate the system inputs to ensure the rod overhang is greater than zero, validate the sensor setup to ensure that the IR sensor 20 location has been set, and validate each of the acquired points. By way of the example, the validation of each of the acquired points ensures, for example, that there are at least two screw points digitized, no two screw locations are too far apart, no two screw locations are too close together, and the span between the superior-most and inferior-most screw locations is not longer than the longest available rod.
At the transformation step 155, the data may be centered and aligned such that the first data point acquired is set at the system 10 coordinate's origin and all data is aligned to the x-axis of the system's coordinates thereby reducing any potential misalignment of the IR sensor 20 relative to the patient's spine.
At the rod calculations step 156, the system 10 may perform rod calculations for a straight rod solution, a pre-bent rod solution, and a custom-bend solution. For a straight rod solution, the system 10 first determines the length of a straight rod that will span all of the screw locations. This length may be calculated to accommodate each of the screw heads, hex and nose lengths of the rods chosen, and the user's selected rod overhang length. The system 10 then fits the data to a straight line, if the screw data is within tolerance of the straight line, then the bend instructions will return a straight rod, otherwise it will return no rod solution and proceed to look for a pre-bent rod solution. By way of example only, the tolerance may be 2 mm in each of the sagittal and coronal planes.
For a pre-bent rod solution, the system 10 first determines the length of the shortest pre-bent rod from the available rod from the available rods (as will be described in greater detail below) that will span all of the screw locations. This length may be calculated to accommodate each of the screw heads, hex and nose lengths of the rods chosen, and the user's selected rod overhang length. Next, the system 10 fits the digitized screw data to a circular arc in 3-dimensional space. If the screw data is within the tolerance of the arc, then the bend instructions will return a pre-bent rod solution, otherwise it will return no rod solution and proceed to look for a custom-bend rod solution. By way of example, this tolerance may be 2 mm in each of the sagittal and coronal planes.
FIG. 12 depicts a flow chart of a custom bend algorithm according to one embodiment. At step 158, screw location and direction data is generated by the spatial tracking system 12 as set forth above. The data is then projected into two planes: the x-y plane (coronal view) and the x-z plane (sagittal view). Each projection is then handled as a 2D data set. At step 159, a fixed size loop is generated over small incremental offsets for the first bend location for the end of the rod which optimizes the ability of the bend reduction step 162 to make smooth solutions. At step 160, the system 10 creates a spline node at each screw location and makes a piecewise continuous 4th order polynomial curve (cubic spline) through the screw points. At step 161, the smooth, continuous spline is sampled at a regular interval (e.g., every 1 cm) along the curve to generate an initial set of proposed bend locations. At step 162, as many bends as possible are removed from the initial set of proposed bend locations from step 161 as possible to reduce the number of bends the user must execute on a rod in order to fit it into a screw at each digitized screw point. According to one embodiment, no bend is removed if eliminating it would: (1) cause the path of the bent rod to deviate more than a predefined tolerance limit; (2) cause any of the bend angles to exceed the maximum desired bend angle; and (3) cause the rod-to-screw intersection angle to exceed the maximum angulation of the screw head. Once the number of bends has been reduced, the 2D data sets are combined and handled as a 3D data set. The 3D line segments are then evaluated based on distance between each line segment interaction (Location), the angle between two line segments (Bend Angle), and the rotation (Rotation) needed to orient the bend into the next bend plane using the following calculations:

Location: ((X2−X1)2+(Y2−Y1)2+(Z2−Z1)2)1/2 

Bend Angle: arc-cosine(V12·V23)

    
    
        where · is the dot product and V is a vector between 2 points

Rotation: arc-cosine(N123·N234)

        where · is the dot product and N is the normal vector to a plane containing 3 points.

These calculated numbers are then tabulated to the physical design of the rod bender 18 and the selected rod material and diameter. Bend angles account for the mechanical rod bender's 18 tolerance and will account for the rod's material and diameter based on previous calibration testing performed with mechanical rod bender 18 and the specific kind of rod. Calibration testing quantifies the amount of spring-back that is expected when bending a certain rod material and diameter. By way of illustration, a 5.5 mm diameter titanium rod's spring-back can be characterized by a 1st order linear equation:

BAA=0.94*BAT−5.66

where BAT is the theoretical bend angle needed that was calculated from the 3D line segment and BAA is the actual bend angle needed to bend the rod to so it can spring back to the theoretical bend angle. Thus, using this equation, when 20 degrees of bend is calculated from the 3D line segment above, the “spring-back” equation for that rod will formulate that a 25 degree bend needs to be executed in order for it to spring-back to 20 degrees. The length of the final rod is the total of all the calculated distances plus the selected rod overhang.

    
    


Once all of the rod solutions have been generated, the loop is completed (step 163). At step 164, from all of the rod solutions generated in the loop above, the system 10 may output the rod solution having the smallest maximum bend angle (i.e., the smoothest bent rod). It is to be appreciated that the system 10 may choose the rod solution displayed based on any number of other criteria. At step 169, the system 10 then generates the three-dimensional locations of the bends in space.
Referring back to the flow chart of FIG. 11, from the geometric bend locations and/or pre-bent rod output of the rod calculations step 156 above, the system 10 generates instructions for the user to choose a straight rod, a pre-bent rod, or to custom bend a rod (step 157). All of the output instructions are human-readable strings or characters. In all cases, the length of the required rod is calculated as described above and is displayed to the user as either a cut rod or standard rod. For custom bend solutions, rods are loaded into the bender with the “inserter end” (e.g., one pre-determined end of the rod) into the bender collet 126. If, due to geometric constraints, the rod cannot be bent from the inserter end, then the instructions are flipped, and the cut (or nose) end of the rod is instructed to be put into the bender collet 126. The bend instructions are generated from the geometric bend locations and are given as “Location”, “Rotation”, and “Bend” values as will be described in greater detail below. These values correspond to marks on the mechanical bender 18.
FIGS. 13-14 depict a flow chart of a second embodiment of a custom bend algorithm. In accordance with this second embodiment, the custom bend algorithm includes a virtual bender used to render a virtual rod. The following calculations and the flowcharts of FIGS. 13-14 highlight the steps of this embodiment.
The 3D vector si=[six, siy, siz]T denotes the i'th screw digitized by the user such that the set of N acquired screws that defines a rod construct may be denoted as

s=[s0, . . . ,sN−1]ε3×N  (1)

It may be assumed that the screws have been collected in order (e.g. superior-most screw to inferior-most screw or inferior-most screw to superior-most screw) so the index i can also be thought of as the index through time.

A virtual rod (R) of length Lr given in mm is broken down into Nr uniformly distributed points, R=[r0, . . . , rNr-1]. Each rod point ri is composed of two components, a spatial component and a directional component ri={ris,rid}, where ris, ridε3. The segments between rod points is constant and defined by

δi=|ri+1s−ris|. Let Δd=Σi=0dδi, then ΔNr−1=Lr.

A virtual bender (B) consists of a mandrel (M) of radius Mr (mm). Preferably, though not necessary, the key assumption when bending the virtual rod around M is the conservation of arc length. For illustrative purposes only, if a 90° bend is introduced to an example rod R of length 100 mm around a mandrel with radius 10 mm to produce a rod {circumflex over (R)}, then

∫dR=∫d{circumflex over (R)}.  (2)

The virtual rod, R, is bent according to a list of instructions. Each instruction consists of a location (Il), rotation (Ir), and bend angle (Iθ). The location is the position of the rod in the bender and corresponds to the point directly under the mandrel M. The rotation is given in degrees (0°-360°) and corresponds to the amount the rod is rotated from 0 in the collet. The bend angle is given by a single letter that corresponds to a specific angle in degrees. There is a corresponding notch on the bender with the same letter for the user to select.
The rod is initialized (step 166) such that the spatial component ris=[Δi,0,0]T┘i=0Nr−1, and the direction component rid=[0,1,0]T|i=0Nr−1 which effectively orients the virtual rod to be at zero rotation in the virtual bender. For each bend instruction (step 167), the system 10 rotates the virtual rod around the x-axis by Ir (step 168). The system 10 finds the point {circumflex over (r)}i that matches Il. The virtual rod is translated by −{circumflex over (r)}i. Next, each rod point from i to i+Mr*Iθ is projected onto the mandrel M while preserving segment length (step 169-170). The virtual rod is then rotated around the x-axis by angle −Ir. Next, the system 10 checks that r0d=[0,1,0]T to verify that the virtual rod in the collet has the correct direction vector (step 171). At this point, R has approximated the geometry of the rod as it would be bent in the physical mechanical bender 18.
The next step is to align the bent virtual rod to the acquired screw positions (step 172). According to one embodiment, the alignment process has two stages—first, the system 100 finds the optimum rotation coarse scale (step 174). Second, the system performs the iterative closest point iteration algorithm fine scale.
Preferably, the system first initializes the result close to a global minimum (step 173). In the rod alignment algorithm, this initialization follows the approach described below:
Using the arc length of the custom rod and the arc length of the screws, putative matches from the screws to the rod are produced. This produces two 3D point sets of equal size. Given two 3D mean centered point sets Σ=[σ0, . . . , σN−1] and Γ=[γ0, . . . , γN−1], then in the least squares sense, it is desirable to minimize




  
    
      
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Where T denotes the rotation matrix. Let {circumflex over (T)} denote the optimum 3D rotation matrix, then





  
    
      
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It turns out that {circumflex over (T)}=UVT, where

C=SVD(H)=UΣVT  (5)

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Due to error potentially introduced by differences in arc length, the proposed solution may not be the global minimum. Thus, the following are repeated until convergence (step 175):
For each si, find the closest rj (step 176)
Calculate the residual vector ei=si−rj 
Calculate the average residual vector




  
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Translate the rod by ê (step 178)
Verify the error is reduced (step 179).
Next the virtual rod is rendered at step 180. The curve may be simplified for rendering purposes by traversing each triad of rod points and calculating the angle between the two vectors. If the first triad is {r0, ri, r2}, the two vectors are formed as v=r1−r0 and w=r2−r0. If |v×w|=0, then the middle point of the triad (in this case r1) is redundant, provides no new information to the geometry of the rod and may be removed.
It will be appreciated that, in accordance with this embodiment of the rod bending algorithm, the virtual bender may be capable of bending a rod at any location of any angle perfectly to observe arc length. Using a virtually bent 3D rod to determine problem screws (i.e. screw locations with a high screw-rod fit error) may give an accurate fit between the actual screws and actual rod before the actual rod is bent. This may be particularly advantageous in certain surgical applications where it is desirable to quantify the amount of offset between a rod solution and the digitized screw locations as well as input one or more surgical parameters into the rod bending calculation.
In accordance with the present invention, there is described a third embodiment of an algorithm for generating a custom bend which may be utilized in conjunction with the second embodiment. The approach is directed to one or more algorithms that sample from probability distributions and employ random sampling to obtain a numerical result. A Markov chain is a sequence of random variables, X0, X1 . . . , such that the current state, the future and past states are independent.

p(Xn+1=x|X0=x0,X1=x1, . . . ,Xn=xn)=p(Xn+1=x|Xn=xn)  (1)

Given an ordered set of screws that define a construct

S=[s0 . . . ,sN−1]ε3×N  (2)

where si=[six, siy, siz]T denotes the ith 3D screw digitized by the user, the system 10 finds the set of bend instructions that define a rod that fits the screws in an optimum way defined by an error function. It is to be appreciated that the search of the bender space is quite complex as there are several constraints that must be observed for the algorithm to produce valid bend instructions (e.g., the bend locations cannot be in close proximity to the screws, the bend locations must be in multiples of 5 mm apart, the bend angles must be in multiples of 5°, no bend angle can be greater than 60°, etc.).

In accordance with the second embodiment, the likelihood or error function may be constructed based on how well the virtual rod fits the data. Here, the rod is fit to the data in the least squares sense. In this way, a likelihood function is defined that incorporates, for example, a prior to prefer fewer bend instructions:




  
    
      
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such that the log-likelihood function may be defined as





  
    
      
        
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Where Nb denotes the number of bends in the rod, Ns denotes the number of screw locations, si is the i'th screw, ri is the i'th rod point, and α is the control hyper-parameter for the number of bends (e.g. α=0.05).

As can be seen from equation (3), there has been introduced a prior to control the number of bends introduced into the rod. This probabilistic approach to bend instruction generation allows for tailoring of constraints, for instance, a prior on the severity of the bends could also be introduced. Further, a prior could be introduced on how to define how close to the screws the bends may be located. This prior may have a “preferred” value, but probabilistically, there may be an optimal solution away from this idealized value. By way of example, some hypothesized rules that may be applied to this algorithm include, but are not limited to: birth move: add a bend to the current solution; death move; remove a bend from the current solution; update move: translate rod points along the rod. Use of this embodiment may provide more potential rod solutions to the user.
Details of the surgical bending system 10 are discussed in conjunction with a first embodiment of a method for obtaining a custom-fit rod. The system 10 is typically utilized at the end of a posterior or lateral fixation surgical procedure after screws, hooks or other instrumentation have been placed, but prior to rod insertion. As shown in the flowchart of FIG. 15, the surgical bending system 10 obtains position information of the implanted screw positions and outputs bend instructions for a rod shaped to custom-fit within those implanted screws. At step 190, pertinent information is inputted into the system via a setup screen. At step 192, the user designates which side (left or right) rod will be created. At step 194, the system 10 digitizes the screw locations. At step 196, the system 10 outputs bend instructions. At step 198, the user bends the rod according to the bend instructions. Steps 190-198 may then be repeated for the other rod.
FIG. 16 illustrates, by way of example only, one embodiment of a screen display 200 of the control unit 16 capable of receiving input from a user in addition to communicating feedback information to the user. In this example (though it is not a necessity), a graphical user interface (GUI) is utilized to enter data directly from the screen display 200. As depicted in FIG. 16, the screen display 200 may contain a header bar 202, a navigation column 204, device column 206, and a message bar 208.
Header bar 302 may allow the user to view the date and time, alter settings, adjust the system volume, and obtain help information via date and time display 210, settings menu 212, volume menu 214, and help menu 216 respectively. Selecting the settings drop-down menu 212 allows the user to navigate to system, history, and shutdown buttons (not shown). For example, choosing the system button displays the rod bending software version and rod bender configuration file; choosing the shutdown option shuts down the rod bending software application as well as any other software application residing on the control unit 16 (e.g. a neuromonitoring software application); and choosing the history option allows the user to navigate to historical bend points/instruction data in previous system sessions as will be described in greater detail below. Selecting the help menu 216 navigates the user to the system user manual. As will be described in greater detail below, navigation column 204 contains various buttons (e.g., buttons 218, 220, 222, 224, 226) for navigation through various steps in the rod bending process. Pressing button 204 expands/minimizes the details of the navigation column. Devices column 206 contains various buttons indicating the status of one or more devices associated with the surgical bending system 10. By way of example, devices column 206 may include buttons 228 and 230 for the digitizer 23 and IR sensor 20 components of the system 10, respectively. Pressing button 206 expands/minimizes the details of the devices column. Furthermore, pop-up message bar 208 communicates instructions, alerts, and system errors to the user.
FIGS. 16-17 depict an example setup screen. Upon selecting setup button 218 on the display screen 200, the surgical bending system 10 automatically initiates the setup procedure. The system 10 is configured to detect the connection status of each of its required components. By way of example only, icons 228, 230 indicate the connectivity and activity status of the digitizer 23 and IR sensor 20, respectively. If one or more required components are not connected or are connected improperly, the display 200 may alert the user to address the issue before proceeding via textual, audio, and/or visual means (e.g., textual messages, audible tones, colored icons or screens, blinking icons or screens, etc.). According to one embodiment, the digitizer icon 228 is a status indicator for the active acquisition and/or recognition of the digitizer and the presence and background color of the icon 228 may change to indicate the digitizer tracking status. By way of example, the icon 228 may be absent when the system 10 is not acquiring screws and does not recognize the digitizer, gray when the system 10 is not acquiring screws and recognizes the digitizer, green when the system 10 is in screw acquisition mode and recognizes the digitizer, and red when the system 10 is in screw acquisition mode and does not recognize the digitizer. Pressing button 206 expands minimizes the details of the device column 206. Depending on the type of surgery, type of patient deformity, etc., it may be advantageous for the user to choose a digitizer from a selection of different digitizers. According to one embodiment, pressing icon 228 expands a pull-out window for the different stylus options available with the rod bending system 10 (e.g., styluses 22, 24, 26, 30 as described above). According to another embodiment, the IR sensor graphic icon 230 is a status indicator for the IR sensor 20. The presence and background color of the icon 230 may change to indicate the status of the IR sensor 20. By way of example, the icon 230 may be absent when the system 10 does not recognize the IR sensor 20, gray when the system 10 recognizes the IR sensor 20 is connected to the system 10, and red when the system 10 senses a communication or bump error for the IR sensor 20. Preferably, the IR sensor 20 should be recognized if it is connected after initialization of the bending application.
With all of the required components properly connected to the surgical bending system 10, the user may then input one or more pieces of case-specific information from one or more drop-down menus. By way of example, drop-down menus for rod system 234, rod material/diameter 236, rod overhang 238, procedure type (not shown), and surgical levels) may be accessed from the setup selection panel 232 of the screen display 200. The rod system drop-down menu 234 allows the user to choose the rod system he/she plans to use. This selection drives choices for the rod material/diameter 236 drop-down menus. By way of example, under the rod system drop-down menu 234, the system 10 may be programmed with numerous fixation options from one or more manufacturers. Alternatively, it may be programmed with the fixation system selections for one manufacturer only (e.g. NuVasive® Precept®, Armada®, and SpherX® EXT). The user may also choose the combination of rod material (e.g. titanium, cobalt chrome, etc.) and rod diameter (e.g. 5.5 mm diameter, 3.5 mm diameter, etc.). The drop-down menu 238 for material and diameter options may preferably be dependent upon the choice of rod system. Because the geometry and sizes can vary between manufacturers and/or rod systems, programming the system 10 with these specific inputs can aid in outputting even more accurate bend instructions. The user may also choose the amount of overhang from the rod overhang pull-down menu 238. By way of example, the amount of overhang may be selectable in 0 mm, 2.5 mm, 5 mm, 7.5 mm, and 10 mm lengths. According to one embodiment, this function prescribes a symmetric overhang on both the superior and inferior ends of the rod. According to another embodiment, this function also prescribes different overhang lengths on either end of the rod based on user preference and patient anatomical considerations. Although not shown, the system 10 also contains functionality for accommodating multiple rod diameters and transitional rods as used, for example in Occipital-Cervical-Thoracic (OCT) fusion procedures.
After the setup inputs have been inputted into the setup selection panel 232, the surgical bending system 10 aids the user in setting up the IR sensor 20 in an optimal position for positional data acquisition. It is to be appreciated that any visual (textual, graphic) indicator may be used to indicate the IR sensor placement instructions. According to some implementations, an active graphic directs the user to position the IR sensor 20 relative to the digitizer array 22 held static within the patient's body. As shown in FIG. 17, the user first selects the side of the patient the IR sensor 20 is located on by selecting the left side sensor position button 242 or right side sensor position button 244 in the IR sensor setup panel 240. Choosing the left or right side sensor position button 242, 244 activates a the IR sensor positioning panel 246 such that IR sensor graphic 248 and a tracking volume box graphic 250 appear on the display screen 200. Tracking volume box 252 that moves with the IR sensor graphic 248 as the IR sensor 20 is moved. Next, the user positions the digitizer array 22 into the body of the patient. Once recognized by the system 10, a target volume box 252 (which may be displayed as white in color) is positioned over the patient graphic 254. Next, the user moves the IR sensor 20 relative to the digitizer array 22 until the tracking volume box 250 matches up to the position of the target volume box 252. According to some implementations, the IR sensor graphic 248 increases in size if it is moved superior to the target tracking volume and decreases in size if it is moved inferior to the target volume. According to some other implementations, the tracking volume box 250 may be color-coded to depict the relative distance to the target volume. By way of example, the tracking volume box 250 may be depicted in red if the distance to the target volume is outside of a certain distance in one or more axes (e.g., outside ±8 cm in all 3 axes.) and green if within or equal to ±8 cm in all 3 axes. Once the optimal position of the IR sensor 20 has been ascertained, the setup process is complete.
Once the user has completed all of the required steps in the setup screen, a graphic (e.g., a check) may appear on setup button 218 to indicate such a completion and the system 10 proceeds to step 192 in the flowchart of FIG. 15. Using the GUI, the user designates which side of the patient's spine to acquire digitized positional information from by selecting either the Left “L” toggle/status button 220 or Right “R” toggle/status button 222. The user then selects the Acquire Screws button 224 which navigates the display screen 200 to an Acquire Screws (left or right) screen shown by way of example in FIGS. 18-20. In Acquire Screws mode, the display screen 200 includes a sagittal view panel 256 and a coronal view panel 258 with spine graphics 260, 262 in each of the sagittal and coronal views, respectively. Spine graphic 260 may flip orientation depending on which side of the spine the user is digitizing (left or right). Additionally, spine graphic 262 may highlight the side of the patient the user is digitizing (left or right). The user may digitize the location of each implanted screw using, by way of example, the digitizer pointer 23 as described above. As each screw point 264 is digitized, its relative location with respect to the other acquired screw points 264 can be viewed in both sagittal and coronal views via the sagittal view panel 256 and the coronal view panel 258 as shown in FIG. 19. Optionally, the last screw point digitized may have a different graphic 266 than the previously-acquired screw points 264 (by way of example, the last screw point acquired 266 may be a halo and the previously-acquired screw points 264 may be circles). The screws locations may be digitized from a superior-to-inferior or inferior-to-superior direction and according to some embodiments, the system 10 can detect which direction the digitization is occurring in after the acquisition of two consecutive screw point locations. If during the digitization process, the user wishes to delete a digitized screw point, he/she may do so by pressing the “Clear Point” button 270. If the user wishes to delete all digitized screw points, he/she may do so by pressing the “Clear All Points” button 268.
Once the digitized screw points 264 are deemed acceptable, the user may press the “Calculate Rod” button 272 which initiates the curve calculation preferably using one of the algorithms discussed above. Once a rod solution has been calculated, a rod graphic 274 populates through the screw points 264, 266 and a confirmation graphic (e.g., a check) may appear on the “Acquire Screws” button 224 to indicate that the system 10 has generated a rod solution. Simultaneously, the “Calculate Rod” button 272 becomes the “Undo Rod” button 272. If the user presses the “Undo Rod” button 272, the rod solution 274 is cleared and the user may acquire more screw points or clear one or more screw points. After the “Undo Rod” button 272 is pressed, it then changes back to the “Calculate Rod” button 272. Optionally, the system 10 may include a visual graphic for where along a rod the curve calculation is generating a severe bend (acute angle). The user may select “Undo Rod” button 272, perform one or more surgical maneuvers (e.g. reduce the screw, backup the screw, adjust the screw head, etc.), redigitize the screw point, and generate a more feasible solution. If the rod solution is acceptable to the user, the Screw Acquisition step 194 is complete and the system 10 proceeds the Bend Instructions step 196 in the flowchart of FIG. 15.
The user then selects the “Bend Instructions” button 226 which navigates the display screen 200 to a Bend Instructions (left or right) screen shown by way of example in FIG. 21. The bend instructions within the bend instructions panel 276 allows the user to view the bend instructions corresponding to the resulting rod solution in the Acquire Screws screen (FIG. 20). By way of example, the bend instructions panel 276 contains three fields containing various aspects of the bending instruction: upper message field 278, bender instructions field 280, and lower message field 282. By way of example, the upper message field 278 may communicate the rod cut length, rod type, and/or rod loading instructions to the user (e.g. “Cut Rod: 175.00 mm Load Inserter End Into Bender”). The bender instructions field 280 displays rows 284 of bend maneuvers in location 286, rotation 288, and bend angle 290 to perform on the mechanical bender 18 as will be described in greater detail below. In the example shown in FIG. 21, there are five rows indicating five bend instructions. The lower message field 282 may communicate the direction of insertion or orientation of implanting the rod to the user. For example, the lower message field 282 shown in FIG. 21 provides the following sample instruction: “Insert Rod head to foot.” In some implementations, the rod insertion direction into the patient is dependent on the sequence of screw digitization (superior-to-inferior or inferior-to superior). According to one or more preferred embodiments, the bend instruction algorithm takes into account the orientation of the inferior, superior, anterior, and posterior aspects of the rod and ensures that these aspects are known to the user. As the instructions for use direct the user to load the rod into the bender, the system 10 manages which bends are imparted on the rod first based on the severity of the bend angles. The section of the bend instructions with greater bend angles may be performed first then the straighter bend sections of the bend instructions are performed last. Further, the instructions may also direct the user to align a laser line or orientation line on the rod to an alignment arrow (not shown) on the mechanical rod bender 18. This alignment controls the Anterior/Posterior orientation of the rod geometry and generates bend instructions accordingly. The user follows the bend instructions generated by the system 10 for location (location may be color-coded on the bender 18 and on the screen 200 as green triangle), rotation (rotation may be color-coded on the bender 18 and on the screen 200 as red circle), and bend angle (bend angle may be color-coded on the bender 18 and on the screen 200 as blue square), sequentially, starting at the first bend instruction and working sequentially until the final bend is completed. From here, the user may repeat steps 190-198 on the construct for the opposite side of the spine.
Within a surgical procedure, a user may wish to toggle between left and right screens to view left and right digitized screw points, rod previews, and bend instructions for reference or comparison. Selecting the Left “L” toggle/status button 220 and right “R” toggle/status button 222 allows the user to do so. According to one more implementations, the GUI may additionally include a History feature. Selecting the History button (not shown) will allow the user to refer back to any previous rod bending solution. The user navigates to the Bend Instructions screen 226 based on choice of the L/R toggle buttons 220,222 and pressing Bend Instruction button 226. If navigating to previous bend instructions, the Bend Instructions screen will display previous bend instructions. Once the user has selected the desired rod solution, the user then executes the bends using the mechanical bender 18.
The embodiments described with respect to FIGS. 15 and 18-21 above contemplate digitizing the implanted screw positions and outputting bend instructions for a rod shaped to custom-fit within those implanted screws. In one or more additional embodiments, the system 10 obtains position information of the implanted screws (steps 192 and 194), accepts correction inputs via one or more advanced options features (step 195), and generates for viewing bend instructions for a rod shaped to fit at locations apart from those implanted screw positions (step 196) as depicted in the flowchart of FIG. 22. Installing a rod shaped in this manner could correct a curvature or deformity in the patient's spine according to a user's prescribed surgical plan. Details of the surgical bending system 10 are discussed now discussed with examples for obtaining a rod bent according to one or more surgical plans.
As depicted in FIG. 23, selecting the “Advanced Options” button 292 expands an Advanced Options menu 294 from which the user may perform one or more corrections to the digitized screw points and the system 10 generates bend instructions that will achieve those desired corrections on the patient's spine once the rod is implanted and the screws are brought to the rod.
In some surgical procedures, a user may wish that the rod bend solution will consider a point that is not a digitized screw point in determining the bend instructions. According to some implementations, this point is an adjusted distance from the digitized screw point location. Selecting the “Adjust Points” button 296 from the Advanced Options menu 294 navigates the user to an Adjust Points screen as depicted in FIG. 23. Selecting a digitized screw location of interest (for example the screw point represented as dot 304 in FIG. 24) highlights the screw point and brings up an adjust points control 306 in each of the sagittal and coronal views 256, 258. The user adjusts point 304 to its desired location in the sagittal and coronal planes using arrows 308, 310, 312, and 314. In some implementations, as the point moves, dot 304 changes color based on the distance from the originally digitized screw location as shown in FIG. 25. Preferably, that color corresponds to color-coded offset distance indicator 322 which provides visual feedback to the user as to the distance the point has been adjusted. As depicted by way of example, dot 304 appears yellow in FIG. 25 indicating that the point has moved 4 mm in each of the sagittal and coronal planes. In some implementations, the system 10 may have a maximum distance from the digitized point past which it will not allow the manipulated point to exceed (by way of example only, this distance may be 5 mm). The user may adjust as many points as desired in this fashion. The user may reset all adjusted points to their original configurations via “Reset” button 316 or may undo the last adjusted point via the “Undo Last” button 318. Once satisfied with the adjusted points, the user may either proceed to one or more additional advanced options as set forth below or select “Calculate Rod” 272. Once “Calculate Rod” 272 has been selected, the system 10 generates a rod in which the curve traverses the adjusted points, as in FIG. 26, thereby creating a correction-specific rod and providing the user with the ability to correct the curvature or deformity in the spine to his or her prescribed curve.
According to other implementations, a user may wish for a smoother rod bend. When the “Virtual Point” button 320 (shown by way of example in FIG. 25) is selected, the system 10 allows the user to add an additional point anywhere in between the superior-most and inferior-most digitized screw locations. While there is no screw at this location, this point is taken into consideration during the curve calculation and may coerce the curve into a more natural shape yielding a smoother rod bend. Once satisfied with the virtual points, the user may either proceed to one or more additional advanced options as set forth below or select “Calculate Rod” 272 and as described above, the system 10 generates a correction-specific rod solution 274 that the user may use to correct the spine to the shape of the rod.
It may be advantageous for some patient anatomies for a user to use a pre-bent rod. Use of a pre-bent rod eliminates the need for making additional bends to a rod while assuring that a desirable rod curve is achieved. After all screw points have been digitized in the Acquire Screws step 194, selecting the “View Pre-Bent Rod” button 298 from the Advanced Options menu 294 navigates the user to a “View Pre-Bent Rod” screen as depicted in FIGS. 27-28. Based on the digitized screw locations shown in FIG. 27, the system 10 calculates and outputs the best pre-bent rod geometry based on the selected manufacturer's rod system that was chosen during the setup step 190 (e.g. NuVasive® Precept®) and displays the best fit virtual pre-bent rod solution 324 available on top of the digitized screw points for viewing in the sagittal and coronal views 256, 258 (see FIG. 28). Preferably, the system 10 only generates a pre-bent rod solution if the geometry of the pre-bent rod fits the digitized screw points within a predetermined curve fitting tolerance (e.g. 7 mm). According to one or more embodiments (as depicted in FIG. 28), a color-coded offset distance indicator 322 may provide the user with an indication of the distance each screw position will be from the pre-bent rod construct. If the user is satisfied with the pre-bent rod suggestion, the system 10 proceeds to the Bend Instructions step 196 which displays the corresponding pre-bent rod specifications in the Bend Instructions Screen (FIG. 29). The upper message field 278 instructs the user that, based on the digitized screw points, an 85.0 mm pre-bent rod is recommended. From here, the user may decide whether the patient's anatomical and surgical requirements would be better suited with a pre-bent option or a custom-bent option. Armed with the information from FIGS. 27-29, the user may then adjust the screw positions to fit the pre-bent rod if needed (e.g., adjust the screw head, adjust the screw depth, etc.).
In some instances, a user may want to align or correct the patient's spine in the sagittal plane (i.e., add or subtract lordosis or kyphosis). The surgical bending system 10 includes a sagittal correction feature in which the user is able to measure the amount of lordosis in the spine and adjust angles in the sagittal plane. The system 10 then incorporates these inputs into the bend algorithm such that the rod solution includes the desired alignment or correction.
Selecting the “View Vectors” button 300 from the Advanced Options menu 294 initiates the sagittal correction feature. The user may select at least two points of interest and the system then determines the appropriate vector in the sagittal view. According to the embodiment shown in FIGS. 30-31 and 33, the angles are measured and adjusted based on the screw trajectory screw axis position) using the digitized screw data acquired in the Acquire Screws step 194. As shown in FIG. 30, the user selects at least two screw points of interest (e.g., screw points 338 and 342). The system 10 then measures the angle between the screw trajectories (shown here as 35 degrees). In some implementations, the system 10 may measure the total amount of lumbar lordosis by measuring the lumbar lordosis angle 334 in the superior lumbar spine (shown in FIG. 30 as 15 degrees) and the lumbar lordosis angle 336 in the inferior lumbar spine (show in FIG. 30 as 35 degrees). Using the angle adjustment buttons 328, 330 on the Angle Adjustment Menu 326, the user may increase or decrease the desired angle correction of the spine in the sagittal plane (i.e., add or subtract lordosis or kyphosis superiorly or inferiorly). As the angle is adjusted, the angular position 336 between the two screw points 338, 342 is changed as well. FIG. 31 illustrates an example in which the angular position 336 between points 338 and 342 is increased to 50 degrees). The system 10 may include a color-coded offset distance indicator 322 to provide the user with an indication of the distance each digitized screw position will be adjusted in the sagittal plane as described above. Once the desired amount of angular correction is achieved, the user may select the “Set” button 332, and then the “Calculate Rod” button 270. The system 10 then displays a rod solution 274 incorporating the user's clinical objective for correction of the spine in the sagittal plane as depicted in FIG. 33.
According to the embodiment of the sagittal correction feature shown in FIG. 32, the superior and inferior lumbar lordosis angles 334, 336 are measured, displayed, and adjusted referencing anatomy from an imported lateral radiographic image. By way of example, lateral radiographic image 358 may be inputted into the system 10. The user may touch the screen 200 and move lines 360 over at least two points of interest (e.g. the superior endplate of V1 and the inferior endplate of V3) and the system 10 then measures the angle between the two lines 360. The Using the angle adjustment buttons 328, 330 on the Superior Angle Adjustment Menu 346 or Inferior Angle Adjustment Menu 348, the user may increase or decrease the desired angle correction of the spine in the sagittal plane (i.e., add or subtract lordosis or kyphosis superiorly or inferiorly). As either the superior or inferior lumbar lordosis angle is adjusted, the amount of adjustment is dynamically altered in its respective angle measurement box (i.e., either superior lumbar lordosis angle box 354 or inferior lumbar lordosis angle box 356). As depicted in FIG. 32, the user adjusts angle lines 360 as part of the inferior lumbar lordosis angle. The system 10 measures this angle as 20 degrees as depicted in angle measurement field 350. The user then uses button 330 in superior angle adjustment menu 346 to increase the angle. This change is depicted in inferior lumbar lordosis angle box 356. Once the desired amount of correction is achieved, in this example, it is achieved at 50 degrees. The user may then press the capture angle button 352 and this parameter may be correlated to the digitized screw positions corresponding to the vertebral levels that those angles were measured off of. The system 10 may include a color-coded offset distance indicator 322 to provide the user with an indication of the distance each digitized screw position will be adjusted in the sagittal plane as described above. Once the desired amount of angular correction is achieved, the user may select the “Set” button 332, and then the “Calculate Rod” button 272. The system 10 then displays a rod solution 274 incorporating the user's clinical objective for correction of the spine in the sagittal plane as depicted in FIG. 33.
It is to be appreciated that, because patient position (e.g., pelvic tilt) may have an effect on the lumbar lordosis measurements, the sagittal correction feature of the system will be able to account for any patient positioning-related deviations. It will also be appreciated that in addition to lordotic corrections, the sagittal angle assessment tool may be useful for other types of surgical maneuvers, including but not limited to pedicle subtraction osteotomy (PSO) procedures and anterior column reconstruction (ACR) procedures.
In some instances, a user may want to align or correct the patient's spine in the coronal plane (i.e., correct scoliosis). The system 10 includes a coronal correction feature in which the user is able persuade one or more screw locations towards a particular coronal alignment profile by manually or automatically biasing which direction the rod bend curve is adjusted. The system 10 then incorporates these inputs into the bend algorithm such that the rod solution includes the desired alignment or correction.
Selecting the “Coronal Correction” button 302 from the Advanced Options menu 294 initiates the coronal correction feature. The user may select at least two points of interest and the system then generates a best fit reference line through all points including and lying between the at least two points of interest. In some instances, the ideal correction of the spine in the coronal plane is a straight vertical line extending between the superior-most and inferior-most screw locations of interest. However, depending on a patient's individual anatomy, achieving a straight vertical line may not be feasible. The user may wish to achieve a certain amount of correction relative to the ideal correction. From the display screen, the user may select a percentage of relative correction between the screw points as digitized (0% correction) and the best fit reference line (100%). Furthermore, the system then calculates a rod solution and shows an off-center indicator 322 to provide a user with an indication of the distance each screw is from the coronally-adjusted rod construct as wet forth above.
According to the embodiment shown in FIGS. 34-37, the user may straighten all points within the construct (global coronal correction). From the display screen 200, the superior and inferior screw points 362, 364 are selected and the system 10 generates a best fit global reference line 366 through all points 362, 364, 368. Using the Coronal Correction Menu 370, the user manipulates the + and − buttons 372, 374 to adjust the percentage of correction desired. In the example shown in FIG. 36, the amount of desired correction is shown as 100% on the percentage correction indicator 376, meaning the rod solution 274 will be a straight line in the coronal plane and all screw locations will be adjusted to fit the rod/line. As depicted in FIG. 36, the system 10 may include a color-coded offset distance indicator 322 to provide the user with an indication of the distance each digitized screw position will be adjusted in the coronal plane as set forth above. If the user deems this an acceptable rod solution, the user selects the “Calculate Rod” button 272 to view the rod solution 274 (FIG. 37) and receive bend instructions or proceeds to another advanced feature as will be described in greater detail below.
According to the embodiment shown in FIGS. 38-40, the user may straighten a subset of the screw points within the construct (segmental coronal correction). Based on the sequence those points are inputted into the system, a best-fit segmental reference line is generated through the points in the direction of the last chosen point. If an inferior point 364 is selected first and then a superior point 362 is selected second, the system 10 will draw the best-fit segmental reference line 378 superiorly as shown in FIG. 38. Conversely, if a superior point 362 is selected first and then an inferior point 364 is selected second, the system 10 will draw the best-fit segmental reference line 378 inferiorly. Using the Coronal Correction Menu 370, the user manipulates the + and − buttons 372, 374 to adjust the percentage of correction desired. In the example shown in FIG. 39, the amount of desired correction is shown as 100% on the percentage correction indicator 376, meaning the rod solution 274 will be a straight line in the coronal plane and all selected screw locations will be adjusted to fit the rod/line. As shown in FIG. 40, however, unselected screw locations 380 will not be adjusted to fit the rod/line and their relative locations will be inputted into the system 10 and taken into consideration when the rod calculation is made. As depicted in FIG. 39, the system 10 may include a color-coded offset distance indicator 322 to provide the user with an indication of the distance each digitized screw position will be adjusted in the coronal plane as set forth above. If the user deems this an acceptable rod solution, the user selects the “Calculate Rod” button 272 to view the rod solution 274 (FIG. 40) and receive bend instructions or proceeds to another advanced feature as will be described in greater detail below.
In some spinal procedures (e.g., anterior column deformity correction procedures), restoring a patient's spine to a balanced position may be a desired surgical outcome. The surgical bending system 10 may include a Global Spinal Balance feature configured to receive preoperative and/or theoretical spinal parameter inputs, use these spinal parameter inputs to determine a target rod shape that will restore or improve spinal balance, display the balanced rod curvature and how that rod would traverse the screws in the deformed spine, and output a target rod that may be used to correct the spine to the rod and achieve a desired balanced alignment. Depending on user preference, these spinal parameters may comprise Pelvic Incidence (PI), Pelvic Tilt (PT), Sacral Slope (SS), Lumbar Lordosis (LL), Superior Lumbar Lordosis (↑ LL), Inferior Lumbar Lordosis (↓LL), C7 Plumb Line offset (C7PL), and Thoracic Kyphosis (TK) measurements. The surgical bending system 10 may be further configured to assess spinal parameter inputs intraoperatively to determine how the surgical correction is progressing.
FIG. 41 depicts a flowchart indicating the steps of the Global Spinal Balance feature according to one embodiment. At step 390, the system 10 inputs a patient's preoperative spinal parameter measurements. Next, the system generates theoretical target spinal parameter measurements (step 392). One or more target spinal parameter measurements may be optionally adjusted the user in accordance with a surgical plan a step 394. At step 396, a target spinal rod may be scaled to match the patient's anatomy using the theoretical or adjusted target spinal parameter measurements from step 392 or 394. This scaled target rod may then be displayed 398 to the user. Optionally, the system 10 may generate one or more measurements (step 400) during the surgical procedure. At step 402, the target spinal parameter data may then be adjusted based on the intraoperative measurements from step 400. Finally, the system 10 may generate bend instructions for balanced spine correction.
The user may input a patient's preoperative measurements into the system 10 as depicted, by way of example in FIG. 42. Selecting the Pre-Op measurement button 404 allows the user to input measurements into PI, LL, Superior LL, Inferior LL, C7PL, and TK input fields 408, 410, 412, 414, 416, 418, and 420 respectively. These pre-operative anatomical measurements may be used to understand the imbalance in the patient's deformed spine as well as help determine an operative plan to implant devices that would adjust or form the spine to a more natural balance (e.g., rods, screws, a hyperlordotic intervertebral implant, etc.).
As depicted in FIG. 43, the global spinal balance feature allows the user to adjust the patient's anatomical measurement values to the user's preferred target spinal parameters for a balanced and/or aligned spine. According to one implementation, selecting the target measurement button 406 populates measurements into input fields 410, 412, 414, 416, 418, 420 that represent an ideal or properly balanced spine. If the user accepts these target spinal parameters, the system 10 would output a theoretical rod solution comprising rod shapes and curves representing an ideal or properly balanced spine scaled and overlaid onto the digitized screw points as shown in FIG. 44. The system 10 may also include a color-coded offset distance indicator 322 to provide the user with an indication of the distance each digitized screw position is from the rod solution in the sagittal and coronal planes as set forth above. Alternatively, if the user seeks to achieve a different alignment, he or she may use buttons 422, 424, 426 to adjust these target spinal parameters. The user could then refer to the correction indicator 428 for an indication of how much correction (relative to the pre-operative and theoretical spinal parameters) would be achieved based on those adjusted input correction values. The user's input correction values would then drive the rod bending algorithm (based on the digitized screw locations) to a rod shape customized to the user's plan for that particular placement. The final rod could be positioned within the patient and the screws and spine would be adjusted to the rod at the desired alignment.
In accordance with the Global Spinal Balance feature, spinal parameter inputs may be assessed intraoperatively. For example, the user may wish to intraoperatively measure the amount of lumbar lordosis that has been achieved (for example, after placement of an intervertebral implant). As depicted in FIGS. 45-46, the system 10 may include be configured to obtain or import one or more lateral images, generate one or more lines between two or more landmarks on the patient's anatomy, determine a relationship between those landmarks, and adjust one or more spinal parameters to be used in generating the rod solution. As shown by way of example in FIG. 45, the user first selects the intraoperative measurement button 408. Next, lateral radiographic image 358 may be inputted into the system 10. The user may touch the screen 200 and move lines 360 over at least two points of interest (e.g. the superior endplate of V1 and the superior endplate of V2) and the system 10 then measures the angle between the two lines 360. As shown in FIG. 45, the system 10 measures this angle as 15 degrees as indicated in the angle measurement field 350. Optionally, the system may compare the intraoperative measurement to the preoperative and/or target spinal parameter value and provide an indication to the user of how much correction has been achieved relative to the pre-operative and theoretical spinal parameters. Using the angle measurement buttons 328, 330, the user may increase the desired angle of correction of the spine in the sagittal plane (i.e., add or subtract lordosis or kyphosis). As the angle is adjusted, the amount of adjustment may dynamically displayed within angle measurement field 350. The system 10 may include a color-coded offset distance indicator (not shown) to provide the user with an indication of the distance each digitized screw position will be adjusted in the sagittal plane as described above. Once the desired amount of angular correction is updated, the user may press the “Set” button 332 and then the “Calculate Rod” button (not shown in this view). The system then displays a rod solution 274 incorporating the user's intraoperative objective for correction of the spine in the sagittal plane.
The user may also wish intraoperatively measure the patient's pelvic incidence angle. As shown in FIG. 47, selecting the intra-op measurement button 408 optionally brings up a PI assessment tool. The system 10 obtains a fluoroscopic image 452 of the patient's pelvis. The user first selects the femoral head button 432 and uses arrows 450 on the PI Adjustment Menu 448 to locate the center point of the femoral head 434. Next, the user selects the posterior sacrum button 436 and uses arrows 450 to identify the posterior aspect of the sacral endplate 438. Then, the user selects the anterior sacrum button 440 and uses arrows 450 to identify the anterior aspect of the sacral end plate 442. With all PI inputs selected, the user may press the “Draw PI” button 446 after which the system 10 automatically draws and measures the pelvic incidence angle 446 for the user.
In some circumstances, the user may want to assess the amount/severity of coronal plane decompensation and/or intraoperatively ascertain the amount of correction achieved with a given rod bend configuration. The system may include a Coronal Offset Assessment feature configured to obtain or import one or more Anterior-Posterior images, acquire digital position information regarding landmarks on the patient's anatomy, generate one or more lines between those landmarks, and determine a relationship between those landmarks.
According to some implementations, the system 10 first obtains a fluoroscopic image 454 of the iliac sacral region (FIG. 48). The user digitizes two points 456 and selects the Iliac Line: Set button 460 to establish a horizontal iliac line 458. Next, the user digitizes the midpoint 462 of the sacrum and selects the CSVL Line: Set button 466 and the system 10 automatically generates an orthogonal line (CSVL line 464) from the sacral midpoint 462 to the iliac line 458. The system 10 then obtains a fluoroscopic image 468 of the C7 vertebra as depicted in FIG. 49. The user digitizes the midpoint 470 of the C7 vertebra and selects the “C7PL: Set” button 474 and the system 10 automatically generates an orthogonal line (C7PL line 476) from the midpoint 470 of C7 to the iliac line 458. Finally, the system 10 calculates the coronal offset distance (in box 476) using the offset distance between the CSVL line 464 and the C7PL line 476 line. As such, the user is given an intraoperative assessment of the amount of coronal offset corrected or left to be corrected which affords the opportunity to decide if a surgical planning goal has been achieved or if one or more spinal parameter inputs need to be updated with respect to coronal alignment.
Once the user has selected the desired rod solution, the user then executes the bends using a mechanical rod bender 18. It is contemplated that the mechanical rod bender 18 may be any bender that takes into account six degrees of freedom information as it effects bends onto a spinal rod. By way of example, according to one implementation, the mechanical rod bender 18 may be the bender described in commonly-owned U.S. Pat. No. 7,957,831 entitled “System and Device for Designing and Forming a Surgical Implant” patented Jun. 7, 2011, the disclosure of which is hereby incorporated by reference as if set forth in its entirety herein. According to a second implementation, the mechanical rod bender 18 may be the bender shown in FIG. 50. First and second levers 106, 110 are shown as is lever handle 108 designed for grabbing the lever 106 manually and a base 112 for holding lever 110 in a static position. Second lever 110 has a rod pass through 114 so that an infinitely long rod can be used as well as steady the rod during the bending process with the rod bending device 18. The user grabs handle 108 and opens it to bend a particular rod by picking an angle on the angle gauge 132 and closing the handle 108 such that levers 106, 110 are brought closer together. The mechanical rod bender 18 in other embodiments could be produced to bend the rod during the handle opening movement as well. The rod moves through mandrel 118 and in between moving die 120 and fixed die 122. The rod is bent between the two dies 120, 122. Gauges on the bender 18 allow the user to manipulate the rod in order to determine bend position, bend angle, and bend rotation. The rod is held in place by collet 126. By sliding slide block 128 along base 112, the rod can be moved proximally and distally within the mechanical rod bender 18. Position may be measured by click stops 130 at regular intervals along base 112. Each click stop 130 is a measured distance along the base 112 and thus moving a specific number of click stops 130 gives one a precise location for the location of a rod bend.
The bend angle is measured by using angle gauge 132. Angle gauge 132 has ratchet teeth 116 spaced at regular intervals. Each ratchet stop represents five degrees of bend angle with the particular bend angle gauge 132 as the handle 106 is opened and closed. It is to be appreciated that each ratchet step may represent any suitable degree increment (e.g., between 0.25 degrees to 10 degrees). The bend rotation is controlled by collet knob 134. By rotating collet knob 134 either clockwise or counterclockwise, the user can set a particular rotation angle. The collet knob 134 is marked with regular interval notches 136 but this particular embodiment is continuously turnable and thus has infinite settings. Once a user turns knob 134, the user can set the knob 134 at a particular marking or in between or the like to determine a particular angle rotation to a high degree of accuracy. Additionally, base 112 may have a ruler 138 along its length to aid the user in measuring a rod intraoperatively.
According to another implementation, the rod bender 18 may be a pneumatic or motor-driven device which automatically adjusts the location, rotation and bend angle of the rod. By way of example, three motors may be utilized for each movement. A linear translator motor would move the rod in and out of the mandrel 118 and moving die 120. One rotational motor would rotate the rod and moving die 120. The bend calculations could be converted into an interface program that would run to power and control the motors. The automated bender would lessen the possibility of user error in following the manual bend instructions. It would also increase the resolution or number of bends that can be imparted in the rod making for a smoother looking rod.
Throughout this disclosure, discussion has centered around the ability to custom bend with specificity a spinal rod during a spinal fixation procedure utilizing a rod-based spinal fixation construct. An example method for the minimally invasive implantation of such a rod-based spinal fixation construct 510 will now be described with specific reference to FIG. 51. First, a spinal fixation anchor 512 is anchored through the pedicle of each vertebra to be fixated (e.g. three vertebra as shown in FIG. 51). For the purpose of this disclosure, spinal fixation anchor 512 may be any type of bone anchor capable of receiving and securing a spinal fixation rod thereto (e.g., a bone screw). By way of example only the spinal fixation anchor 512 includes a rod housing 514 for receiving the spinal rod 516 therein and a shank (not shown) for anchoring the housing 514 to the bone. As shown in FIG. 51, each spinal fixation anchor 512 has an extension guide 518 mated thereto for the purpose of guiding the spinal rod 516 into the rod housing 514. Although not expressly depicted in FIG. 51, it is to be understood that the extension guides 518 provide passage through minimally invasive surgical openings in the patient's skin from the outside to the surgical target site.
With the fixation anchors 512 in position, a rod 516 appropriately sized to span the distance between the superior and inferior spinal fixation anchors is selected. The rod 516 may then be prebent or custom-bent according to any of the implementations of the disclosure described above. In a traditional “open” surgical procedure, a long incision is made in the patient and the spinal rod is advanced to each screw via the attached guides at essentially the same time through the long incision. Thus, the incision must be at least as long as the rod. During some insertion techniques the rod 516 is inserted into the guide channel of the first fixation anchor 512 generally parallel to the extension guide while the insertion instrument is angled back towards the remainder of the extension guides 518. As the inserter is rocked towards the insertion end, the rod 516 advances through each guide.
In a minimally invasive procedure, in contrast, the extension guides 518 are placed in a minimally invasive fashion (i.e. through individual openings without a long incision). As such, an additional opening is needed either cephalad or caudal to one terminus of the construct. The rod 516 is inserted (via rod inserter 536) through this additional opening and then sequentially guided (below the skin) through each successive extension guide 518. Once the rod 516 has been fully positioned within the guides relative to each of the rod housings 514, a rod pusher 520 is advanced along the screw guide and employed to seat the rod 516 within the rod housing 514. The rod inserter 536 is then detached from the proximal end 522 of the rod 516 and removed from the additional opening.
Various examples of rod inserters and rod pushers that may be used (with or without further modification) with the present invention, as well as a more detailed discussion of the surgical technique involved are disclosed in commonly owned and co-pending U.S. patent application Ser. No. 13/456,210, filed on Apr. 25, 2012 and entitled “Minimally Invasive Spinal Fixation System & Method,” the entire contents of which is hereby incorporated by reference into this disclosure as if set forth fully herein.
FIG. 52 illustrates one example of a rod pusher 520 that may be adapted for use with the present invention. The rod pusher 520 is used to fully seat (“reduce”) the spinal rod 516 into the rod housing 514 and thereafter insert a lock screw (not shown) to secure the rod 516 to the anchor 512. The rod pusher 520 may be configured for use with any of the rod guide assemblies, for example the extension guides 518 shown herein. Generally, the rod pusher 520 has a proximal end 526, a distal end 528, an elongated central shaft 529 extending longitudinally therebetween. The proximal end 526 may further include a recess 527 configured to mate with an IR tracking array 22 described above. Distal end 528 further includes distal tip 530 for assisting with seating the rod 516 within anchor 512. Alternatively, the rod pusher 520 may be provided with an integrated IR tracking array 22 located at the proximal end 526. The rod pusher 520 further includes a handle 532 and a connector 534. The handle 532 is located near the proximal end 526 and is configured to allow manual operation of the rod pusher 520 by the user. The connector 534 releasably couples the rod pusher 520 to a guide assembly (for example the extension guides 518 described herein).
FIG. 53 illustrates one example of a rod inserter 536 that may be adapted for use with the present invention. By way of example only, the rod inserter 536 is an adjustable-angle rod inserter that introduces the spinal rod 516 through the operative corridor at one angle (relative to the inserter), and then is capable of pivoting the rod at the surgical target site. However, fixed angle rod inserters may also be used without departing from the scope of the present invention.
By way of example only, the rod inserter 536 includes an outer sleeve 538, an inner shaft 540, a handle 542, and a rod holder 544. The outer sleeve 538 is an elongated cylindrical member having an inner lumen extending throughout. The inner shaft 540 is an elongated rod member having a proximal end 546 and a distal end (not shown). The proximal end 546 includes a knob 548 that is enables a user to employ the various functions of the rod inserter, which are not pertinent to the present invention. Further discussion of the rod inserter 536 is available in the above-referenced '210 application (incorporated by reference). The proximal end 546 may further include a recess 550 in the top surface of the proximal end configured to mate with a IR tracking array 22 described above. Alternatively, the rod inserter 536 may be provided with an integrated IR tracking array 22 located at the proximal end 546. The rod holder 544 is configured to releasably hold the proximal end 522 of a spinal rod 516.
Once the fixation anchors 512 have been implanted and the spinal rod 516 has been contoured, in some instances the user may want to use the spatial tracking system 12 of the present disclosure to assist with the insertion and positioning of the spinal rod 516 in the patient. Such use may make minimally invasive placement of the spinal rod 516 of a long construct much easier than currently possible by giving the user a real time digitized image of the location of the rod tip 524 relative to the rod pusher 520 (and implanted anchors 512/guides 518). To facilitate this, the Advance Options menu 294 discussed above (FIG. 23) may include an additional option to initiate the rod tracking program, for example a “Rod Tracking” option (not shown).
In the instant case, the rod inserter 536 and rod pusher 520 are each provided with an attached (or integrated) IR tracking array, such as the IR tracking array 22 shown and described above with reference to FIGS. 2-5. Operation of the IR tracking array 22 with regard to the rod inserter and/or rod pusher is essentially the same as the operation of the IR tracking array 22 with the digitizer pointer 30 described above.
The user selects the “Rod Tracking” button from the Advance Options menu 294 that navigates the user to a Rod Tracking screen as depicted in FIGS. 54 and 55. The proximal end of the contoured rod 516 is attached to the rod holder 544 of the rod inserter 536 (with IR tracking array). To calibrate the system 110, the user inserts the distal tip 524 of the spinal rod 516 into a calibration aperture 550 located on the distal end 528 of the rod pusher 520 and then presses the “Calibrate Rod” button 556 on the GUI. This calibration step calculates the distance and orientation of the rod inserter handle 542 to the rod pusher 520.
The user then inserts the rod pusher 520 (with attached or integrated IR tracking array) into the first targeted extension guide 518 (i.e. the extension guide that this closest to the additional skin opening) and digitizes the screw via the process described above. As shown in FIG. 54, at this point the GUI then shows a graphic representation of the targeted screw head 552 (e.g. depicted as a static sphere, detailed tulip, and the like) in both the sagittal and coronal views. The user then inserts the rod 516 though the additional opening and advances it toward the first targeted extension guide 518. As the distal tip 524 of the rod 516 approaches the target extension guide 518, the GUI shows a dynamic graphical representation of the distal tip 554 in both distance and direction/orientation relative to the target extension guide 518. Using this information, the user can then manipulate the rod inserter 536 to accurately guide the distal tip 524 of the rod 516 to the targeted screw, by guiding the graphical representation of the rod tip 554 to the graphical representation of the screw head 552 on the GUI, as shown in FIG. 55. Once the distal tip 524 of the rod 526 is successfully positioned within the first extension guide 518, the rod pusher 520 is removed (or a second rod pusher 520 with IR tracking is used) and inserted into the extension guide 518 for the second targeted screw. This second location is then digitized using the process described above. The user then continues to advance the distal tip 524 of the rod 516 toward and through the second targeted extension guide 518. This process continues until the entire rod 516 is properly positioned within the extension guides 518.
Once the rod 516 is properly positioned within the extension guides 518, the rod holder 544 of the rod inserter 536 is detached from the proximal end 522 of the rod 516 and the rod inserter 536 removed from the additional opening, which can then be closed. One or more rod pushers 520 are employed to seat and secure the rod 516 within the rod housing 514 of the screw head, and the pusher 520 and extension guides 518 are removed from the operative corridor(s) before closing the operative wounds.
While the invention is susceptible to various modifications and alternative forms, specific embodiments thereof have been shown, by way of example only, in the drawings and are herein described in detail. It should be understood, however, that the description herein of specific embodiments is not intended to limit the invention to the particular forms disclosed. On the contrary, the invention is to cover all modifications, equivalents, and alternatives falling within the spirit and scope of the invention as defined herein.

## Claims

1. A method for correcting the curvature of a spine of a patient, comprising the steps of:
implanting a plurality of bone screws at various locations along a spine, each of the plurality of bone screws having an anchor portion and a rod housing, the anchor portion adapted to provide purchase within bone and the rod housing configured to receive at least a portion of a spinal rod therein;
digitizing the locations of said plurality of implanted screws using a digitizing pointer comprised of a housing having shutters manually operable between an open position and a closed position, whereby said shutters expose reflective markers attached to said housing in the open position upon squeezing a handle of said housing, and whereby a digitizing pointer sensor detects said locations of said plurality of implanted screws when the shutters are in the open position;
digitizing a distal end of a spinal rod attached to a rod inserter that enables the spinal rod to advance through an operative corridor;
seating, with a rod pusher, the spinal rod in at least one of said rod housings;
wherein at least one of the rod inserter and the rod pusher has an emitting component thereon that can be sensed by a sensor;
continuously generating a dynamic visual output on a graphic user interface corresponding to the relative locations of the digitized screws and the digitized distal end; and
advancing the distal end of the spinal rod through the operative corridor toward a first of the implanted screws while receiving the dynamic visual output on the graphic user interface.

2. The method of claim 1, wherein each implanted screw has an extension guide removeably attached to the rod housing, the extension guide adapted to transiently receive at least a portion of the spinal rod therein, the extension guide further adapted to receive at least a portion of the rod pusher.

3. The method of claim 2, wherein the rod pusher is adapted to mate with the extension guide, the rod pusher having at least one rod engaging surface adapted to contact the spinal rod.

4. The method of claim 3, further comprising the step of calibrating a distal end of the rod pusher with the distal end of the spinal rod.

5. The method of claim 4, further comprising the step of advancing the rod pusher along the extension guide until the at least one rod engaging surface is positioned near the rod housing.

6. The method of claim 5, further comprising the step of advancing the distal end of the spinal rod through the extension guide removeably attached to the first implanted bone screw.

7. The method of claim 6, further comprising the step of advancing a second rod pusher along a second extension guide, the second extension guide removeably attached to a second implanted bone screw.

8. The method of claim 7, further comprising the step of advancing the distal end of the spinal rod toward the second extension guide removeably attached to the second implanted bone screw.

9. The method of claim 8, further comprising the step of advancing the distal end of the spinal rod through the second extension guide removeably attached to the second implanted bone screw.

10. The method of claim 9, further comprising the steps of:
advancing the first rod pusher along the first extension guide until the at least one rod engaging surface contacts the portion of the spinal rod present within the rod housing;
securing the spinal rod within the first rod housing;
advancing the second rod pusher along the second extension guide until the at least one rod engaging surface contacts the portion of the spinal rod present within the second rod housing; and
securing the spinal rod within the second rod housing.