Abstract:
Methods and systems are disclosed for accessing and treating the interior of the facet joint for vertebral distraction and immobilization. The systems include a number of tools that facilitate access to the facet joint, distraction of the articulating decortication of the articulating surfaces, and delivery of implants and agents into the facet joint for fusion.

Description:
CROSS-REFERENCE TO RELATED APPLICATION(S) 
       [0001]    This application is a continuation application of Ser. No. 12/350,609, filed Jan. 8, 2009, entitled “METHODS AND APPARATUS FOR ACCESSING AND TREATING THE FACET JOINT,” which claims priority to U.S. Provisional Patent Application No. 61/020,082, entitled “METHODS AND APPARATUS FOR ACCESSING AND TREATING THE FACET JOINT,” filed on Jan. 9, 2008. The full disclosures of the above-listed patent applications are hereby incorporated by reference herein. 
     
    
     FIELD 
       [0002]    This invention pertains generally to treatment of the facet joint, and more particularly to tools and methods for accessing, preparing and facilitating spinal distraction. 
       BACKGROUND 
       [0003]    Neck and arm pain is a common ailment of the aging spine due to disc herniations, facet arthropathy and thickening of spinal ligaments which narrow spinal canal dimensions. This results in compression of the spinal cord or nerve roots, or both. Radicular pain is typically due to disc herniation and foraminal narrowing, which compresses the cervical nerve roots and causes radicular pain. Extension and ipsilateral rotation of the neck further reduces the foraminal area and contributes to pain, nerve root compression, and neural injury. Neck flexion generally increases the foraminal area. 
         [0004]    Cervical disc herniations and foraminal stenosis typically present with upper extremity radicular pain without major motor or sensory neurologic deficit. A well-described treatment for cervical disc herniations is closed traction. There are a number of marketed devices that alleviate pain by pulling on the head to increase foraminal height. 
         [0005]    Cervical disc herniations have been treated with anterior and posterior surgery. The vast majority are performed through an anterior surgical approach, which entails a spinal fusion. These surgeries are expensive and beget additional surgeries due to change in biomechanics of the neck. There is a 3% incidence of re-operation per year that is cumulative at adjacent levels. 
         [0006]    There is a need in the art for minimally invasive methods and devices for accessing and preparing and distracting the facet joint to increase foraminal height and reduce radicular symptoms for patients with soft and hard disc disease. 
       BRIEF SUMMARY 
       [0007]    Devices and techniques are disclosed for a percutaneous or minimally invasive surgical implantation to reduce radicular symptoms by inserting an expandable cervical distraction implant in the facet joint at a symptomatic level to decompress the nerve tissue and preserve motion. In particular, embodiments of the present invention provide for accessing and distracting the cervical facet to increase the foraminal dimension. In one embodiment, the implant of the present invention, when positioned in the cervical facet joint, increases the space between the articular facets, to increase the foraminal area or dimension, and reduce pressure on the nerve and associated blood vessels. 
         [0008]    The procedure may be performed under conscious sedation in order to obtain intra-operative patient symptom feedback. 
         [0009]    An aspect of an embodiment of the invention is an apparatus for accessing an interior region of a facet joint, comprising an elongate handle having a proximal end and a distal end, and a blade disposed at the distal end of the handle. The blade may have a flat leading edge such that placement of the blade through the facet capsule and into the facet cavity to generate a slit-shaped aperture in the facet capsule. Preferably, the aperture may extend substantially parallel to the first and second articulating subchondral surfaces. 
         [0010]    In one embodiment, the blade comprises a planar lower surface extending from the leading edge, and extending proximally away from the leading edge, wherein the planar surface provides a platform to guide a second instrument through the aperture for treatment of the facet joint. 
         [0011]    In one mode of the current embodiment, the blade comprises an upper surface opposite the lower surface, with the upper surface and lower surface defining a thickness, generally sized to be smaller than the distance between the first and second boundaries of a facet cavity. 
         [0012]    Preferably, in one embodiment, a beveled surface emanates from the upper blade surface and extends proximally away from the leading edge. Accordingly, the thickness increases proximally along the beveled surface. The beveled surface generally facilitates manipulation of the blade into the cavity. 
         [0013]    In one embodiment, the handle comprises a shaft extending from the distal end to the proximal end, wherein the shaft comprises a beveled surface emanating at or near the leading edge and extending proximally away from the leading edge. The beveled surface facilitates insertion of the blade into the cavity at an angle not aligned with the first and second cavity boundaries. 
         [0014]    In another embodiment, the shaft is disposed within a central channel running along the length of the handle, and extends from the distal end of the handle. The shaft may have a D-shaped cross section providing a flat planar surface in cooperation with the blade. 
         [0015]    Another aspect of an embodiment is an apparatus for decorticating an interior region of a facet joint, comprising an elongate handle having a proximal end and a distal end, and a rasp configured to decorticate a at least one of the articulating subchondral surfaces. The rasp may have a roughened planar surface extending distally outward from the distal end of the handle, and may be generally spatula-shaped and sized to be delivered into the facet joint via an aperture in the joint capsule and oriented in the joint substantially in line with the plane of the facet joint articulating surfaces. Generally the rasp comprises a compliant, thin cross section that allows the rasp to bend while being delivered into the facet from an angle out of alignment with the plane of the facet joint articulating surfaces. 
         [0016]    The blade may have substantially planar lower surface extending from the leading edge, and extend proximally away from the leading edge. This planar surface may provide a platform for guiding the rasp in cooperation with a second instrument through the aperture for treatment of the facet joint. 
         [0017]    In another embodiment, the rasp comprises an upper roughened surface opposite and substantially parallel with the lower surface, wherein the thickness is sized to be smaller than the distance between the first and second boundaries of a facet cavity, and to dispose the rasp to bending under light to moderate pressure. A beveled surface may emanate from the upper surface at a point proximal from a leading edge of the rasp and extending proximally away from the leading edge. 
         [0018]    Another aspect of an embodiment is an apparatus for accessing an interior region of a facet joint, comprising an elongate handle having a proximal end and a distal end, and a spatula-shaped tip disposed at the distal end of the handle, with the tip comprising upper and lower parallel planar surface extending distally outward from the distal end of the handle. The tip may be sized to be delivered into the facet joint via an aperture in the joint capsule and oriented in the joint substantially in line with the plane of the facet joint articulating surfaces. 
         [0019]    In one embodiment, the upper and lower parallel planar surfaces define a thickness that allows the tip to bend while being delivered into the facet from an angle out of alignment with the plane of the facet joint articulating surfaces. 
         [0020]    In another embodiment, lower planar surface provides a platform for guiding a second instrument through the aperture for treatment of the facet joint. 
         [0021]    The thickness may be generally sized to be smaller than the distance between the first and second boundaries of a facet cavity, and to dispose the tip to bending under light to moderate pressure. The apparatus may have a beveled surface emanating from the upper surface at a point proximal from a leading edge of the tip and extending proximally away from the leading edge. 
         [0022]    In one embodiment, the handle comprises a shaft extending from the distal end to the proximal end, the shaft having a beveled surface emanating from the upper surface and terminating at a proximal location toward the handle. The lower planar surface may extend beyond the proximal location to create a platform for guiding a second instrument to the aperture and introducing the second instrument into the cavity. 
         [0023]    The second instrument may comprise a rasp configured to decorticate at least one of the articulating surfaces, a distracter for distracting the articulating surfaces, an injector for delivering an agent into the cavity, or an introducer for delivering an implant into the cavity. The tip may function as a platform configured to receive an expandable implant and deliver the implant to a location within the cavity. 
         [0024]    Another aspect of an embodiment is an apparatus for distracting two adjacent vertebrae, the being vertebrae separated by a facet joint comprising first and second articulating subchondral surfaces forming a facet cavity enclosed by a facet capsule. The apparatus may include an elongate handle having a proximal end and a distal end; and a wedge detachably disposed at the distal end of the handle. The wedge may have upper and lower beveled surfaces that converge toward a distal tip of the wedge, and is sized to be delivered into the cavity through an aperture in the capsule so that the upper and lower beveled surfaces contact the first and second articulating subchondral surfaces and distract the surfaces as the wedge is driven into the cavity. 
         [0025]    In one embodiment, the wedge may comprise a recess on a proximal end of the wedge for detachably coupling the wedge to the handle. 
         [0026]    In another embodiment, the apparatus may further include a shaft extending from the distal end of the handle proximal to the wedge. The wedge may be detachably coupled to the shaft. In one embodiment, the shaft may have a planar surface leading from the handle to the wedge to provide a platform for guiding the wedge in cooperation with a second instrument through the aperture. 
         [0027]    Generally, the upper and lower beveled surfaces extend proximally from the distal tip to parallel upper and lower distraction surfaces, wherein the distraction surfaces are distanced from each other by a distraction thickness. The distraction thickness may correlate to a desired distraction of the articulating surfaces of the facet joint. 
         [0028]    In another embodiment, wherein the wedge comprises one of a plurality of detachable wedges, with each of the detachable wedges having an increasingly larger distraction thickness such that the plurality of detachable wedges may be delivered to the facet joint in series from thinnest to thickest to incrementally distract the facet joint. 
         [0029]    In a preferred embodiment, the upper and lower beveled surfaces converge to a nipple located at the distal end of the wedge, wherein the nipple is sized to be inserted in the cavity between the articulating surfaces. 
         [0030]    Another aspect of an embodiment is an apparatus for distracting two adjacent vertebrae, having an elongate handle with a proximal end and a distal end, and upper and lower reciprocating members disposed at the distal end of the handle. The upper and lower reciprocating members may be coupled to the handle via a hinge located between proximal and distal ends of the upper and lower reciprocating members. The distal ends of the upper and lower reciprocating members may extend past the distal end of the handle such that the distal ends of the upper and lower reciprocating members may be pressed together to create a smaller profile for entry into the facet capsule and in between the first and second articulating subchondral surfaces. The entry into the facet capsule may result in extension of the proximal ends of the upper and lower reciprocating members away from the handle, wherein the proximal ends of the upper and lower reciprocating members are configured be articulated toward the handle, the hinge acting as a fulcrum to separate the distal ends of the upper and lower reciprocating members and distract the first and second articulating subchondral surfaces. 
         [0031]    Generally, the distal ends of the upper and lower reciprocating members may be sized to be delivered into the facet cavity through an aperture in the facet capsule. 
         [0032]    In one embodiment, the handle may comprise a hollow tube, with a shaft running through the tube to the distal end of the handle, and a rasp coupled to the shaft at the distal end of the handle, wherein the shaft may be reciprocated within the tube such that the rasp runs along a subchondral surface to decorticate the surface. 
         [0033]    Another aspect of an embodiment is an introducer for delivering an implant to an interior region of a facet joint, comprising an elongate handle having a proximal end and a distal end, and a spatula-shaped tip disposed at the distal end of the handle, the tip comprising upper and lower parallel planar surface extending distally outward from the distal end of the handle. The tip may be sized to be delivered into the facet joint via an aperture in the joint capsule and oriented in the joint substantially in line with the plane of the facet joint articulating surfaces, and comprises a platform configured to receive the implant and deliver the implant to a location within the cavity. 
         [0034]    In one embodiment, the implant may comprise an inflatable membrane with a pocket configured to slide over the distal tip of the introducer. In this case, the introducer has a delivery line extending from the proximal end of the handle to distal tip and being configured to dispense an inflation medium to the inflatable membrane. 
         [0035]    Another aspect of an embodiment is an apparatus for delivering an agent to an interior region of a facet joint, having an elongate handle with a proximal end and a distal end, and a shaft extending from the distal end of the handle. The shaft has a beveled surface at its distal tip, and a delivery line extending from the proximal end of the handle to the distal tip of the shaft. The beveled distal tip of the shaft may be sized to be delivered into the facet joint via an aperture in the joint capsule and oriented in the joint to deliver the agent to a treatment location within the joint. A blade may also be included on the distal end of the shaft, the blade configured to facilitate access into the facet joint. 
         [0036]    In one embodiment of the current aspect, the shaft may comprise a lower planar surface extending proximally from the distal tip, wherein the lower planar surface provides a platform for guiding the apparatus in cooperation with a second instrument through the aperture. 
         [0037]    Another aspect of an embodiment is a surgical system for treating the facet joint, comprising a first apparatus configured to gain access to the joint. The first apparatus may have an elongate handle having a proximal end and a distal end, and spatula-shaped tip disposed at the distal end of the handle, the tip comprising upper and lower parallel planar surface extending distally outward from the distal end of the handle. The tip may be sized to be delivered into the facet joint via an aperture in the joint capsule and oriented in the joint substantially in line with the plane of the facet joint articulating surfaces. The lower planar surface may provide a platform for guiding a second instrument through the aperture for treatment of the facet joint. The second instrument may comprise a planar surface that is configured to mate with the planar surface of the first instrument and slide distally along the first instrument to into the facet joint. 
         [0038]    Another aspect of an embodiment is a system for facet joint immobilization, comprising: a facet access blade configured to pierce through the facet capsule and into the facet cavity to generate a slit-shaped aperture in the facet capsule that extends substantially parallel to the first and second articulating subchondral surfaces. The system may include a distraction apparatus configured to be delivered through the facet capsule and into the facet cavity to distract the first and second articulating subchondral surfaces a predetermined distance, and a decortication apparatus configured to be delivered through the facet capsule and into the facet cavity to decorticate at least one of the first and second articulating subchondral surfaces a predetermined distance. An introducer may also be delivered through the facet capsule and into the facet cavity to deliver an implant between the first and second articulating subchondral surfaces to immobilize the joint at the predetermined distance. 
         [0039]    Another aspect of an embodiment is a method for accessing the facet joint of a patient, comprising: delivering a cutting blade to the facet joint capsule; and piercing through the facet capsule and into the facet cavity with the cutting blade to generate a slit-shaped aperture in the facet capsule, the aperture being oriented and sized to accommodate access into the facet joint 
         [0040]    The method may further include delivering an introducer through the aperture and into the facet cavity. The cutting blade may be configured to guide delivery of the introducer. 
         [0041]    Another aspect of an embodiment is a method for accessing the facet joint of a patient, comprising: delivering a first apparatus configured to gain access to the joint. The first apparatus comprising an elongate handle having a proximal end and a distal end, and a spatula-shaped tip disposed at the distal end of the handle, the tip comprising upper and lower parallel planar surface extending distally outward from the distal end of the handle. The tip is sized to be delivered into the facet joint via an aperture in the joint capsule and oriented in the joint substantially in line with the plane of the facet joint articulating surfaces. A second apparatus is delivered by guiding the second apparatus along the lower planar surface of the first apparatus and through the aperture for treatment of the facet joint. The second apparatus may have a planar surface that is configured to mate with the planar surface of the first apparatus and slide distally along the first apparatus to into the facet joint. 
         [0042]    Yet another aspect of an embodiment is a method for immobilizing the facet joint of a patient; comprising delivering a cutting blade to the facet joint capsule; piercing through the facet capsule and into the facet cavity with the cutting blade to generate an aperture in the facet capsule accessing the joint with an introducer; preparing the joint by sanding down cortical bone with a rasp; wherein the rasp is configured to be non-invasively inserted within the aperture created by the cutter; and delivering a distraction device into the facet cavity and distracting the first and second articulating subchondral surfaces. 
         [0043]    In one embodiment, the introducer facilitates delivery of the rasp and distraction device. 
         [0044]    In one embodiment, the distraction device comprises a wedge detachably disposed at the distal end of an elongate handle, with the method further including delivering the wedge into the cavity through an aperture in the capsule so that the wedge contacts the first and second articulating subchondral surfaces and distract the surfaces as the wedge is driven into the cavity. 
         [0045]    In another embodiment, the distraction device comprises an inflatable membrane, and distracting the first and second articulating subchondral surfaces comprises inflating the membrane. 
         [0046]    In yet another embodiment, the distraction device comprises a reciprocating introducer, and distracting the first and second articulating subchondral surfaces comprises inserting the introducer into the facet joint and articulating a pair of distal reciprocating members. 
         [0047]    Further aspects of the invention will be brought out in the following portions of the specification, wherein the detailed description is for the purpose of fully disclosing preferred embodiments of the invention without placing limitations thereon. 
     
    
     
       BRIEF DESCRIPTION OF DRAWINGS 
         [0048]    The invention will be more fully understood by reference to the following drawings which are for illustrative purposes only: 
           [0049]      FIG. 1  is a lateral view of two cervical vertebral members in a stenosed condition. 
           [0050]      FIG. 2  is a view of a traditional introducer needle being inserted into the facet joint of the vertebral members. 
           [0051]      FIGS. 3A-3H  include several views of a facet access tool according to certain embodiments. 
           [0052]      FIG. 4  is a schematic lateral view of the facet access tool of  FIGS. 3A-3H  positioned at the facet joint capsule of two cervical vertebral members. 
           [0053]      FIG. 5  is a schematic lateral view of the facet access tool of  FIGS. 3A-3H  piercing and being manipulated within the facet joint capsule, according to certain embodiments. 
           [0054]      FIG. 6  is another view of the of the facet access tool of  FIGS. 3A-3H  piercing the facet joint capsule, according to certain embodiments. 
           [0055]      FIG. 7  is a view of the slit-shaped aperture created by the facet access tool of  FIGS. 3A-3H . 
           [0056]      FIGS. 8A-8H  include several views of a facet introducer, according to certain embodiments. 
           [0057]      FIG. 9  is a schematic lateral view of the introducer tool of  FIGS. 8A-8H  being manipulated within the facet joint capsule, according to certain embodiments. 
           [0058]      FIG. 10  is a schematic lateral view of the facet blade being used to guide the introducer tool of  FIGS. 8A-8H  into the joint capsule, according to certain embodiments. 
           [0059]      FIGS. 11A-11I  include several views of a facet distraction device, according to certain embodiments. 
           [0060]      FIGS. 12A-H  include several views of a detachable wedge used with the facet distraction device of  FIGS. 11A-11I . 
           [0061]      FIGS. 13A-13G  include several views of an alternative facet distraction device, according to certain embodiments. 
           [0062]      FIGS. 14A-14I  include several views of a facet decortication tool, according to certain embodiments. 
           [0063]      FIGS. 15A-15G  include several views of a facet delivery tool for delivering an injectable biomaterial, according to certain embodiments. 
           [0064]      FIGS. 16A-16I  include several views of a facet inflatable membrane introducer, according to certain embodiments. 
       
    
    
     DETAILED DESCRIPTION 
       [0065]    Referring more specifically to the drawings, for illustrative purposes, one embodiment of an apparatus is generally shown in  FIG. 3A  through  FIG. 16 . It will be appreciated that the apparatus may vary as to configuration and as to details of the parts, and that the method may vary as to the specific steps and sequence, without departing from the basic concepts as disclosed herein. 
         [0066]      FIG. 1  illustrates a simplified lateral view of a portion of the cervical spine  10 . The basic biomechanical unit or motion segment of the spine consists of two adjacent vertebrae  12  and  14  and the three joint articular complex through which they move and are constrained in relation to one another. The spine articulations generally consist of an intervertebral disc  26  located between the vertebral bodies  26  of adjacent vertebrae  12 ,  14 , and two facet joints  16  symmetrically located laterally from the sagittal plane at the posterior end of the vertebral bodies  26 . 
         [0067]    The facet joints  16  allow constrained spinal motion, while protecting the contained neural structures. From a kinematic viewpoint, the intervertebral facet joints  16  are highly constrained sliding planar articulations, lubricated by synovial fluid contained within the facet joint capsule  30 . In the cervical spine, the geometry of the cervical vertebral bodies provides a high degree of protection for the neural elements by limiting normal motion of the spine to within physiologic limits. The upward inclination of the superior articular surfaces of the facet joints allows for considerable flexion and extension, as well as for lateral mobility. 
         [0068]    The distraction, preparation and delivery devices disclosed herein facilitate minimally invasive or percutaneous surgical access, distraction and implant delivery to the facet joint, which is advantageous due to reduced surgical time, reduced recovery time, and improved surgical outcome. Each vertebral segment comprises a spinous process  34  located at the posterior end of the vertebrae, with the vertebral body located anteriorly. Each vertebra comprises an inferior articular (or transverse) process  35  and the superior articular process  37  that form four posterior articulating, e.g. opposing subchondral, surfaces: two superior facets  18  and two inferior facets  16 . The inferior facet  18  from the inferior articular process  35  of the upper vertebra  12  and the superior facet from the superior articular process  37  of the lower vertebra  14  form the facet joint  16  on each lateral side of the spine. 
         [0069]    Located medial to the articular processes  37  and vertebral bodies  26  is an aperture, or intervertebral foramina  38 , that serves as a nerve root canal for the spinal nerves and vessels that transmit signals from the spinal chord to respective locations in the body. 
         [0070]    Each facet joint  16  is covered by a dense, elastic articular capsule  28 , which is attached just beyond the margins of the articular facets  18 ,  22 . The inside of the capsule is lined by a synovial membrane (not shown), which secretes synovial fluid for lubricating the facet joint. The exterior of the joint capsule is surrounded by a capsular ligament (not shown), which may be temporarily repositioned to give access for insertion of the extendable implant of the present invention, described in further detail below. Thus, from a posterior-lateral approach, access to the facet joint  16  is relatively straightforward and well prescribed, as compared to other regions of the spine, which present a higher likelihood of trauma and risk of permanent damage. 
         [0071]    It should also be noted that  FIG. 1  depicts cervical foraminal stenosis, e.g. loss of height between the adjacent vertebrae  12 ,  14 . As a result of disc  36  herniation and corresponding height loss, the nerve root canal  38 , or intervertebral foraminal height, having a value H.sub.s, is narrowed relative to that of healthy anatomy. This narrowing of the foraminal height H.sub.s often leads to compression of the spinal cord and nerve roots (not shown), causing radicular symptoms. 
         [0072]    As a result of the stenosed foraminal height H.sub.s, the height of the facet joint  16 , or distance between subchondral articulating surfaces  18  and  22 , is also narrowed, (shown as value D.sub.s in  FIG. 1 ). This may pose complications in the facet joint  16  as well. However, because the height of the disc will be relatively fixed, an increase in the facet joint height will also have a corresponding increase in foraminal height, as described in greater detail below. 
         [0073]      FIG. 2  illustrates a typical procedure for accessing the facet joint using a standard discography introducer needle  44  to access the facet joint. Because the gap or cavity  30  bound between subchondral articulating surfaces  18  and  22  is generally planar, the cylindrical needle  44  may be difficult to navigate into the capsule  30 . Generally precise alignment and orientation of the needle  44  with the subchondral surface  18  and  22  may be used for the needle to enter the cavity  30 . Thus, the shape and size constraints of the facet joint  16  make typical cylindrical needles  44  difficult to predictably and consistently gain access to the facet joint capsule. 
         [0074]      FIGS. 3A-16  show a system and method of the present invention for performing a minimally invasive procedure configured to distract one or more of the facet joints  16  of vertebrae  12 ,  14 , thereby increasing the dimension of the neural foramen while retaining facet joint mobility. One of the major advantages of minimally invasive surgery is the ability to perform the procedure with minimal tissue trauma. Television image intensifier fluoroscopy may be used to provide guidance for surgeon placement of instrumentation and implants precisely to the desired anatomic target in the facet joint  16 . The radiographic landmarks are well taught and the relative procedural difficulty of this technique is low. 
         [0075]      FIGS. 3A-3H  illustrate a facet access tool  100  in accordance with certain embodiments. Tool  100  comprises an elongate handle having a flat cutting blade  112  on its distal end  102 . The blade  112  generally comprises a straight, flat (i.e. planar), leading edge  110  at distal tip  102  that is sharpened to allow for piercing of the facet joint capsule  28 . Although the leading edge  110  is shown as a straight-line surface when viewed from above in  FIG. 3B , it is appreciated that different shapes may also be utilized, (e.g. arcuate, triangular, etc.) 
         [0076]    The blade  110  is coupled to shaft  108  that is received inside a central channel  116  running axially down handle  106 . The shaft and blade protrude distally from the handle  106  so that flat surface  114  running along the bottom of the blade  112  is exposed. The flat surface  114  facilitates introduction and cooperation of additional instruments used for the procedure, discussed in further detail below. 
         [0077]    The shaft  108  has a beveled surface  118  that terminates at a point on the distal tip  102  of blade  112 . As will be described in further detail below, the beveled surface  118  allows the blade  112  to access into the facet joint from sub-optimal angles of entry, and wedge the blade  112  into the joint for treatment. 
         [0078]    It is appreciated that blade  112  may be a separable from shaft  108  and joined with an adhesive, fastener or other securing means. Alternatively blade  112  and shaft  108  may comprise one contiguous or integral piece of material. The blade and shaft may comprise a hardened metal, such as stainless steel or titanium. 
         [0079]    The blade  112  and shaft  108  correspondingly have a D-shaped cross-section. Accordingly, chamber  116  of handle  106  also has a D-shaped cross-section, and is sized to receive shaft  108  and blade  112  with a snug fit. Handle  106  may comprise a plastic or similar polymer that is extruded, molded, or heat-shrunk in shape. 
         [0080]      FIG. 4  illustrates lateral views of facet access tool  100  positioned at the facet joint  16 . According to the method of the present invention, the blade  112  is positioned at the desired location facet joint capsule  28  and then pushed into the capsule to generate an opening  32 .  FIG. 5  shows the access tool  100  manipulated in the facet cavity  30  through the opening  32  in the capsule wall  28 . 
         [0081]      FIGS. 6 and 7  illustrate a postero-lateral view of the incision created by the access tool. As seen in  FIG. 7  a slit-like opening  32  is generated that runs generally parallel to the facet joint articular surfaces  18 ,  22 . 
         [0082]    Once we have gained access to the facet joint cavity  30  with the cutting blade of the facet access tool  100 , an introducer  150  may be inserted into the joint. The introducer  150 , illustrated in  FIG. 8 , comprises a handle  164  at its proximal end, and a malleable “spatula” shaped tip  154  at its distal end  152 . 
         [0083]    The tip  154  generally comprises a straight, flat leading edge  110  at distal end  152 . Although the leading edge  152  is shown as a straight-line surface when viewed from above in  FIG. 8A , it is appreciated that different shapes may also be utilized, (e.g. arcuate, triangular, etc.) 
         [0084]    The tip  254  is coupled to shaft  158  that is received within a D-shaped opening channel  168  of the handle  156 . The shaft  158  and tip  154  protrude distally from the handle  156  so that flat surface  160  running along the bottom of the tip and shaft is exposed. The shaft  158  has a beveled surface  162  that terminates at a point proximal to the distal tip end  152  of tip  154 . 
         [0085]    The malleable and thin planar shape of the “spatula” tip  154  and beveled shaft  158  allow for suboptimal entry angles and compensates for the narrow spacing of the facet joint. In the method of the present invention, the tip  154  is inserted into the opening  32  created by the facet access tool  100 . The flat, thin cross-section of tip  154  is configured to easily slide into thin, planar cavity  30  of the facet joint  30 . 
         [0086]    As shown in  FIG. 9 , the tip  154  of introducer is malleable so that it bends into the cavity  30  if introduced from a sub optimal angle. This, along with the beveled surface  162 , allows the blade introducer  150  to access into the facet joint from sub-optimal angles of entry, and wedge or manipulate the introducer  150  into the proper orientation in the joint  16  for treatment. 
         [0087]    The introducer  150  may be inserted into the cavity  30  after the access blade  100  has been removed, or may be inserted while the access blade  100  is still in place, essentially using the access blade to guide the introducer  150  by sliding the flat bottom surface  160  along the bottom surface  114  of the access blade, as shown in  FIG. 10 . 
         [0088]    In a similar fashion as illustrated in  FIG. 10  with the access blade  100 , the flat tip  154  of the introducer is also configured to provide a point of entry for later devices used in the surgical method of the present invention, e.g. to enable distraction, decortication, decompression, and fusion of the facet joint  16 . 
         [0089]    With proper access and orientation of the instruments in the facet joint  16 , the articular surfaces  18  and  22  may be distracted to increase the distance D.sub.s. Distraction of the joint  16  may be accomplished via a number of methods, including use of an inflatable membrane such as that disclosed in U.S. patent application Ser. No. 11/618,619 filed on Dec. 29 2006, herein incorporated by reference in its entirety. 
         [0090]    Referring now to  FIGS. 11A-11I  and  12 A- 12 H, distraction may be achieved via a wedge-inserter  170 . The wedge inserter  170  comprises an elongate handle  178  at its proximal end  180  and detachable wedge-shaped tip  172  disposed on shaft  174  that is encased, at least proximally, within the handle  178 . 
         [0091]    The detachable tip  172 , further illustrated in  FIGS. 12A-12H , converges to a nipple  176  at the distal extremity via beveled surfaces  182  and lateral arcuate surfaces  184 . The detachable tip  172  has a keyed receiving hole  186  for attaching the tip  172  to the shaft  174 . 
         [0092]    The upper and lower beveled surfaces  182  converge to nipple  176  from a box shaped platform defined by lower and upper parallel distraction surfaces  188 , and  190 . The distance between the lower and upper distraction surfaces  188 , and  190  sets the thickness T of the wedge. 
         [0093]    The inserter  170  may be directed into to the facet joint cavity  30  with guidance from sliding it along introducer  150 . When inserted into the cavity  30 , the inserter generates an outward compressive force on the subchondral surfaces  18  and  22  to increase the distance between them to a desired treatment or nominal value D.sub.T. As shown in  FIGS. 12B-12D , a set of tips  192 ,  194  and  196 , all having a different thickness T, may be used in series so that the joint is progressively distracted. The final thickness T will correspond to the treatment or nominal value D.sub.T. 
         [0094]    This distraction of walls  18  and  22  correspondingly increases the height of the intervertebral foramin to a treatment or nominal value H.sub.T. The value of D.sub.T, and resulting increase in H.sub.T may be predetermined by the surgeon prior to the surgery based on pre-op analysis of the patient&#39;s condition and anatomy, and/or may also be iteratively devised by patient feedback of symptom improvement during the procedure. 
         [0095]    Referring now to  FIGS. 13A-13G , distraction may also be achieved via duck-billed distraction device  200 . The duckbill comprises an upper pivoting member  204  and lower pivoting member  202  mounted to a tube  214  at hinge  206 . A rasp  208  is mounted on shaft  220  that is slideably received within the tube  214 . 
         [0096]    The distal tips  210  of the pivoting members  202 ,  204  are configured to collapse down over rasp  208  to facilitate entry of the duckbill into the facet joint cavity  30 . Correspondingly, the proximal ends  212  of the pivoting members  202 ,  204  expand outward from tube  214 . Once properly positioned within the cavity  30 , the proximal ends of the pivoting members  202 ,  204  (which are in an expanded configuration), can be manually pressed inward toward the shaft  214 . This activation causes the duckbill to expand at distal tips  210 , and distract the facet joint  16 . 
         [0097]    With the facet joint surfaces  18 ,  22  distracted, the rasp  232  may be articulated distally outward from the duckbill and on to the facet surfaces  18 ,  22 . The rasp  208  may be reciprocated back and forth within the tube  214  (via manual manipulation of the proximal end of shaft  220 ), thereby decorticating (by sanding or grating the surface) the surfaces in preparation for fusion. 
         [0098]      FIGS. 14A-14I  illustrate a standalone decorticator  230 . Decorticator  230  comprises a flat, flexible spatula-shaped rasp  232  at its distal end  236 . The rasp  232  is coupled to shaft  238  that is received inside a central channel running axially down handle  246 . The shaft and rasp protrude distally from the handle  246  so that flat surface  242  running along the bottom of the rasp  232  is exposed. The flat surface  242  facilitates introduction and cooperation with the introducer  150  described above. 
         [0099]    The shaft  238  has a beveled surface  240  that terminates at a point proximal to the distal tip  236  of the rasp  232 . The thin, flexible shape allows the rasp to bend and access into the facet joint from sub-optimal angles of entry. The rasp may have one or more surfaces comprise a plurality of teeth  234  configured to grate down the hard cortical surface of the opposing facet joint surfaces  18 ,  22 . 
         [0100]    Alternative decorticating devices may include a flat device with an aggressive cutting surface that is rolled to achieve roughening of the facet surface (not shown), and a device with two opposing rasp surfaces that articulate in a lateral motion through a “scissor like” activation feature. In such a configuration, the two blades of the scissors have flat upper and lower roughened surfaces that would simultaneously decorticate the opposing subchondral surfaces by remote manipulation of the blades. In other embodiments, decorticating devices may take the form of an abraded shaft and decorticating may be performed by rolling the device. In yet other embodiments, decorticating device may take the form of a file mechanism and decorticating may be performed with a back and forth filing motion, where the decorticating device is positioned and actuated using floss. 
         [0101]    With the facet joint  16  distracted and decorticated, the method of the present invention includes an embodiment where a specifically shaped piece of structural bone allograft (not shown) is then inserted into the space of distraction between the opposing facet joint surfaces. The bone allograft may be one of a series or kit of bone allograft having a predetermined shape and size (e.g. be sized in thickness that vary by small increments). The bone allograft may then be further shaped by the physician to have a custom size and shape correlating to the specific anatomy of the patient to be treated. 
         [0102]    The bone allograft is further supplemented with an injectable biomaterial such as bone morphogenic protein (BMP) to supplement the fusion potential at this level.  FIGS. 15A-15G  illustrate an injection device  260  for injecting BMP or like substances in accordance with the present invention. In some embodiments, the injectable biomaterial is used alone without a bone allograft. In either case, the injectable biomaterial may take the form of BMP as mentioned or other injectable biomaterials such as, but not limited to OP 1 , bonegraft, stem cells, bone cement (PMMA), or other injectable biomaterials now known or later developed. 
         [0103]    Device  260  includes an elongate handle  268  having a flat cutting blade  264  on its distal end  262 . The blade  264  generally comprises a straight, flat (i.e. planar), leading edge at distal tip  262 . Although the leading edge  262  is shown as a straight-line surface when viewed from above in  FIG. 15C , it is appreciated that different shapes may also be utilized, (e.g. arcuate, triangular, etc.) 
         [0104]    The blade  264  is coupled to shaft  272  that is received inside a central channel running axially down handle  268 . The shaft and blade protrude distally from the handle  268  so that flat surface  266  running along the bottom of the blade  262  is exposed. The flat surface  266  facilitates introduction and cooperation with additional instruments such as introducer  150 . 
         [0105]    The shaft  272  has a beveled surface  274  that terminates at a point on the distal tip  262  of blade  264 . The beveled surface  274  allows the blade  112  to access into the facet joint from sub-optimal angles of entry, and wedge the blade into the joint for treatment. 
         [0106]    The blade  264  and shaft  272  correspondingly have a D-shaped cross-section. Accordingly, the chamber of handle  268  also has a D-shaped cross-section, and is sized to receive shaft  272  and blade  264  with a snug fit. 
         [0107]    The shaft has one or more channels  276  that run axially down the length of the shaft to deliver an injectable biomaterial from lines  280  located at the proximal end  270  of handle  268  to the distal tip  262  of the device. Thus, with the distal tip  262  positioned in the facet joint cavity  230 , bmp is delivered though channels  276  to distal tip  262  at the treatment site. 
         [0108]    Distraction may also be accomplished via insertion of an inflatable membrane in the joint  16 .  FIGS. 16A-16I  illustrate an insertion device  300  for inserting inflatable membrane  302  into the facet joint in accordance with the present invention. 
         [0109]    The insertion device  300  comprises a handle  316  at its proximal end  318 , and a malleable “spatula” shaped tip  306  at its distal end  308 . 
         [0110]    The tip  306  generally comprises a straight, flat leading edge at distal end  308 . Although the leading edge  308  is shown as a straight-line surface when viewed from above in  FIG. 16A , it is appreciated that different shapes may also be utilized, (e.g. arcuate). 
         [0111]    The tip  306  is coupled to shaft  310  that is received within a D-shaped opening channel of the handle  316 . The shaft  310  and tip  306  protrude distally from the handle  316  so that flat surface  314  running along the bottom of the tip and shaft is exposed. The shaft  310  has a beveled surface  312  that terminates at a point proximal to the distal tip end  308  of tip  306 . 
         [0112]    Inflatable membrane  302 , in accordance with the present invention, has a pocket  304  such that the inflatable membrane  302  can be disposed on distal end  308 , and delivered through opening  32  created by the access tool  100  and into the cavity  30 . Delivery into the cavity may be guided by sliding lower surface  314  along introducer  150 . Once the inflatable membrane  302  is positioned in the proper location within cavity  30 , inflation medium is delivered through line  330  running axially along shaft  310  from proximal end  318  to distal tip  308 , and the inflatable membrane  302  is expanded inside the joint  30 . The inflatable membrane  302  generates a force on the opposing facet surfaces and distracts the joint. With the added pressure, the insertion device  300  is simply just pulled out of the joint, with the tip  306  sliding out of pocket  304  while the inflatable membrane  302  retains its position. 
         [0113]    The malleable and thin planar shape of the “spatula” tip  306  and beveled shaft  312  allow for suboptimal entry angles and compensates for the narrow spacing of the facet joint. Thus, the inflatable membrane  302  may be delivered from a less invasive, by non-aligned orientation. 
         [0114]    The delivered implant is configured to distract the joint and reverse narrowing of the nerve root canal  38  and alleviate symptoms of cervical stenosis. However, it is also within the scope of the present invention to size the implant according to other spinal conditions, for example to correct for cervical kyphosis or loss of cervical lordosis 
         [0115]    The process for achieving indirect cervical decompression and fusion may also include posterior stabilization with any number of commercially available implants &amp; instrument sets available in the art. 
         [0116]    Although the embodiments disclosed above are directed primarily to installation in the cervical facet joint, it is contemplated that the devices and methods may also be used to increase foraminal dimension in other regions of the spine, e.g. thoracic, lumbar, etc. 
         [0117]    Although the description above contains many details, these should not be construed as limiting the scope of the invention but as merely providing illustrations of some of the presently preferred embodiments of this invention. Therefore, it will be appreciated that the scope of the present invention fully encompasses other embodiments which may become obvious to those skilled in the art, and that the scope of the present invention is accordingly to be limited by nothing other than the appended claims, in which reference to an element in the singular is not intended to mean “one and only one” unless explicitly so stated, but rather “one or more.” All structural, chemical, and functional equivalents to the elements of the above-described preferred embodiment that are known to those of ordinary skill in the art are expressly incorporated herein by reference and are intended to be encompassed by the present claims. Moreover, it is not necessary for a device or method to address each and every problem sought to be solved by the present invention, for it to be encompassed by the present claims. Furthermore, no element, component, or method step in the present disclosure is intended to be dedicated to the public regardless of whether the element, component, or method step is explicitly recited in the claims. No claim element herein is to be construed under the provisions of 35 U.S.C. 112, sixth paragraph, unless the element is expressly recited using the phrase “means for.” 
         [0118]    Although this invention has been disclosed in the context of certain preferred embodiments and examples, it will be understood by those skilled in the art that the present invention extends beyond the specifically disclosed embodiments to other alternative embodiments and/or uses of the invention and obvious modifications and equivalents thereof. Thus, it is intended that the scope of the present invention herein disclosed should not be limited by the particular disclosed embodiments described above, but should be determined only by a fair reading of the claims that follow.