Abstract:
This invention relates to medical methods, instruments and systems for creating a controlled lesion using temperature to control the growth of the lesion. The treatment can be used in any tissue area and is particularly useful in or around a vertebral body. The features relating to the methods and devices described herein can be applied in any region of soft or hard tissue including bone or hard tissue.

Description:
RELATED APPLICATION DATA 
       [0001]    This application is a non-provisional of U.S. Provisional Application 61/616,359 filed on Mar. 27, 2012 and is a non-provisional of U.S. Provisional Application 61,659,604 filed on Jun. 14, 2012, the entirety of each of which is incorporated by reference. This application is also related to International Application No. PCT/US2013/024019 filed Jan. 31, 2012, the content of which is incorporated herein by reference. 
     
    
     FIELD OF THE INVENTION 
       [0002]    This invention relates to medical methods, instruments and systems for creating a controlled lesion using temperature to control the growth of the lesion. The treatment can be used in any tissue area and is particularly useful in or around a vertebral body. The features relating to the methods and devices described herein can be applied in any region of soft or hard tissue including hone or hard tissue. 
       SUMMARY OF THE INVENTION 
       [0003]    Methods and devices described herein relate to improved treatment of tissue using temperature information to assist in producing a desired region of treated tissue and/or using temperature information to produce a region of treated tissue of a known or pre-determined sized. 
         [0004]    In one variation, the methods described herein include of applying, energy to tissue by positioning a treatment device into a tissue area, the treatment device having an energy transfer portion located at a distal portion of a shaft, the treatment device further including at least a first temperature detecting element coupled to the shaft and axially along the shall from the energy transfer portion; applying energy to the energy transfer portion to produce a region of heated tissue about the energy transfer portion; continuing application of energy to expand the region of heated tissue; measuring an actual temperature of a tissue area adjacent to the first temperature detecting element; and monitoring a size of the region of heated tissue as it expands by comparing the temperature to at least one associated temperature, such that the associated temperature correlates to a previously measured region of heated tissue having a known size. 
         [0005]    The method can include controlling expansion of the region of heated tissue after comparing the temperature to at least one associated temperature. Optionally controlling expansion of the region of heated tissue comprises ceasing application of energy when the temperature reaches the associated temperature. 
         [0006]    The areas of tissue that can be treated by the methods and devices described herein include hard and soft tissue. The methods are particularly useful for treatment of a vertebral body and/or a tumor within the vertebral body. However, the method and devices can be applied to any number of body tissues. 
         [0007]    In one variation of the methods described herein monitoring the size of the area of heated tissue further comprises determining a characteristic selected from a volume of the region of heated tissue and a length of the region of heated tissue. Monitoring the size of the region of heated tissue can also comprise providing user feedback selected from the group consisting of: the temperature is approaching the associated temperature, the approximated length of the heated tissue. 
         [0008]    The methods can also include monitoring the size of the region of heated tissue by adjusting a power supplied to the energy transfer portions during the continuing application of energy to control the growth of the region of heated tissue. 
         [0009]    In certain variations, an axial distance between the first temperature detecting element and the energy transfer portion can be adjusted between a plurality of positions, the method further comprising selecting one of the positions to adjust the axial distance between the temperature detecting element and the energy transfer portion. 
         [0010]    The associated temperature can comprise a plurality of associated temperatures each corresponding to a plurality of previously measured regions of heated tissue, where each of the plurality of previously measured regions of heated tissue comprises a distinct shape in such cases the method can further comprise controlling expansion of the region of heated tissue after comparing the temperature to the at, least one associated temperature by selecting one of the plurality of associated temperatures and ceasing, application of energy when the temperature reaches the selected associated temperature. 
         [0011]    In an additional variation, the present disclosure includes a method of using temperature measurements to produce a region of heated tissue in the vertebral body. For example, such a method can comprise inserting a treatment device into a tissue area, the treatment device having an energy transfer portion located at a distal portion of a shaft, the treatment device further including at least one temperature detecting element coupled to the shaft; selecting an actual location in tissue that corresponds to a perimeter of a desired treatment zone having a desired profile; positioning the temperature detecting element at or near the actual location; applying energy to the energy transfer portion to produce the region of heated tissue about the energy transfer portion; continuing application of energy to cause growth of the region of heated tissue; measuring a temperature of a tissue area located adjacent to the temperature detecting element; and comparing the temperature to an associated temperature to control the application of energy to the energy transfer unit, where the associated temperature correlates to a previously determined region of heated tissue having a known profile where the known profile is similar to the desired profile. 
         [0012]    Variations of the method can include at least a first temperature detecting element and a second temperature detecting element, where the second temperature detecting element is located proximally to the first temperature detecting element; where measuring the temperature comprises measuring a first temperature and a second temperature at the respective temperature detecting elements; and where comparing the temperature to the associated temperature to control the application of energy to the energy transfer unit comprises selecting either the first or second temperatures to the associated temperature. 
         [0013]    The present disclosure also includes medical systems for creating regions of heated tissue using temperature to monitor a desired profile of the regions. For example, the medical system can include: an energy controller capable of controlling energy delivery in response to comparing at least one temperature measurements to at least at least one associated temperature, where the associated temperature correlates to a previously measured region of heated tissue having a known profile; a treatment device having a shaft coupled to a handle, where the handle includes a connector for electrically coupling to the energy control unit; a shaft extending from the handle to a distal portion, an energy transfer portion for delivering, energy from the power supply to tissue located at the distal portion; at least a first and second temperature detecting elements spaced proximally from a proximal end of the energy transfer portion, each temperature sensor configured to independently and respectively provide a first and a second actual temperature measurements to the energy controller. 
         [0014]    In one variation, the medical system comprises an extendable element and a portion of the shaft, where the extendable element is configured to extend axially relative to a distal end of the shaft. In an additional variation, at least one of the temperature detecting elements is axially moveable along the shaft independently of the energy transfer unit. 
         [0015]    The present disclosure also includes medical devices for creating, regions of heated tissue using temperature to monitor a desired profile of the regions. Such a medical device can include a shaft coupled to a handle, where the handle includes a connector for electrically coupling to a source of energy; a first temperature detecting element spaced axially proximally along the shaft from a proximal end of the energy transfer portion; a second temperature detecting element spaced proximally from the first temperature detecting element; where the first and second temperature detecting elements are configured to independently and respectively provide a first and a second actual temperature measurements. 
         [0016]    The device can further include  34  an energy controller capable of delivering the source of energy to the energy transfer portion, the energy controller configured to control energy delivery in response to comparing at least the first or second actual temperature measurements to at least at least one associated temperature, where the associated temperature correlates to a previously measured region of heated tissue having a known profile. 
         [0017]    Another variation of the method includes a method of treating a tumor in or near bone. For example, such a method can include providing an elongated shaft with an articulating working end carrying first and second polarity electrodes; utilizing articulation of the working end to navigate the working end to a position in or near a bone tumor; activating an RE source, such that when activated, current flows between the first and second polarity electrodes to ablate the tumor; and terminating activation of the RE source when a temperature sensor spaced apart from the second polarity electrode reaches a predetermined temperature. 
         [0018]    In one variation, the temperature sensor spacing from the second polarity electrode is configured to provide a predetermined tissue ablation volume, in an alternate variation, the shaft has a plurality of temperature sensors spaced apart from the second polarity electrode to provide a plurality of predetermined tissue ablation volumes. 
         [0019]    Variations of the device can include one or more lumens that extend through the shaft and working end. These lumens can exit at a distal tip of the device or through a side opening in a wall of the device. The lumen can include a surface comprising a lubricious polymeric material. For example, the material can comprise any bio-compatible material having low frictional properties (e.g., TEFLON®, a polytetrafluroethylene (PTFE), FEP (Fluorinated ethylenepropylene), polyethylene, polyamide, ECTFE (Ethylenechlorotrifluoro-ethylene), ETFE, PVDF, polyvinyl chloride and silicone). 
         [0020]    Variations of the access device and procedures described above include combinations of features of the various embodiments or combination of the embodiments themselves wherever possible. 
         [0021]    The methods, devices and systems described herein can be combined with the following commonly assigned patent applications and provisional applications, the entirety of each of which is incorporated by reference herein: application Ser. No. 12/571,174 filed Sep. 30, 2009; application Ser. No. 12/578,455 filed Oct. 13, 2009; application Ser. No. 13/083,411 filed Apr. 8, 2011; application Ser. No. 13/097,998 tiled Apr. 29, 2011; application Ser. No. 13/098,116 filed Apr. 29, 2011; application Ser. No. 3/302,927 filed Nov. 22, 2011; Provisional Application No. 61/194,766 filed Sep. 30, 2008; Provisional Application No. 61/104,380 filed Oct. 10, 2008; Provisional Application No. 61/322,281 filed Apr. 8, 2010; Provisional Application No. 61/329,220 filed Apr. 29, 2010; Provisional Application No. 61/329,394 filed Apr. 29, 2010; Provisional Application No. 61/416,042 filed Nov. 22, 2010; Provisional Application No. 61/616,359 filed Mar. 27, 2012; and Provisional Application No, 61/659,604. 
     
    
     
       BRIEF DESCRIPTION OF DRAWINGS 
         [0022]      FIG. 1  is a plan view of an osteotome of the invention, 
           [0023]      FIG. 2  is a side view of the osteotome of  FIG. 1 . 
           [0024]      FIG. 3  is a cross sectional view of the osteotome of  FIG. 1 . 
           [0025]      FIG. 4  is an enlarged sectional view of the handle of the osteotome of  FIG. 1 . 
           [0026]      FIG. 5  is an enlarged sectional view of the working end of the osteotome of FIG. 
           [0027]      FIG. 6A  is a sectional view of the working end of  FIG. 5  in a linear configuration. 
           [0028]      FIG. 6B  is a sectional view of the working end of  FIG. 5  in a curved configuration. 
           [0029]      FIGS. 7A-7C  are schematic sectional views of a method of use of the osteotome of  FIG. 1 . 
           [0030]      FIG. 8  is another embodiment of an osteotome working end. 
           [0031]      FIG. 9  is another embodiment of an osteotome working end. 
           [0032]      FIG. 10  is another variation of an osteotome with an outer sleeve. 
           [0033]      FIG. 11  is a cut-away view of the working end of the osteotome of  FIG. 10 . 
           [0034]      FIG. 12A  is sectional view of another embodiment of working, end, taken along line  12 A- 12 A of  FIG. 11 . 
           [0035]      FIGS. 12B and 12C  illustrate additional variations of preventing rotation between adjacent sleeves. 
           [0036]      FIG. 13  is sectional view of another working, end embodiment similar to that of  FIG. 11 . 
           [0037]      FIG. 14  is a cut-away perspective view of the working end of  FIG. 13 . 
           [0038]      FIG. 15  illustrates a variation of an osteotome as described herein having electrodes on a tip of the device and another electrode on the shaft. 
           [0039]      FIG. 16  illustrates an osteotome device as shown in  FIG. 15  after being advanced into the body and where current passes between electrodes. 
           [0040]      FIG. 17  illustrates a variation of a device as described herein further including a connector for providing energy at the working end of the device. 
           [0041]      FIGS. 18A and 18B  illustrate a device having a sharp tip as disclosed herein where the sharp tip is advanceable from the distal end of the shaft. 
           [0042]      FIG. 19  shows a cross sectional view of the device illustrated in  FIG. 18B  and also illustrates temperature sensing elements located on device. 
           [0043]      FIG. 20  shows a variation of a device where the inner sleeve is extended from the device and where current is applied between the extended portion of the inner sleeve and the shaft to treat tissue. 
           [0044]      FIG. 21  illustrates a variation of a device as described herein further including an extendable helical electrode carried by the working end of the device. 
           [0045]      FIGS. 22A and 22B  illustrate the device of  FIG. 21  with the helical electrode in a non-extended position and an extended position. 
           [0046]      FIGS. 22C and 22D  illustrate charts of variations of electrodes having ablated volumes given a particular duration of an ablation cycle. 
           [0047]      FIG. 23  illustrates the working end of the device of  FIG. 21  in a vertebral body with the helical electrode delivering Rf energy to ablate tissue. 
           [0048]      FIG. 24  illustrates the working end of an osteotome similar to that of  FIGS. 22A-22B  showing temperature sensors disposed within the working end. 
           [0049]      FIG. 25  illustrates another osteotome working end similar to that of  FIG. 25 . 
           [0050]      FIGS. 26A to 26E  depict variations of devices having multiple temperature sensing elements adjacent to energy transfer portions. 
           [0051]      FIGS. 27A to 27C  illustrates the use of one or more temperature sensing elements to monitor and/or control the growth of a region of treated tissue. 
       
    
    
     DETAILED DESCRIPTION 
       [0052]    Referring to  FIGS. 1-5 , an apparatus or osteotome  100  is shown that is configured for accessing the interior of a vertebral body and for creating a pathway in vertebral cancellous bone to receive bone cement. In one embodiment, the apparatus is configured with an extension portion or member  105  for introducing through a pedicle and wherein a working end  110  of the extension member can be progressively actuated to curve a selected, degree and/or rotated to create a curved pathway and cavity in the direction of the midline of the vertebral body. The apparatus can be withdrawn and bone fill material can be introduced through a bone cement injection cannula. Alternatively, the apparatus  100  itself can be used as a cement injector with the subsequent injection of cement through a lumen  112  of the apparatus. 
         [0053]    In one embodiment, the apparatus  100  comprises a handle  115  that is coupled to a proximal end of the extension member  105 . The extension member  105  comprises an assembly of first (outer) sleeve  120  and a second (inner) sleeve  122 , with the first sleeve  120  having a proximal end  124  and distal end  126 . The second sleeve  122  has a proximal end  134  and distal end  136 . The extension member  105  is coupled to the handle  115 , as will be described below, to allow a physician to drive the extension member  105  into bone while contemporaneously actuating the working end  110  into an actuated or curved configuration (see  FIG. 6 ). The handle  115  can be fabricated of a polymer, metal or any other material suitable to withstand hammering or impact threes used to drive the assembly into bone e.g., via use of a hammer or similar device on the handle  115 ). The inner and outer sleeves are fabricated of a suitable metal alloy, such as stainless steel or NiTi. The wall thicknesses of the inner and outer sleeves can range from about 0.005° to 0.010° with the outer diameter the outer sleeve ranging from about 2.5 mm to 5.0 mm. 
         [0054]    Referring to  FIGS. 1 ,  3  and  4 , the handle  115  comprises both a first grip portion  140  and a second actuator portion indicated at  142 . The grip portion  140  is coupled to the first sleeve  120  as will be described below. The actuator portion  142  is operatively coupled to the second sleeve  122  as will be described below. The actuator portion  142  is rotatable relative to the grip portion  140  and one or more plastic flex tabs  145  of the grip portion  140  are configured to engage notches  146  in the rotatable actuator portion  142  to provide tactile indication and temporary locking of the handle portions  140  and  142  in a certain degree of rotation. The flex tabs  145  thus engage and disengage with the notches  146  to permit ratcheting (rotation and locking) of the handle portions and the respective sleeve coupled thereto. 
         [0055]    The notches or slots in any of the sleeves can comprise a uniform width along the length of the working end or can comprise a varying width. Alternatively, the width can be selected in certain areas to effectuate a particular curved profile. In other variation, the width can increase or decrease along the working end to create a curve having a varying radius. Clearly, it is understood that any number of variations are within the scope of this disclosure. 
         [0056]      FIG. 4  is a sectional view of the handle showing a mechanism for actuating the second inner sleeve  122  relative to the first outer sleeve  120 . The actuator portion  142  of the handle  115  is configured with a fast-lead helical groove indicated at  150  that cooperates with a protruding thread  149  of the grip portion  140  of the handle. Thus, it can be understood that rotation of the actuation portion  142  will move this portion to the position indicated at  150  (phantom view). In one embodiment, when the actuator portion  142  is rotated a selected amount from about 45° to 720°, or from about 90° to 360°, the inner sleeve  122  is lifted proximally relative to the grip portion  140  and Outer sleeve  120  to actuate the working end  110 . As can be seen in  FIG. 4  the actuator portion  142  engages flange  152  that is welded to the proximal end  132  of inner sleeve  122 . The flange  152  is lifted by means of a ball bearing assembly  154  disposed between the flange  152  and metal bearing surface  155  inserted into the grip portion  140  of the handle. Thus, the rotation of actuator  142  can lift the inner sleeve  122  without creating torque on the inner sleeve. 
         [0057]    Now turning to  FIGS. 5 ,  6 A and  6 B, it can be seen that the working end  110  of the extension member  105  is articulated by cooperating slotted portions of the distal portions of outer sleeve  120  and inner sleeve  122  that are both thus capable of bending in a substantially tight radius. The outer sleeve  120  has a plurality of slots or notches  162  therein that can be any slots that are perpendicular or angled relative to the axis of the sleeve. The inner sleeve  122  has a plurality of slots or notches indicated at  164  that can be on an opposite side of the assembly relative to the slots  162  in the outer sleeve  120 . The outer and inner sleeves are welded together at the distal region indicated at weld  160 . Ii thus can be understood that when inner sleeve  122  is translated in the proximal direction, the outer sleeve will be flexed as depicted in  FIG. 6B . It can be understood that by rotating the actuator handle portion  142  a selected amount, the working end can be articulated to a selected degree. 
         [0058]      FIGS. 4 ,  5 ,  6 A and  6 B further illustrate another element of the apparatus that comprises a flexible flat wire member  170  with a proximal end  171  and flange  172  that is engages the proximal side of flange  152  of the inner sleeve  122 . At least the distal portion  174  of the flat wire member  170  is welded to the inner sleeve at weld  175 . This flat wire member thus provides a safety feature to retain the working end in the event that the inner sleeve fails at one of the slots  164 . 
         [0059]    Another safety feature of the apparatus comprises a torque limiter and release system that allows the entire handle assembly  115  to freely rotate—for example if the working end  110  is articulated, as in  FIG. 68 , when the physician rotates the handle and when the working end is engaged in strong cancellous bone. Referring to  FIG. 4 , the grip portion  142  of the handle  115  engages a collar  180  that is fixed to a proximal end  124  of the outer sleeve  120 . The collar  180  further comprises notches  185  that are radially spaced about the collar and are engaged by a ball member  186  that is pushed by a spring  188  into notches  185 . At a selected force, for example a torque ranging from greater than about 0.5 inch*lbs but less that about 7.5 inch*lbs, 5.0 inch*lbs or 2.5 inch*lbs, the rotation of the handle  115  overcomes the predetermined limit. When the torque limiter assembly is in its locked position, the ball bearing  186  is forced into one of the notches  185  in the collar  180 . When too much torque is provided to the handle and outer sleeve, the ball bearing  186  disengages the notch  185  allowing the collar  180  to turn, and then reengages at the next notch, releasing anywhere from 0.5 inch*lbs to 7.5 inch*lbs of torque. 
         [0060]    Referring to  FIGS. 6A and 68 , it can be understood that the inner sleeve  122  is weakened on one side at its distal portion so as to permit the inner sleeve  122  to bend in either direction but is limited by the location of the notches in the outer sleeve  120 . The curvature of any articulated configuration is controlled by the spacing of the notches as well as the distance between each notch peak. The inner sleeve  122  also has a beveled tip for entry through the cortical bone of a vertebral body. Either the inner sleeve or outer sleeve can form the distal tip. 
         [0061]    Referring to  FIGS. 7A-7C , in one variation of use of the device, a physician taps or otherwise drives a stylet  200  and introducer sleeve  205  into a vertebral body  206  typically until the stylet tip  208  is within the anterior ⅓ of the vertebral body toward cortical bone  210  ( FIG. 7A ). Thereafter, the stylet  200  is removed and the sleeve  205  is moved proximally ( FIG. 7B ). As can be seen in  FIG. 78 , the tool or osteotome  100  is inserted through the introducer sleeve  205  and articulated in a series of steps as described above. The working end  110  can be articulated intermittently while applying driving forces and optionally rotational forces to the handle  115  to advance the working end through the cancellous bone  212  to create path or cavity  215 . The tool is then tapped to further drive the working end  110  to, toward or past the midline of the vertebra. The physician can alternatively articulate the working end  110 , and drive and rotate the working end further until imaging shows that the working end  100  has created a cavity  215  of an optimal configuration. Thereafter, as depicted in  FIG. 7C , the physician reverses the sequence and progressively straightens the working, end  110  as the extension member is withdrawn from the vertebral body  206 . Thereafter, the physician can insert a bone cement injector  220  into the path or cavity  215  created by osteotome  100 .  FIG. 7C  illustrates a bone cement  222 , for example a PMMA cement, being injected from a bone cement source  225 . 
         [0062]    In another embodiment (not shown), the apparatus  100  can have a handle  115  with a Luer fitting for coupling a bone cement syringe and the bone cement can be injected through the lumen  112  of the apparatus. In such an embodiment  FIG. 9 , the lumen can have a lubricious surface layer or polymeric lining  250  to insure least resistance to bone cement as it flows through the lumen. In one embodiment, the surface or lining  250  can be a fluorinated polymer such as TEFLON® or polytetrafluroethylene PTFE). Other suitable fluoropolymer resins can be used such as FEP and PFA. Other materials also can be used such as FEP (Fluorinated ethylenepropylene), ECTFF (Ethylenechlorotrifluoro-ethylene), ETFE, Polyethylene, Polyamide, PVDF, Polyvinyl chloride and silicone. The scope of the invention can include providing a polymeric material having a static coefficient of friction of less than 0.5, less than 0.2 or less than 0.1. 
         [0063]      FIG. 9  also shows the extension member or shaft  105  can be configured with an exterior flexible sleeve indicated at  255 . The flexible sleeve can be any commonly known biocompatible material, for example, the sleeve can comprise any of the materials described in the preceding paragraph. 
         [0064]    As also can be seen in  FIG. 9 , in one variation of the device  100 , the working end  110  can be configured to deflect over a length indicated at  260  in a substantially smooth curve. The degree of articulation of the working end  100  can be at least 45°, 90°, 135° or at least 180° as indicated at  265  ( FIG. 9 ). In additional variations, the slots of the outer  120  and inner sleeves  120  can be varied to produce a device having a radius of curvature that varies among the length  260  of the device  100 . 
         [0065]    In another embodiment of the invention, the inner sleeve can be spring loaded relative the outer sleeve, in such a way as to allow the working end to straighten under a selected level of force when pulled in a linear direction. This feature allows the physician to withdraw the assembly from the vertebral body partly or completely without further rotation the actuating portion  142  of handle  115 . In some variations, the force-limiter can be provided to allow less than about 10 inch*lbs of force to be applied to bone. 
         [0066]    In another embodiment shown in  FIG. 8 , the working end  110  is configured with a tip  240  that deflects to the position indicated at  240 ′ when driven into bone. The tip  240  is coupled to the sleeve assembly by resilient member  242 , for example a flexible metal such as stainless steel or NiTi. It has been found that the flexing of the tip  240  causes its distal surface area to engage cancellous bone which can assist in deflecting the working end  110  as it is hammered into bone. 
         [0067]    In another embodiment of the invention (not shown), the actuator handle can include a secondary for optional) mechanism for actuating the working end. The mechanism would include a hammer-able member with a ratchet such that each tap of the hammer would advance assembly and progressively actuate the working end into a curved configuration. A ratchet mechanism as known in the art would maintain the assembly in each of a plurality of articulated configurations. A release would be provided to allow for release of the ratchet to provide for straightening the extension member  105  for withdrawal from the vertebral body. 
         [0068]      FIGS. 10 and 11  illustrate another variation of a boric treatment device  400  with a handle  402  and extension member  405  extending to working end  410  having a similar construction to that  FIGS. 1 to 6B . The device  400  operates as described previously with notched first (outer) sleeve  120  and cooperating notched second (inner) sleeve  122 . However, the variation shown in  FIGS. 10 and 11  also includes a third concentric notched sleeve  420 , exterior to the first  120  and second  122  sleeves. The notches or slots in sleeve  420  at the working end  410  permit deflection of the sleeve as indicated at  2 ( 5  in  FIG. 11 . 
         [0069]      FIG. 10  also illustrates the treatment device  400  as including a luer fitting  412  that allows the device  402  to be coupled to a source of a filler material (e.g., a bone filler or bone cement material). The luer can be removable from the handle  402  to allow application of an impact force on the handle as described above. Moreover, the luer fitting  402  can be located on the actuating portion of the handle, the stationary part of the handle or even along the sleeve. In any case, variations of the device  400  permit coupling the filler material with a lumen extending through the sleeves (or between adjacent sleeves) to deposit tiller material at the working end  410 . As shown by arrows  416 , filler material can be deposited through a distal end of the sleeves (where the sharp tip is solid) or can be deposited through openings in a side-wall of the sleeves. Clearly, variations of this configuration are within the scope of those familiar in the field. 
         [0070]    In some variations, the third notched sleeve  420  is configured with its smooth (non-notched) surface  424  disposed to face inwardly on the articulated working end ( FIG. 11 ) such that a solid surface forms the interior of the curved portion of the working end  410 . The smooth surface  424  allows withdrawal of the device  110  into a cannula or introducer  205  without creating a risk that the slots or notches become caught on a cannula  205  (see e.g.,  FIG. 7B ). 
         [0071]    As shown in  FIGS. 10-11 , the third (outermost) sleeve  420  can extend from an intermediate location on the extension member  405  to a distal end of the working end  410 . However, variations of the device include the third sleeve  420  extending to the handle  402 . However, the third sleeve  420  is typically not coupled to the handle  402  so that any rotational force or torque generated by the handle  402  is not directly transmitted to the third sleeve  420 . 
         [0072]    In one variation, the third sleeve  420  is coupled to the second sleeve  120  at only one axial location. In the illustrated example shown in  FIG. 11 , the third sleeve  420  is affixed to second sleeve  420  by welds  428  at the distal end of the working end  410 . However, the welds or other attachment means (e.g., a pin, key/keyway, protrusion, etc.) can be located on a medial part of the sleeve  420 . The sleeve  420  can be fabricated of any bio-compatible material. For example, in one variation, the third sleeve is fabricated form a 3.00 mm diameter stainless steel material with a wall thickness of 0.007″. The first, second and third sleeves are sized to have dimensions to allow a sliding fit between the sleeves. 
         [0073]      FIG. 12A  is a sectional view of extension member  405  of another variation, similar to that shown in  FIGS. 10-11 . However, the variation depicted by  FIG. 12A  comprises non-round configurations of concentric slidable sleeves (double or triple sleeve devices). This configuration limits or prevents rotation between the sleeves and allows the physician to apply greater forces to the bone to create a cavity. While  FIG. 12A  illustrates an oval configuration, any non-round shape is within the scope of this disclosure. For example, the cross-sectional shape can comprise a square, polygonal, or other radially keyed configuration as shown in  FIGS. 12B and 12C . As shown in  FIG. 12C  the sleeves can include a key  407  and a receiving keyway  409  to prevent rotation but allow relative or axial sliding of the sleeves. The key can comprise any protrusion or member that slides within a receiving keyway. Furthermore, the key can comprise a pin or any raised protrusion on an exterior or interior of a respective sleeve. In this illustration, only the first  122  and second  120  sleeves are illustrated. However, any of the sleeves can be configured with the key/keyway. Preventing rotation between sleeves improves the ability to apply force to bone at the articulated working end. 
         [0074]      FIGS. 13-14  illustrate another variation of a working end  410  of an osteotome device. In this variation, the working end  410  includes one or more flat spring elements  450 ,  460   a ,  460   b ,  460   c ,  460   d , that prevent relative rotation of the sleeves of the assembly thus allowing greater rotational forces to be applied to cancellous bone from an articulated working end. The spring elements further urge the working end assembly into a linear configuration. To articulate the sleeves, a rotational force is applied to the handle as described above, once this rotational force is removed, the spring elements urge the working end into a linear configuration. As shown in  FIG. 13 , one or more of the spring elements can extend through the sleeves for affixing to a handle to prevent rotation. Furthermore, the distal end  454  of flat spring element  450  is fixed to sleeve assembly by weld  455 . Thus, the spring element is fixed at each end to prevent its rotation. Alternate variations include one or more spring elements being affixed to the inner sleeve assembly at a medial section of the sleeve. 
         [0075]    As shown in  FIGS. 13-14 , variations of the osteotome can include any number of spring elements  460   a - 460   d . These additional spring elements  460   a - 460   d  can be welded at either a proximal or distal end thereof to an adjacent element or a sleeve to allow the element to function as a leaf spring. 
         [0076]    In an additional variation, the osteotome device can include one or more electrodes  310 ,  312  as shown in  FIG. 15 . In this particular example, the device  300  includes spaced apart electrodes having opposite polarity to function in a bi-polar manner. However, the device can include a monopolar configuration. Furthermore, one or more electrodes can be coupled to individual channels of a power supply so that the electrodes can be energized as needed. Any variation of the device described above can be configured with one or more electrodes as described herein. 
         [0077]      FIG. 16  illustrates an osteotome device  300  after being advanced into the body as discussed above. As shown by lines  315  representing current flow between electrodes, when required, the physician can conduct RF current between electrodes  310  and  312  to apply coagulative or ablative energy within the bone structure of the vertebral body (or other hard (issue). While  FIG. 16  illustrates RF current  315  flow between electrodes  310  and  312 , variations of the device can include a number of electrodes along the device to apply the proper therapeutic energy. Furthermore, an electrode can be spaced from the end of the osteotome rather than being placed on the sharp tip as shown by electrode  310 . In some variations, the power supply is coupled to the inner sharp tip or other working end of the first sleeve. In those variations with only two sleeves, the second pole of the power supply is coupled with the second sleeve (that is the exterior of the device) to form a return electrode. However, in those variations having three sleeves, the power supply can alternatively be coupled with the third outer sleeve. In yet additional variations, the second and third sleeves can both function as return electrodes. However, in those devices that are monopolar, the return electrode will be placed outside of the body on a large area of skin. 
         [0078]      FIGS. 17 to 20  illustrate another variation of an articulating probe or osteotome device  500 . In this variation, the device  500  includes a working end  505  that carries one or more RF electrodes that can be used to conduct current therethrough. Accordingly, the device can be used to sense impedance of tissue, locate nerves, or simply apply electrosurgical energy to tissue to coagulate or ablate tissue. In one potential use, the device  500  can apply ablative energy to a tumor or other tissue within the vertebra as well as create a cavity. 
         [0079]      FIGS. 17 ,  18 A,  18 B and  19 , illustrate a variation of the device  500  as having a handle portion  506  coupled to a shaft assembly  510  that extends along axis  512  to the articulating working end  505 . The articulating working end  505  can be actuatable as described above. In addition,  FIG. 17  shows that handle component  514   a  can be rotated relative to handle component  514   b  to cause relative axial movement between a first outer sleeve  520  and second inner sleeve  522  ( FIG. 19 ) to cause the slotted working ends of the sleeve assembly to articulate as described above. The working end  505  of  FIG. 19  shows two sleeves  520  and  522  that are actuatable to articulate the working end, but it should be appreciated that a third outer articulating sleeve can be added as depicted above. In one variation, the articulating working end can articulate 90° by rotating handle component  514   a  between ¼ turn and ¾ turn. The rotating handle component  514   a  can include detents at various rotational positions to allow for controlled hammering of the working, end into bone. For example, the detents can be located at every 45° rotation or can be located at any other rotational increment. 
         [0080]      FIG. 17  depict an RF generator  530 A and RF controller  530 B connectable to an electrical connector  532  in the handle component  514   a  with a plug connector indicated at  536 . The RF generator is of the type known in the art for electrosurgical ablation. The outer sleeve  520  comprises a first polarity electrode indicated at  540 A (+). However, any energy modality can be employed with the device. 
         [0081]      FIGS. 18A and 18B  illustrate yet another variation of a working end of a device for creating cavities in hard tissue. As shown, the device  500  can include a central extendable sleeve  550  with a sharp tip  552  that is axially extendable from passageway  554  of the assembly of first and second sleeves  520  and  522  ( FIG. 19 ). The sleeve  550  can also include a second polarity electrode indicated at  540 B (−). Clearly, the first and second electrodes will be electrically insulated from one another. In one variation, and as shown in  FIG. 19 , the sleeve assembly can carry a thin sleeve  555  or coating of an insulative polymer such as PEEK or Ceramic to electrically isolate the first polarity electrode  540 A (+) from the second polarity electrode  540 B (−). The electrode can be deployed by rotating knob  558  on the striking surface of handle component  514   a  ( FIG. 17 ). The degree of extension of central sleeve  550  can optionally be indicated by a slider tab  557  on the handle, in the illustrated variation, the slider tab is located on either side of handle component  514   a  ( FIG. 17 ). Sleeve  550  can be configured to extend distally beyond the assembly of sleeves  520  and  522  a distance of about 5 to 15 mm. 
         [0082]    Referring to  FIG. 19 , the central extendable sleeve  550  can have a series of slots in at least a distal portion thereof to allow it to bend in cooperation with the assembly of first and second sleeves  520  and  522 . In the embodiment shown in  FIG. 188 , the central sleeve  550  can optionally include a distal portion that does not contain any slots. However, additional variations include slots on the distal portion of the sleeve. 
         [0083]      FIG. 19  further depicts an electrically insulative collar  560  that extends length A to axially space apart the first polarity electrode  540 A (+) from the second polarity electrode  540 B (−). The axial length A can be from about 0.5 to 10 mm, and usually is from 1 to 5 mm. The collar can be a ceramic or temperature resistant polymer. 
         [0084]      FIG. 19  also depicts a polymer sleeve  565  that extends through the lumen in the center of electrode sleeve  550 . The polymer sleeve  565  can provide saline infusion or other fluids to the working end and/or be used to aspirate from the working end when in use. The distal portion of sleeve  550  can include one or more ports  566  therein for delivering fluid or aspirating from the site. 
         [0085]    In all other respects, the osteotome system  500  can be driven into bone and articulated as described above. The electrodes  540 A and  54013  are operatively coupled to a radiofrequency generator as is known in the art for applying coagulative or ablative electrosurgical energy to tissue. In  FIG. 20 , it can be seen that RF current  575  is indicated in paths between electrodes  540 A and  540 B as shown by lines  575 , RF generator  530 A and controller  530 B for use with the devices described herein can include any number of power settings to control the size of targeted coagulation or ablation area. For example, the RF generator and controller can have Low or power level 1 (5 watts), medium or power level 2 (10 Watts) and High or power level 3 (25 watts) power settings. The controller  530 B can have a control algorithm that monitors the temperature of the electrodes and changes the power input in order to maintain a constant temperature. At least one temperature sensing, element (e.g., a thermocouple) can be provided on various portions of the device. For example, and as shown in  FIG. 19 , a temperature sensing element  577  can be provided at the distal tip of sleeve  550  tip while a second temperature sensing element  578  can be provided proximal from the distal tip to provide temperature feedback to the operator to indicate the region of ablated tissue during the application of RF energy. In one example, the second temperature sensing element was located approximately 15 to 20 mm from the distal tip. 
         [0086]      FIG. 21  illustrates another variation of articulating osteotome  600  with RF ablation features. Variations of the illustrated osteotome  600  can be similar to the osteotome of  FIGS. 17-18B . In this variation, the osteotome  600  of has a handle  602  coupled to shaft assembly  610  as described above. The working end  610  again has an extendable assembly indicated at  615  in  FIG. 21  that can be extended by rotation of handle portion  622  relative to handle  602 . The osteotome can be articulated as described previously by rotating handle portion  620  relative to handle  602 . 
         [0087]      FIGS. 22A-22B  are views of the working end  610  of  FIG. 21  in a first non-extended configuration ( FIG. 22A ) and a second extended configuration ( FIG. 22B ). As can be seen in  FIGS. 22A-22B , the extension portion  615  comprises an axial shaft  624  together with a helical spring element  625  that is axially collapsible and extendible. In one embodiment, the shaft can be a tube member with ports  626  fluidly coupled a lumen  628  therein. In some variations, the ports can carry a fluid to the working end or can aspirate fluid from the working end. 
         [0088]    In  FIGS. 22A-22B , it can be seen that axial shaft  624 , helical spring element  625  together with sharp tip  630  comprise a first polarity electrode (+) coupled to electrical source  530 A and controller  530 B as described previously. An insulator  632  separates the helical spring  625  electrode from the more proximal portion of the sleeve which comprises opposing polarity electrode  640  (−). The RF electrodes can function as described above (see  FIG. 20 ) to ablate tissue or otherwise deliver energy to tissue. 
         [0089]    In one variation, the extension portion  615  can extend from a collapsed spring length of 2 mm, 3 mm, 4 mm or 5 mm to an extended spring length of 6 mm, 7 mm, 8 mm,  9  min 10 mm or more. In the working end embodiment  615  in  FIG. 22B , the spring can comprise a flat rectangular wire that assists in centering the spring  625  about shaft  624  and still can collapse to short overall length, with the flat surfaces of rectangular wire oriented for stacking. However, other variations are within the scope of the variations described herein. 
         [0090]    Of particular importance, it has been found that ability of the osteotome  600  to ablate tissue is greatly enhanced over the embodiment  500  of  FIG. 20  by utilizing the helical spring. The use of the spring  625  as an electrode provides significant improvements in delivering energy. This spring provides (i) greatly increased electrode surface area and (ii) a very greatly increased length of relatively sharp edges provided by the rectangular wire—which provides for edges from which RF current can jump. Because the edges provide low surface area the concentration or density of RF current is greater at the edges and allows for the RF current to jump or arc. Both these aspects of the invention—increased electrode surface area and increased electrode edge length—allow for much more rapid tissue ablation. 
         [0091]    In one aspect of the invention, the surface area of the spring electrode  625  can be at least 40 mm 2 , at least 50 min 2  or at least 60 mm over the spring electrode lengths described above. 
         [0092]    In another aspect of the invention, the total length of the 4 edges of rectangular wire spring can be greater than 50 mm, greater than 100 mm or greater than 150 mm over the spring electrode lengths described above. 
         [0093]    In one example used in testing, an osteotome  600  as in  FIG. 21-22B  was configured with a helical spring that had a collapsed length of 1.8 mm and an extended length of 7.5 mm. In this embodiment, the surface area of the spring electrode  625  when extended was 64.24 mm 2  and the total length of the electrodes edges was 171.52 mm (four edges at 42.88 mm per edge). 
         [0094]    In a comparison test, a first osteotome without a helical electrode was compared against a second osteotome  600  with a helical, electrode as in  FIG. 22B . These devices were evaluated at different power levels and different energy delivery intervals to determine volume of ablation. The working ends of the devices had similar dimensions excepting for the helical spring electrode. Referring to  FIG. 22C , RF energy was delivered at a low power setting of 5 Watts. It can be seen in  FIG. 22C  that at a treatment interval of 120 seconds and 5 W, the volume of ablation was about 3 times faster with the helical electrode compared to the working end without the helical electrode (1.29 cc vs. 0.44 cc). 
         [0095]    Another comparison test of the same first osteotome  500  ( FIG. 18B ) and second osteotome  600  with a helical electrode ( FIG. 22B ) were evaluated at higher 15 Watt power level. As can be seen in  FIG. 221 ), RF energy at a treatment interval of 25 seconds and 15 W, the volume of ablation was again was about 3 times faster with the helical electrode compared to the working end without the helical electrode (1.00 cc vs. 0.37 cc). Referring to  FIG. 22D , the device without the helical electrode impeded out before 60 seconds passed, so that data was not provided. The testing shows that the helical electrode is well suited for any type of tissue or tumor ablation, with a 60 second ablation resulting in 1.63 cc of ablated tissue. 
         [0096]      FIG. 23  schematically illustrates the osteotome  600  in use in a vertebral body, wherein the RF current between the electrodes  625  and  640  ablate a tissue volume indicated at  640 . 
         [0097]      FIG. 24  is an enlarged sectional view of a working end  710  of ablation osteotome similar to that of  FIGS. 21-22B . In this embodiment, shaft or introducer sleeve assembly  712  has an outside diameter of 4.5 mm or less, or 4.0 mm or less. In one embodiment, the diameter of introducer  712  is 3.5 mm and comprises outer sleeve  715   a , intermediate sleeve  715   b  and inner sleeve  715   c  all of which are slotted, to permit articulation of a portion of the working end as can be seen in phantom view in  FIG. 24A . 
         [0098]    In  FIG. 24 , the extendable element or sleeve  720  is shown in an extended configuration which extends helical spring element  725  as described above. In this embodiment, the sleeve  720  and helical spring element  725  together with sharp tip  730  comprises a first polarity electrode coupled to an RF source  530 A and controller  530 B as described previously. An insulator  732  separates the helical spring  725  electrode from the distal portion  734  of the sleeve which comprises opposing polarity electrode  740 . It can be seen that extendable sleeve  720  has a distal portion that is slotted to permit bending as the working end is articulated. The RF electrodes can function as described above (see  FIG. 20 ) to ablate tissue. 
         [0099]    In one aspect of the invention, the electrode surface portion of the extendable assembly  735  (sleeve  720  and helical element  725 ) is moveable from a non-extended position to an extended position during which the electrode surface area varies less than 10% between said non-extended and extended positions. In another embodiment, the electrode surface area varies less than 5% between said non-extended and extended positions. This aspect of the invention allows for similar ablation volumes per unit time no matter the dimension of the extendable assembly  735  since the surface are of the helical element  725  accounts for nearly all of the electrode surface area. The extendable element can have an electrode surface area of at least 40 min, at least 50 mm 2 , or at least 60 mm 2 . 
         [0100]      FIG. 24  further illustrates another aspect of the invention which includes at least one temperature sensor, also referred to as a temperature detecting element, in the working end for controlling or terminating RF energy delivery when tissue adjacent the temperature reaches a predetermined level. 
         [0101]    In one variation, as shown in  FIG. 24 , a temperature detecting element  745  can be disposed between first and second dielectric sleeves  746  and  748  that insulate the introducer sleeve assembly  712  from the extendable sleeve  720 . In an embodiment, the RF energy can be activated to ablate tissue until the boundary of ablated tissue adjacent the temperature detecting element  745  reached a predetermined temperature and the temperature detecting element signal can then be coupled to the controller to terminate RE energy delivery. In one embodiment, the temperature detecting element  745  can be disposed between first and second layers of a thin wall dielectric material,  746  and  748 , such as PEEK that is used to insulate the opposing polarity electrodes from each other, in  FIG. 24 , the temperature detecting element  745  can be positioned dimension AA from the distal end of the introducer sleeve assembly  712  which can range from 5 mm to 15 mm.  FIG. 24  depicts a second temperature detecting element  750  that can be positioned dimension BB from the first temperature detecting element  745  which can be a distance ranging from 5 mm to 15 mm. 
         [0102]    As shown  FIG. 24 , a temperature detecting element  745  can be disposed on an outer radius of an articulated distal portion of the working end. In another embodiment, the temperature detecting element(s) can be disposed on an inner radius of the articulated distal portion of the working end. 
         [0103]    In  FIG. 25 , it can be seen that the helical element  725  has a distal end coupled, for example by weld  752 , to the distal tip element  730  of the extendable assembly  735 .  FIG. 25  further shows that helical element  725  has a proximal end coupled to a safety wire  760  that extends proximally and is bonded to the introducer assembly, for example being secured with adhesives or other means between the first and second layers of dielectric material,  746  and  748 . 
         [0104]    In one embodiment shown in  FIG. 25 , a conductive fluid source  765  communicates with a lumen  770  extending through the extendable sleeve  720  to provide saline infusion through ports  772  into the region of tissue targeted for treatment. 
         [0105]    In general, a method corresponding to the invention comprises introducing an elongated introducer sleeve comprising return electrode into targeted tissue, articulating a distal region of the introducer sleeve and extending an extendable member from the introducer sleeve, wherein the extendable member comprises an active or first polarity electrode having an electrode surface area that varies less than 10% between non-extended and extended positions, and activating an RF source, such that when activated, current flows between the extendable member and the introducer sleeve to apply energy to the targeted tissue. The method includes terminating activation of the RF source when a temperature sensor spaced apart from the first polarity electrode reaches a predetermined temperature. The temperature sensor can be spaced apart from the first polarity electrode by at least 5 mm, 10 mm or 15 mm. The method can target tissue in or near a bone such as a vertebra or long bone. The targeted tissue can be a tumor. 
         [0106]    Another method of the invention comprises treating a tumor in or near bone which includes providing an elongated shaft with an articulating working end carrying first and second polarity electrodes, utilizing articulation of the working end to navigate the working end to a position in or near a bone tumor, activating an RF source, such that when activated, current flows between the first and second polarity electrodes to ablate the tumor; and terminating activation of the RF source when a temperature sensor spaced apart from the second polarity electrode reaches a predetermined temperature. In this method, the temperature sensor spacing from an active electrode is configured to provide a predetermined tissue ablation volume. As shown in  FIG. 24 , the working end can carry a plurality of axially spaced apart temperature sensors, and each sensor can be used to indicate a particular dimension of ablated tissue as each sensor reaches a predetermined temperature based on the expanding, volume of ablated tissue. 
         [0107]    In another embodiment, the medial and proximal regions of the outer sleeve can be covered with a thin-wall insulative material to provide an distal electrode surface having a predetermined surface area that matches the surface area of the helical element  725 . The sleeve  720  at the interior of the helical element also can be covered with a thin-wall dielectric material. In use the device then would operate in a truly bi-polar manner since the opposing polarity electrodes would have an equal surface area no matter the length of extension of the extendable assembly  735 . In general, a device corresponding to the invention would comprise an elongate introducer having a distal end, wherein a surface portion of the introducer comprises an electrode, an extendable member including a helical element comprising an second electrode moveable from a non-extended position to an extended position from the introducer wherein the electrode surface area of the first electrode and the second electrode match no matter the non-extended or extended position of the second electrode. 
         [0108]    In another variation of the invention under the present disclosure, the devices, systems and methods described herein can include the use of one or more temperature sensors (also called temperature detecting elements) to monitor, control, and/or otherwise provide a physician with the information needed to ensure a desired treatment. 
         [0109]    The temperature sensor/temperature detecting element can comprise any element that can measure temperature of the adjacent tissue or measure temperature of the device immediately adjacent to tissue provide this information to a controller or other portion of the system as described herein. In most variations of the device, the temperature detecting element is used to assess temperature of the tissue before, during, or after application of energy. Examples of temperature detecting elements include thermocouples, resistance temperature detectors (RTDs), optical temperature measurement sensors, pyrometers. In addition, the present disclosure can include any type of temperature measurement device capable of determining a temperature of tissue or even parts of the device that would otherwise indicate a relative temperature of the tissue. 
         [0110]      FIG. 26A  illustrates a device similar to that shown in  FIG. 24  where a temperature detecting element  745  is disposed between first and second dielectric sleeves  746  and  748  that insulate the introducer sleeve assembly  712  from the extendable sleeve  720 . As shown the temperature detecting element  745  can be disposed on an outer radius of an articulated distal portion of the working end. In addition,  FIG. 26A  shows a second temperature detecting element  750  positioned proximally from the first temperature detecting element  745  where spacing of such temperature detecting elements allows for control and/or monitoring a region of heated tissue as described below. However, variations of the devices allow for any number of temperature detecting elements to be used in any number of positions. 
         [0111]    For example,  FIG. 26B  illustrates two temperature detecting element  245 ,  250  positioned on an exterior sleeve  715 A of the device. In an additional variation, the temperature detecting elements can be positioned in between the slots of the exterior sleeve  715 A. 
         [0112]      FIG. 26C  shows another variation of a device having a plurality of temperature detecting elements  745 ,  750 ,  754 ,  756 ,  758  spaced along, the shaft. Clearly, the temperature detecting elements could be located on an interior of the device, similar to that shown in  FIG. 24A . Alternatively, as shown in  FIG. 26D , temperature detecting elements can be included both on an interior and exterior of the device.  FIG. 26E  illustrates temperature detecting elements  745 ,  750 ,  754  located on both sides of the device. Alternatively, the temperature detecting element can comprise a ring type element that measures temperature adjacent to a full or partial circumference of the device. As noted herein, the temperature detecting elements can be evenly spaced along the shaft. Alternatively, the spacing of the elements can vary depending upon the intended application of the device. In addition, in most variations of the devices described herein, the temperature detecting elements are located proximally to the heating element of the device. However, additional variations include temperature detecting elements positioned distal to or adjacent to the heating, element. The components of the various temperature detecting elements, such as wires, fibers, etc. are not illustrated for purposes of clarity. Furthermore, one or more temperature detecting elements can be positioned on sleeves that move axially relative to the energy transfer portion. 
         [0113]      FIGS. 27A to 27C  illustrate a concept of using temperature sensing element to guide a treatment where the temperature sensing elements are placed away from the energy transfer unit.  FIG. 27A  shows an example of a treatment device  800  having energy transfer portion  802  at a distal portion of a shaft  804 . As discussed above, one effective variation of a device includes the use of RF energy configuration, either monopolar or bi-polar, that serves as the energy transfer portion. However, any number of energy transfer modes can be employed in the methods, systems and devices described herein where such modalities produced heated tissue. Such modalities can include, but are not limited to, resistive heating, radiant heating, coherent light, microwave, and chemical. In yet another variation, the devices can use radioactive energy modalities as well. Alternatively, variations of devices employing temperature based detection can employ cryosurgical energy configurations that rely upon the application of extreme cold treat tissue. Clearly, in such cases the methods, devices, and systems would monitor regions of cooled tissue rather than heated tissue. 
         [0114]    Turning hack to  FIG. 27A , the treatment device  800  includes at least a first temperature detecting element  806  located axially relative to an energy transfer element  802 . In some variations, the energy transfer element  806  is located proximally along an axis of the shaft from the energy transfer unit  802 . However, as described above, variations of the devices include placement of the temperature detecting elements as needed.  FIG. 27A  also shows a second temperature detecting element  808  located proximally to the first temperature detecting element  806 . Again, the methods and procedures described, herein can employ any number of temperature detecting elements. 
         [0115]    The devices and methods also optionally include conveying temperature information on a controller  830 . Variations of the controller  830  allow for display or conveyance of temperature information specific to each temperature detecting element. For example, in the variation shown in  FIG. 27A , the first temperature detecting element can be coupled to display  832  while the second temperature detecting element  808  can be coupled to display  834 . The controller can also optionally allow a physician to set temperature limits based on readings from each temperature sensing element. In such a case, if a measured temperature at a respective temperature sensing element exceeds the temperature limit, the system can end deliver of the energy or provide any other auditory or visual alert. The control unit  830  can be separate from a power supply or can be integrated into the power supply. Additional variations also include a control unit that can be integrated into a handle or other portion of the device  800 . 
         [0116]    In a first variation, a physician can position the distal end of the shaft  804  containing the energy transfer element  802  within a tumor  12 . Clearly, the methods and procedures are not limited to treatment of a tumor. Instead, the device can be positioned in any target region that a physician seeks to treat. Once the device  800  and energy transfer element  802  are properly positioned, the physician can begin to apply energy to the energy transfer portion to cause an effect (as shown by arrows  14 ) in tissue that produces a region of affected tissue, temperature of the tissue increases or decreases (as described above based on the energy modality used). For convenience, the method shall be discussed with respect to an area of heated tissue. Clearly, alternate variations of the device involve regions of cooled tissue. 
         [0117]      FIG. 27B  illustrates continued application of energy, which results in expansion of the region of heated tissue  16 . The continued application of energy can occur intermittently or continuously. As the physician operates the device  800 , the temperature detecting elements  806 ,  808  can monitor temperature of adjacent tissue.  FIG. 27B  depicts the region of heated tissue  16  as not having yet reached the first or second temperature sensing element  806 ,  808 . The temperature measurements can occur intermittently, continuously, during application of energy, or in between intermittent applications of energy. Likewise, the temperature information  832 ,  834  can optionally be relayed to the controller  830 . 
         [0118]      FIG. 27C  shows the heated region of tissue  16  expanded sufficiently such that it encompasses the desired region of tissue  12  or tumor.  FIG. 27  also depicts the heated region of tissue  16  as being easily visually identified. However, during an actual treatment, the physician simply cannot observe the actual perimeter of the zone of heated tissue  16 . Instead, the temperature detecting elements  806 ,  808  will be able to detect the heated region of tissue  16  as the temperature of the tissue adjacent to the temperature detecting elements  806 ,  808  rises. 
         [0119]    The temperature measured by the temperature detecting elements  806 ,  808  can also provide the physician with the ability to monitor the progression of the region of heated tissue  16 . For instance, the volume, length, area, or other characteristic of the region of heated tissue can be approximated by obtaining a temperature that is associated with the perimeter of the region. Analytic correlation of this associated temperature to the physical characteristic of the heated tissue can be determined from bench testing, animal testing, cadaver testing, and/or computer analysis. Such analytic correlation allows the volume of an area of heated tissue to be approximated based on the temperature of the outer perimeter of that region. In the illustrated example of  FIG. 27C , there exists a pre-determined temperature associated with an area of heated tissue having known dimension. Once the measured temperature at temperature detecting element  808  reaches this associated temperature, the physician can stop the treatment. Alternatively, or in addition, the system or controller  830  can include safety algorithms to automatically warn the physician to cease treatment or even to perform a safety shutoff of the system if a given temperature is reached or if the temperature remains constant while power is applied to the electrode. 
         [0120]    In additional variations, the monitoring, of the size or profile of the region of heated tissue can be used to control the application of applied energy. For example, as the measured temperature approaches the associated temperature, the controller can reduce power to prevent any lags in measurement from overshooting the target treatment zone. 
         [0121]    The variation described above in  FIGS. 27A to 27C  can also be used to position the device  800  relative to a desired target region  12 . For example, the temperature detecting elements  806 ,  808 , can be radiopaque (or can have radiopaque markers) so that a physician can place the appropriate temperature detecting element in a target area or at a perimeter of the target area. In the example shown in  FIG. 27A , a physician could position the second temperature detecting element  808  just outside of a tumor or as otherwise desired. Once the measured temperature reaches the associated temperature the physician can stop application of energy and reposition the device as needed or stop treatment. 
         [0122]    E.g. A physician may choose to use 50 C or 55 C as a target temperature for a specific temperature detecting element based on pre-planning. Once that temperature reaches the desired level; e.g. 50 C or 55 C then the physician may stop delivering any further energy to the tissue by turning off energy delivery. In another embodiment, controller will have an algorithm where a physician inputs the desired temperature for a specific temperature detecting element and controller will apply energy. Energy delivery will stop once the desired temperature is achieved. Further enhancement to the controller may also allow physician with an ability to set desired amount of time associated with each target temperature where controller will maintain energy level sufficient to control the temperature for desired amount of time and then turn off the energy delivery. 
         [0123]      FIG. 27A  also depicts a variation of the device as having visible markers  814 ,  816 , and  818  located on a shaft. The markers can be used to assist the physician in positioning of the energy transfer elements and/or temperature detecting elements. For example, in the illustrated variation, the device can be used with an introducer cannula of a known size so that marker  814  informs the physician that the distal tip or energy transfer element is positioned at the opening of the cannula. Likewise, markers  816  and  818  can inform the physician that energy transfer elements  806  and  808  are respectively located at the opening of the cannula. 
         [0124]    Although particular embodiments of the present invention have been described above in detail, it will be understood that this description is merely for purposes of illustration and the above description of the invention is not exhaustive. Specific features of the invention are shown in some drawings and not in others, and this is for convenience only and any feature may be combined with another in accordance with the invention. A number of variations and alternatives will be apparent to one having ordinary skills in the art. Such alternatives and variations are intended to be included within the scope of the claims. Particular features that are presented in dependent claims can be combined and fall within the scope of the invention. The invention also encompasses embodiments as if dependent claims were alternatively written in a multiple dependent claim format with reference to other independent claims.