Abstract:
Apparatus, systems and methods are used to repair, reconstruct and/or replace spinal features. A flexible longitudinal fixation component such a suture is passed around or through a portion of a spine, with the end sections of the component either being attached to one another or coupled to at least one bone implant. The bone implant may be a bone anchor or may form part of a pedicle screw assembly. The flexible longitudinal fixation component may pass through an anulus fibrosis (AF) and at least one intra-aperture component situated within a void or defect in an AF. The intra-aperture component may be composed of a porous mesh, allograft tissue or xenograft tissue. The intra-aperture component preferably includes one or more proximal-to-distal channels facilitating the intentional initial passage of nucleus pulposis (NP) tissue while preventing the extrusion of the NP long term.

Description:
REFERENCE TO RELATED APPLICATIONS 
       [0001]    This application claims priority from U.S. Provisional Patent Application Ser. No. 61/118,246, filed Nov. 26, 2008. This application is also continuation-in-part of U.S. patent application Ser. No. 12/263,753, filed Nov. 3, 2008. The entire content of each application is incorporated herein by reference. 
     
    
     FIELD OF THE INVENTION 
       [0002]    This invention relates generally to the treatment of intervertebral disc herniation and degenerative disc disease and, in particular, to apparatus and methods for fortifying and/or replacing disc components such as the anulus fibrosis. 
       BACKGROUND OF THE INVENTION 
       [0003]    The human intervertebral disc is an oval to kidney bean-shaped structure of variable size depending on the location in the spine. The outer portion of the disc is known as the anulus fibrosus (AF, also known as the “anulus fibrosis”). The anulus fibrosus (AF) is made of ten to twenty collagen fiber lamellae. The collagen fibers within a lamella are parallel. Successive lamellae are oriented in alternating directions. About 48 percent of the lamellae are incomplete, but this value varies based upon location and increases with age. On average, the lamellae lie at an angle of 60 degrees with respect to the vertebral axis line, but this too varies depending upon location. The orientation serves to control vertebral motion (one half of the bands tighten to check motion when the vertebra above or below the disc are turned in either direction). 
         [0004]    The anulus fibrosus contains the nucleus pulposus (NP). The nucleus pulposus serves to transmit and dampen axial loads. High water content (approximately 70-80 percent) assists the nucleus in this function. The water content has a diurnal variation. The nucleus imbibes water while a person lies recumbent. Nuclear material removed from the body and placed into water will imbibe water swelling to several times its normal size. Activity squeezes fluid from the disc. The nucleus comprises roughly 50 percent of the entire disc. The nucleus contains cells (chondrocytes and fibrocytes) and proteoglycans (chondroitin sulfate and keratin sulfate). The cell density in the nucleus is on the order of 4,000 cells per microliter. 
         [0005]    The intervertebral disc changes or “degenerates” with age. As a person ages, the water content of the disc falls from approximately 85 percent at birth to approximately 70 percent in the elderly. The ratio of chondroitin sulfate to keratin sulfate decreases with age, while the ratio of chondroitin  6  sulfate to chondroitin 4 sulfate increases with age. The distinction between the anulus and the nucleus decreases with age. Generally disc degeneration is painless. 
         [0006]    Premature or accelerated disc degeneration is known as degenerative disc disease. A large portion of patients suffering from chronic low back pain are thought to have this condition. As the disc degenerates, the nucleus and anulus functions are compromised. The nucleus becomes thinner and less able to handle compression loads. The anulus fibers become redundant as the nucleus shrinks. The redundant anular fibers are less effective in controlling vertebral motion. This disc pathology can result in: 1) bulging of the anulus into the spinal cord or nerves; 2) narrowing of the space between the vertebra where the nerves exit; 3) tears of the anulus as abnormal loads are transmitted to the anulus and the anulus is subjected to excessive motion between vertebra; and 4) disc herniation or extrusion of the nucleus through complete anular tears. 
         [0007]    Current surgical treatments for disc degeneration are destructive. One group of procedures, which includes lumbar discectomy, removes the nucleus or a portion of the nucleus. A second group of procedures destroy nuclear material. This group includes Chymopapin (an enzyme) injection, laser discectomy, and thermal therapy (heat treatment to denature proteins). The first two groups of procedures compromise the treated disc. A third group, which includes spinal fusion procedures, either removes the disc or the disc&#39;s function by connecting two or more vertebra together with bone. Fusion procedures transmit additional stress to the adjacent discs, which results in premature disc degeneration of the adjacent discs. These destructive procedures lead to acceleration of disc degeneration. 
         [0008]    Prosthetic disc replacement offers many advantages. The prosthetic disc attempts to eliminate a patient&#39;s pain while preserving the disc&#39;s function. Current prosthetic disc implants either replace the nucleus or replace both the nucleus and the anulus. Both types of current procedures remove the degenerated disc component to allow room for the prosthetic component. Although the use of resilient materials has been proposed, the need remains for further improvements in the way in which prosthetic components are incorporated into the disc space to ensure strength and longevity. Such improvements are necessary, since the prosthesis may be subjected to 100,000,000 compression cycles over the life of the implant. 
         [0009]    Current nucleus replacements (NRs) may cause lower back pain if too much pressure is applied to the anulus fibrosus. As discussed in U.S. Pat. Nos. 6,878,167 and 7,201,774, the content of each being expressly incorporated herein by reference in their entirety, the posterior portion of the anulus fibrosus has abundant pain fibers. 
         [0010]    Herniated nucleus pulposus (HNP) occurs from tears in the anulus fibrosus. The herniated nucleus pulposus often allies pressure on the nerves or spinal cord. Compressed nerves cause back and leg or arm pain. Although a patient&#39;s symptoms result primarily from pressure by the nucleus pulposus, the primary pathology lies in the anulus fibrosus. 
         [0011]    Surgery for herniated nucleus pulposus, known as microlumbar discectomy (MLD), only addresses the nucleus pulposus. The opening in the anulus fibrosus is enlarged during surgery, further weakening the anulus fibrosus. Surgeons also remove generous amounts of the nucleus pulposus to reduce the risk of extruding additional pieces of nucleus pulposus through the defect in the anulus fibrosus. Although microlumbar discectomy decreases or eliminates a patient&#39;s leg or arm pain, the procedure damages weakened discs. 
       SUMMARY OF THE INVENTION 
       [0012]    This invention broadly resides in apparatus, systems and methods to repair, reconstruct and/or replace spinal features. The preferred embodiments include a flexible longitudinal fixation component such as suture material passing around or through a portion of a spine, with the end sections of the flexible longitudinal fixation component either being attached to one another or coupled to at least one bone implant. The bone implant may be a bone anchor or may form part of a pedicle screw assembly. 
         [0013]    In certain embodiments the flexible longitudinal fixation component passes through an anulus fibrosis (AF) and at least one intra-aperture component situated within a void or defect in an AF. The intra-aperture component may be composed of a porous mesh, allograft tissue or xenograft tissue. The intra-aperture component preferably includes one or more proximal-to-distal channels facilitating the intentional initial passage of nucleus pulposis (NP) tissue while preventing the extrusion of the NP long term. Such channels may be formed by folding the intra-aperture component along one or more proximal-to-distal fold lines, or tube-like structures may be used. Such passageways intentionally facilitate at least the initial the escape of nucleus pulposus tissue through or around the intra-aperture component in response to pressure applied by the upper and lower vertebral bodies. 
         [0014]    The invention may be used in the treatment of herniated discs, anular tears of the disc, or disc degeneration, while enabling surgeons to preserve the contained nucleus pulposus. Anulus reconstruction prevents extrusion of the nucleus replacements through holes in the anulus fibrosus. The nucleus replacements and the anulus fibrosus reconstruction prevent excessive pressure on the anulus fibrosus that may cause back or leg pain. The methods and apparatus may be used to treat discs throughout the spine including the cervical, thoracic, and lumbar spines of humans and animals. 
         [0015]    The invention also enables surgeons to reconstruct the anulus fibrosus and replace or augment the nucleus pulposus. Novel or existing nucleus replacements (NRs) may be added to the disc. The nucleus replacements may be made of natural or synthetic materials. Synthetic nucleus replacements may be made of, but are not limited to, polymers including polyurethane, silicon, hydrogels, or other elastomers. 
         [0016]    One spinal repair system according to the invention comprises flexible longitudinal fixation components adapted for placement through portions of the AF with intact fibers, a porous mesh reinforcement component adapted for placement within or over a region of the AF with damaged fibers, and an optional anti-adhesion component for placement over flexible longitudinal fixation components and the porous mesh component. The invention also includes a targeting device that may be used to determine injured and uninjured areas of the AF that lie adjacent to a fissure or aperture in the AF. 
         [0017]    Preferred embodiments of the invention include an intra-aperture component dimensioned for positioning within a defect in the AF, with one or more components being used to maintain the proper placement of the intra-aperture component. The intra-aperture component may be porous and flexible while being intentionally non-expandable in cross section following its positioning within the defect. A component used to maintain the intra-aperture component within the defect includes a flexible longitudinal fixation component that passes through the intra-aperture component and a region of the AF apart from the defect. If available, this may be a region of the AF having overlapping layers with intact fibers in different directions. 
         [0018]    The flexible longitudinal fixation component may pass through a generally vertical passageway in the intra-aperture component and a region of the AF apart from the defect. The flexible longitudinal fixation component may be anchored to one of the upper and lower vertebral bodies. The components used to maintain the intra-aperture component within the defect includes a flexible longitudinal fixation component that passes twice through the intra-aperture component and is anchored to one of the upper and lower vertebral bodies. For example, the flexible longitudinal fixation component may form one or more loop or loops, each passing once through the AF and twice through the intra-aperture component. 
         [0019]    Numerous instruments and tools are also disclosed, some in kit form along with implanted components, to orient the flexible longitudinal fixation components, place anchors, and so forth. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0020]      FIG. 1A  is a superior view of an unfolded intra-aperture component used in a preferred embodiment of the invention; 
           [0021]      FIG. 1B  is an oblique of the embodiment of the invention drawn in  FIG. 1A ; 
           [0022]      FIG. 1C  is a posterior view of an intervertebral disc (IVD) and the embodiment of the invention drawn in  FIG. 1A ; 
           [0023]      FIG. 1D  is a superior view of an axial cross section of an intervertebral disc (IVD) and the embodiment of the invention drawn in  FIG. 1C ; 
           [0024]      FIG. 1E  is an oblique view of an alternative embodiment of the invention drawn in  FIG. 1A ; 
           [0025]      FIG. 1F  is an oblique view of another alternative embodiment of the invention drawn in  FIG. 1A ; 
           [0026]      FIG. 1G  is an oblique view of another alternative embodiment of the invention drawn in  FIG. 1A ; 
           [0027]      FIG. 1H  is an oblique view of the transverse passageways that extend between or within the folds of the embodiment of the invention drawn in  FIGS. 1A and 1C ; 
           [0028]      FIG. 2A  is a superior view of an unfolded intra-aperture component used in the embodiment of the invention drawn in  FIG. 2B ; 
           [0029]      FIG. 2B  is an oblique view of an alternative embodiment of the invention drawn in  FIG. 1A ; 
           [0030]      FIG. 2C  is a posterior view of coronal cross section of a portion of the spine and the embodiment of the invention drawn in  FIG. 2A ; 
           [0031]      FIG. 2D  is a lateral view of a partial sagittal cross section of a portion of the spine and the embodiment of the invention drawn in  FIG. 2C ; 
           [0032]      FIG. 2E  is an oblique view of an alternative embodiment of the invention drawn in  FIG. 2A ; 
           [0033]      FIG. 2F  is an oblique view of another alternative embodiment of the invention drawn in  FIG. 1A ; 
           [0034]      FIG. 3A  is a lateral view of the embodiment of the invention drawn in  FIG. 1A ; 
           [0035]      FIG. 3B  is a lateral view of the embodiment of the invention drawn in  FIG. 3A ; 
           [0036]      FIG. 3C  is a lateral view of the embodiment of the invention drawn in  FIG. 3B ; 
           [0037]      FIG. 3D  is lateral view of the embodiment of the invention drawn in  FIG. 3C ; 
           [0038]      FIG. 3E  is view of the bottom of the footplate of the embodiment of the invention drawn in  FIG. 3C ; 
           [0039]      FIG. 3F  is the opposite lateral view of the distal portion of the embodiment of the invention drawn in  FIG. 3A ; 
           [0040]      FIG. 3G  is a posterior view of the distal portion of the embodiment of the invention drawn in  FIG. 3A ; 
           [0041]      FIG. 3H  is a view of the bottom of an alternative embodiment of the invention drawn in  FIG. 3A ; 
           [0042]      FIG. 3I  is a lateral view of the distal end of the needle of the embodiment of the invention drawn in  FIG. 3H ; 
           [0043]      FIG. 3J  is a lateral view of the embodiment of the invention drawn in  FIG. 3I  and a portion of a flexible longitudinal fixation component; 
           [0044]      FIG. 3K  is lateral view of an alternative footplate of the embodiment of the invention drawn in  FIG. 3A ; 
           [0045]      FIG. 3L  is a lateral view of an alternative embodiment of the footplate drawn in  FIG. 3A ; 
           [0046]      FIG. 3M  is a view of the bottom of an alternative embodiment of the invention drawn in  FIG. 3E ; 
           [0047]      FIG. 3N  is a view of the bottom of the embodiment of the invention drawn in  FIG. 3M ; 
           [0048]      FIG. 3O  is a view of the bottom of the embodiment of the invention drawn in  FIG. 3N ; 
           [0049]      FIG. 4A  is a superior view of an axial cross section of an IVD and a lateral view of the embodiment of the invention drawn in  FIG. 3A ; 
           [0050]      FIG. 4B  is a superior view of an axial cross section of an IVD and a lateral view of the embodiment of the invention drawn in  FIG. 4A ; 
           [0051]      FIG. 4C  is a superior view of an axial cross section of an IVD and a lateral view of the embodiment of the invention drawn in  FIG. 4B ; 
           [0052]      FIG. 4D  is a superior view of an axial cross section of an IVD and a lateral view of the embodiment of the invention drawn in  FIG. 4C ; 
           [0053]      FIG. 4E  is a superior view of an axial cross section of an IVD and a lateral view of the embodiment of the invention drawn in  FIG. 4D ; 
           [0054]      FIG. 4F  is a superior view of an axial cross section of an IVD and a lateral view of the embodiment of the invention drawn in  FIG. 4C ; 
           [0055]      FIG. 4G  is a superior view of an axial cross section of an IVD and a lateral view of the embodiment of the invention drawn in  FIG. 4F ; 
           [0056]      FIG. 4H  is a superior view of an axial cross section of the IVD and the embodiment of the invention drawn in  FIG. 4G ; 
           [0057]      FIG. 4I  is a superior view of an axial cross section of the IVD and the embodiment of the invention drawn in  FIG. 4H ; 
           [0058]      FIG. 4J  is a superior view of an axial cross section of the IVD and the embodiment of the invention drawn in  FIG. 4I ; 
           [0059]      FIG. 5A  is an oblique view of an alternative embodiment of the invention drawn in  FIG. 1F ; 
           [0060]      FIG. 5B  is an oblique view of an alternative embodiment of the invention drawn in  FIG. 5A ; 
           [0061]      FIG. 6A  is view of the bottom of an alternative embodiment of the invention drawn in  FIG. 3E ; 
           [0062]      FIG. 6B  is a lateral view of the distal portion of the embodiment of the invention drawn in  FIG. 6A ; 
           [0063]      FIG. 6C  is a superior view of a transverse cross section of an IVD and the embodiment of the invention drawn in  FIG. 5B ; 
           [0064]      FIG. 6D  is a posterior view of an IVD and the embodiment of the invention drawn in  FIG. 6C ; 
           [0065]      FIG. 7A  is a lateral view of an alternative embodiment of the invention drawn in  FIG. 5B ; 
           [0066]      FIG. 7B  is a lateral view of a partial sagittal cross section of a spinal segment and the embodiment of the invention drawn in  FIG. 7A ; 
           [0067]      FIG. 7C  is a lateral view of a partial sagittal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 7B ; 
           [0068]      FIG. 7D  is a lateral view of a partial sagittal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 7C ; 
           [0069]      FIG. 7E  is a posterior view of a coronal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 7D ; 
           [0070]      FIG. 8A  is an oblique view of an alternative embodiment of the inventions drawn in  FIGS. 2F and 7A   
           [0071]      FIG. 8B  is a lateral view of a coronal cross section of a spinal segment and the embodiment of the invention drawn in  FIG. 8A ; 
           [0072]      FIG. 8C  is posterior view of a coronal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 8B ; 
           [0073]      FIG. 8D  is an oblique view of an alternative embodiment of the invention drawn in  FIG. 8A ; 
           [0074]      FIG. 8E  is a posterior view of a coronal cross section of a spinal segment and the embodiment of the invention drawn in  FIG. 8D ; 
           [0075]      FIG. 8F  is an oblique view of an alternative embodiment of the invention drawn in  FIG. 8D ; 
           [0076]      FIG. 8G  is a posterior view of a coronal cross section of a spinal segment and the embodiment of the invention drawn in  FIG. 8F ; 
           [0077]      FIG. 9A  is a lateral view of a partial sagittal cross section of a spinal segment and an alternative embodiment of the invention drawn in  FIG. 8A ; 
           [0078]      FIG. 9B  is a posterior view of a partial coronal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 9A ; 
           [0079]      FIG. 10A  is a posterior view of a partial coronal cross section of a spinal segment and an alternative embodiment of the inventions drawn in  FIGS. 6C and 8C ; 
           [0080]      FIG. 10B  is a posterior view of a partial coronal cross section of a spinal segment and the embodiment of the invention drawn in  FIG. 10A ; 
           [0081]      FIG. 11A  is a lateral view of an alternative embodiment of the invention drawn in  FIG. 3A ; 
           [0082]      FIG. 11B  is a lateral view of the embodiment of the invention drawn in  FIG. 11A ; 
           [0083]      FIG. 11C  is a lateral view of the distal end of a hook-like tool. The diameter of the tool is preferably slightly smaller than the diameter of the drill bit described in  FIG. 11B ; 
           [0084]      FIG. 11D  is a superior view of the distal end of the embodiment of the invention drawn in  FIG. 11C ; 
           [0085]      FIG. 11E  is a lateral view of the embodiments of the invention drawn in  FIGS. 11B and 11C ; 
           [0086]      FIG. 11F  is a lateral view of the embodiment of the invention drawn in  FIG. 11E ; 
           [0087]      FIG. 11G  is a lateral view of the embodiment of the invention drawn in  FIG. 11F ; 
           [0088]      FIG. 11H  is a view of the proximal end of the vertical portion of the L-shaped feature of the tool; 
           [0089]      FIG. 11I  is a superior view of a transverse cross section through the horizontal portion of the L-shaped feature of the tool and a portion of the first arm of the flexible longitudinal fixation component; 
           [0090]      FIG. 11J  is a superior view of a transverse cross section of the embodiment of the invention drawn in  FIG. 11I ; 
           [0091]      FIG. 11K  is a lateral view of a spinal segment and an alternative embodiment of the invention drawn in  FIG. 2D ; 
           [0092]      FIG. 12A  is a posterior view of a spinal segment and an alternative view of the embodiment of the invention drawn in  FIG. 8F ; 
           [0093]      FIG. 12B  is a lateral view of a partial sagittal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 12A ; 
           [0094]      FIG. 12C  is a posterior view of the spinal segment and embodiment of the invention drawn in  FIG. 12A ; 
           [0095]      FIG. 12D  is a posterior view of the spinal segment and the embodiment of the invention drawn in  FIG. 12A ; 
           [0096]      FIG. 13A  is a posterior view of a spinal segment and an alternative embodiment of the invention drawn in  FIG. 12A ; 
           [0097]      FIG. 13B  is a lateral view of a partial sagittal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 13A ; 
           [0098]      FIG. 14A  is a posterior view of a spinal segment and an alternative embodiment of the invention drawn in  FIG. 13A ; 
           [0099]      FIG. 14B  is a lateral view of a partial sagittal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 14A ; 
           [0100]      FIG. 14C  is posterior view of the spinal segment and embodiment of the invention drawn in  FIG. 14A ; 
           [0101]      FIG. 15A  is a posterior view of a spinal segment and an alternative embodiment of the invention drawn in  FIG. 14C ; 
           [0102]      FIG. 15B  is a lateral view of a partial sagittal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 15A ; 
           [0103]      FIG. 15C  is a view of the proximal end of a pedicle screw and the ends of flexible longitudinal fixation component drawn in  FIG. 15A ; 
           [0104]      FIG. 15D  is an exploded lateral view of the embodiment of the invention drawn in  FIG. 15C ; 
           [0105]      FIG. 15E  is lateral view of the embodiment of the invention drawn in  FIG. 15D ; 
           [0106]      FIG. 16  is a posterior view of a spinal segment and an alternative embodiment of the invention drawn in  FIG. 15A ; 
           [0107]      FIG. 17A  is posterior view of spinal segment and an alternative embodiment of the invention drawn in  FIG. 16A ; 
           [0108]      FIG. 17B  is a lateral view of a partial sagittal cross section of the spinal segment and embodiment of the invention drawn in  FIG. 17C ; 
           [0109]      FIG. 17C  is a posterior view of the embodiment of the invention drawn in  FIG. 17A ; 
           [0110]      FIG. 17D  is an oblique view of a connective tissue ingrowth sleeve that surrounds portions of the flexible longitudinal fixation components drawn in  FIG. 17A ; 
           [0111]      FIG. 17E  is a view of the end of the component drawn in  FIG. 17D ; 
           [0112]      FIG. 17F  is a lateral view of the component drawn in  FIG. 17D ; 
           [0113]      FIG. 17G  is a posterior view of a spinal segment and the embodiments of the invention drawn in  FIGS. 17A and 17D ; 
           [0114]      FIG. 17H  is a lateral view of a partial sagittal cross section of a spinal segment and the embodiment of the invention drawn in  FIG. 17G ; 
           [0115]      FIG. 17I  is lateral view of an alternative embodiment of the invention drawn in  FIG. 17H ; 
           [0116]      FIG. 17J  is a view of the top of the embodiment of the invention drawn in  FIG. 17I ; 
           [0117]      FIG. 17K  is a view of the top of the embodiment of the invention drawn in  FIG. 17J ; 
           [0118]      FIG. 17L  is an anterior view of a spinal segment and the embodiment of the invention drawn in  FIG. 17I ; 
           [0119]      FIG. 17M  is lateral view of a partial sagittal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 17L ; 
           [0120]      FIG. 17N  is a view of the top of a novel device used to hold the components of the embodiment of the invention drawn in  FIG. 17J  in their proper position; 
           [0121]      FIG. 17O  is a view of the top of the embodiments of the invention drawn in  FIGS. 17J and 17N ; 
           [0122]      FIG. 17P  is a lateral view of the embodiments of the invention drawn in  FIG. 17O ; 
           [0123]      FIG. 17Q  is an anterior view of a spinal segment and the embodiment of the invention drawn in  FIG. 17P ; 
           [0124]      FIG. 17R  is an anterior view of the spinal segment and the embodiment of the invention drawn in  FIG. 17Q ; 
           [0125]      FIG. 17S  is an anterior view of a spinal segment and an alternative embodiment of the invention drawn in  FIG. 17L ; 
           [0126]      FIG. 17T  is a lateral view of the embodiment of the invention drawn in  FIG. 17S ; 
           [0127]      FIG. 17U  is an anterior view of a spinal segment and the embodiment of the invention drawn in  FIG. 17S ; 
           [0128]      FIG. 18A  is posterior view of a spinal segment and an alternative embodiment of the invention drawn in  FIG. 17A ; 
           [0129]      FIG. 18B  is a lateral view of a partial sagittal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 18A ; 
           [0130]      FIG. 18C  is an exploded lateral view of an alternative embodiment of the invention drawn in  FIG. 18B ; 
           [0131]      FIG. 18D  is an exploded lateral view of an alternative embodiment of the invention drawn in  FIG. 18C ; 
           [0132]      FIG. 19A  is an exploded view of a partial transverse cross section of a vertebra, anchors and flexible longitudinal fixation components; 
           [0133]      FIG. 19B  is a view of the partial transverse cross section of the vertebra and the embodiment of the invention drawn in  FIG. 19A ; 
           [0134]      FIG. 20A  is lateral view of an alternative embodiment of the flexible longitudinal fixation components drawn in preferred embodiments of the invention; 
           [0135]      FIG. 20B  is a lateral view of the embodiment of the invention drawn in  FIG. 20A ; 
           [0136]      FIG. 21A  is the view of the distal end of a suture-passing tool; 
           [0137]      FIG. 21B  is a lateral view of the embodiment of the invention drawn in  FIG. 21A ; 
           [0138]      FIG. 21C  is a posterior view of spinous processes, interspinous ligaments, and the embodiment of the invention drawn in  FIG. 21A ; 
           [0139]      FIG. 22A  is a lateral view of an alternative embodiment of the invention drawn in  FIG. 21A ; 
           [0140]      FIG. 22B  is a lateral view of a partial sagittal cross section of three spinal laminae, the ligamentum flavum between the laminae, and the embodiment of the invention drawn in  FIG. 22A ; 
           [0141]      FIG. 23A  is a view of the top of an alternative embodiment of the invention drawn in  FIG. 12A ; 
           [0142]      FIG. 23B  is a posterior view of two spinous processes and the embodiment of the invention drawn in  FIG. 23A ; 
           [0143]      FIG. 23C  is a posterior view of the spinous processes and embodiment of the invention drawn in  FIG. 23B ; 
           [0144]      FIG. 23D  is a posterior view of a spinal segment and the embodiment of the invention drawn in  FIG. 23C ; 
           [0145]      FIG. 24A  is a posterior view of a portion of the spine and an alternative embodiment of the ingrowth sleeve drawn in  FIG. 17D ; 
           [0146]      FIG. 24B  is lateral view of a spinal segment and the embodiment of the invention drawn in  FIG. 24A ; 
           [0147]      FIG. 24C  is a view of a transverse cross section of a vertebra and the embodiment of the invention drawn in  FIG. 24B   
           [0148]      FIG. 25A  is an end view of an alternative embodiment of the inventions drawn in  FIGS. 17E and 24B ; 
           [0149]      FIG. 25B  is a lateral view of the embodiment of the invention drawn in  FIG. 25A ; and 
           [0150]      FIG. 25C  is a posterior view of a spinal segment and the embodiment of the invention drawn in  FIG. 25A . 
       
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
       [0151]      FIG. 1A  is a drawing of an intra-aperture component  100  constructed in accordance with the invention. In this and in other embodiments of the invention, the component is preferably made of synthetic mesh, allograft tissue or xenograft tissue. For example, the component could be made of polyester, polypropylene, or expanded polytetrafluoroethylene (ePTFE) mesh or allograft fascia. The intra-aperture component taught in this and other embodiments of the invention taught in this application is preferably 3 to 12 mm wide (left to right), tall (high), and long (proximal to distal). The intra-aperture component may be larger in alternative embodiments of the invention. The unfolded component shown in  FIG. 1A  is preferably 0.5 to 2.5 mm thick. For the purposes of this description, the intra-aperture component  100  has a proximal end  112  and a distal portion  108 . Holes  104  may be provided near the distal end of the intra-aperture component  100 , and the intra-aperture component may include a plurality of fold lines  106  running generally proximal-distal. 
         [0152]    In the oblique representation of  FIG. 1B , a flexible longitudinal fixation component  102  was passed through holes  104  in the intra-aperture component  100 . The flexible longitudinal fixation component taught in this and other embodiments of the invention is preferably made of high tensile strength multi-filament or braided polyester. For example, the flexible longitudinal fixation component could be made of #2 to #5 sized Fiberwire (Arthrex, Naples, Fla., USA), Orthocord (DePuy Orthopaedics, Warsaw, Ind., USA), suture from Tornier (Edina, Minn., USA), nylon or other type or size suture material. The flexible longitudinal component is preferably 20 to 60 mm long. 
         [0153]    The flexible longitudinal fixation component  102  generally passes through the intra-aperture component in a direction transverse to the proximal-distal orientation. The folds  106  and the direction that the flexible longitudinal fixation component passes through the intra-aperture component may be oriented in other directions in accordance with alternative embodiments of the invention. 
         [0154]    The flexible longitudinal fixation component preferably passes through the reinforced area of the intra-aperture component several times. With four holes in the intra-aperture component of  FIG. 1A , the component may be folded three times along the flexible longitudinal fixation component to create shape drawn in  FIG. 1B . As discussed in more detail below, however, the flexible longitudinal fixation component may pass more or fewer times through the intra-aperture component in alternative embodiments of the invention. 
         [0155]    The invention also maximizes the force required to tear the intra-aperture component, which would release the flexible longitudinal fixation component. In particular, the material which forms the distal portion  108  of the intra-aperture component is preferably reinforced to increase the tensile strength of the intra-aperture component in the area through which the flexible longitudinal fixation component passes. The material around the holes in intra-aperture component may be doubly reinforced (the additional circles surrounding the holes). Areas of reinforcement  109  are also seen around the edges of the component. For example, embroidery or other overstitching of bonding technology may be used to reinforce such areas. 
         [0156]      FIG. 1C  is a posterior view of an intervertebral disc (IVD)  110  and the embodiment of the invention drawn in  FIG. 1A . The invention drawn in  FIG. 1A  was placed into an aperture or defective region  111  of the IVD. The ends of the flexible longitudinal fixation component  102  were welded over the proximal end of the intra-aperture component. The ends of the flexible longitudinal fixation component were passed through anulus fibrosis (AF) tissue on either side of the aperture before the ends were welded together. 
         [0157]    As drawn in FIGS. 29M-29P, 30A-30B, and 36A-37F of U.S. patent application Ser. No. 12/263,753, the distal end of the flexible longitudinal fixation component was preferably passed through AF tissue on one side of the aperture, then through the holes in the intra-aperture component, then through AF tissue on the opposite side of the aperture, followed by tension on the ends of the flexible longitudinal fixation component before the ends of the flexible longitudinal component or otherwise fastened together. 
         [0158]    The present invention facilitates nucleus pulposus (NP) tissue extrusion between AF tissue and the device and through or between the folds of the device. The spaces between folds of the device, which may be 2 to 11 mm or more tall, extend from the proximal to distal end of the intra-aperture component. Connective tissue preferably grows over the proximal end of the aperture, as occurs naturally, the first few days or weeks following surgery to prevent NP extrusion. Connective tissue also preferably grows into the aperture between the AF and the intra-aperture component and between the folds of the intra-aperture component days of weeks following surgery to prevent NP extrusion. Connective tissue also preferably grows through pores of the intra-aperture component and between the folds of the intra-aperture component a few days or weeks following surgery to prevent NP extrusion. 
         [0159]    Naturally occurring connective tissue—not the implanted device—prevents NP tissue extrusion starting several days to weeks following surgery. The device does not seal the aperture per se. Rather, like a natural aperture in the AF, the device allows a limited amount of extrusion of NP tissue. Large NP pieces, too big to extrude, may be converted into smaller pieces of tissue that may extrude. Connective tissue grows over and into the treated aperture to eventually seal the aperture, however, thus preventing extrusion of the entire NP. 
         [0160]      FIG. 1D  is a superior view of an axial cross section of an intervertebral disc (IVD) and the embodiment of the invention drawn in  FIG. 1C . The proximal end  112  of the intra-aperture component preferably sits flush with, or is recessed with respect to, the outer layer of the AF. 
         [0161]      FIG. 1E  is an oblique view of an alternative embodiment of the invention drawn in  FIG. 1A . The intra-aperture component does not have folds. One, 2, 3, 4, 5, or more intra-aperture components per flexible longitudinal fixation components may be used in this and the other embodiments of the invention taught in this application.  FIG. 1F  is an oblique view of another alternative embodiment of the invention drawn in  FIG. 1A . The intra-aperture component has a single fold. 
         [0162]      FIG. 1G  is an oblique view of another alternative embodiment of the invention drawn in  FIG. 1A . The intra-aperture component has two folds. Four, five, six or more folds may be used in alternative embodiments of the invention. However, as drawn in  FIGS. 1C and 1D , the folds are preferably oriented generally perpendicular to the lamellae of the AF so as to create intentional transverse passageways between the folds of the intra-aperture component. As discussed above, these passageways facilitate partial NP extrusion from the IVD before connective tissue in-growth across or into the aperture, thus preventing unwanted, excessive NP extrusion. 
         [0163]      FIG. 1H  is an oblique view of the transverse passageways that extend between or within the folds of the embodiment of the invention drawn in  FIGS. 1A and 1C . The invention taught in this and other embodiments taught in this application and my co-pending U.S. patent application Ser. No. 12/263,753 create unobstructed transverse spaces or passageways that are preferably at least 2 mm tall or wide. Such unobstructed passageways extend from the proximal to the distal ends of the component to facilitate extrusion of NP tissue. The unobstructed passageways also extend from the NP to the exterior of the IVD. Such passageways are generally larger than 2 mm tall or wide and generally at least 3 mm long. For example, such passageways are generally 11 mm tall in 12 mm tall components with vertical folds and generally 11 mm wide in 12 mm wide components with horizontal folds. The transverse passageways between or within the folds are preferably 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 mm wide or tall. Such passageways can be less than 2 or more than 11 mm wide or tall in alternative embodiments of the invention. The unobstructed passageways are preferably 3, 4, 5, 6, 7, 8, 9, 10, 11 mm long. Such passageways may be less than 3 or more than 11 mm long in alternative embodiments of the invention. Unobstructed spaces or passageways between the intra-aperture components and the apertures also facilitate NP extrusion through the aperture. 
         [0164]    The folds of the intra-aperture component and the direction of the flexible longitudinal fixation component may be oriented in other directions in alternative embodiments of the invention. For example,  FIG. 2A  is a superior view of an unfolded intra-aperture component according to an alternative embodiment of the invention. The device is preferably made of the same materials and made in the same sizes as the device described in  FIG. 1A . The folds of the device run generally proximal-distal. However, the holes are arranged diagonally, allowing the flexible longitudinal fixation component to pass through the intra-aperture component in a proximal-distal direction when the device is folded, as shown in  FIG. 2B . 
         [0165]    The component is folded three times to create shape drawn in  FIG. 2B . The intra-aperture component is preferably reinforced to increase the tensile strength of the intra-aperture component in the area through which the flexible longitudinal fixation component passes. The material around the holes in intra-aperture component is preferably doubly reinforced (additional circles surrounding the holes). Areas of reinforcement are also seen around the edges of the component. The unfolded component is preferably 0.5 to 2.5 mm thick. The invention maximizes the force required to pull tear the intra-aperture component thus releasing the flexible longitudinal fixation component. 
         [0166]    The flexible longitudinal fixation component  202  passes through the reinforced area of the intra-aperture component four times. As drawn in  FIGS. 2E-2F , the flexible longitudinal fixation component may pass through 1, 2, 3, or more holes in the intra-aperture component in alternative embodiments of the invention. 
         [0167]      FIG. 2C  is a posterior view of a coronal cross section of a portion of the spine and the embodiment of the invention drawn in  FIG. 2A . The invention drawn in  FIG. 2A  was placed into and aperture or defective region of the IVD. The ends of the flexible longitudinal fixation component  202  pass over the proximal end of the intra-aperture component and pass into a vertebral fixation component  220  as drawn in FIG. 48C of U.S. patent application Ser. No. 12/263,753. 
         [0168]    The first end  206  of the flexible longitudinal fixation component was passed through anulus fibrosis (AF) tissue above the aperture, then through the holes in the intra-aperture component, then into the locking mechanism of the vertebral fixation component  220 . The invention enables nucleus pulposus (NP) tissue to extrude between AF tissue and the device and through or between the folds of the device. The spaces between folds of the device are preferably 2 to 11 mm or more tall and extend from the proximal to distal end of the intra-aperture component. Connective tissue preferably grows over the proximal end of the aperture, as occurs naturally, the first few days of weeks following surgery to prevent NP extrusion. Connective tissue also preferably grows into the aperture between the AF and the intra-aperture component and between the folds of the intra-aperture component a few days or weeks following surgery to prevent NP extrusion. Connective tissue also preferably grows through pores of the intra-aperture component and between the folds of the intra-aperture component days of weeks following surgery to prevent NP extrusion. The device tightens during spinal flexion, the position most likely to expulse anulus repair devices, reducing the height of the aperture and thus reducing extrusion of NP tissue during spinal flexion. 
         [0169]      FIG. 2D  is a lateral view of a partial sagittal cross section of a portion of the spine and the embodiment of the invention drawn in  FIG. 2C  (and FIG. 48A of co-pending U.S. patent application Ser. No. 12/263,753), and  FIG. 2E  is an oblique view of an alternative embodiment of the invention drawn in  FIG. 2A . The intra-aperture component does not have folds. One, 2, 3, 4, 5, 6, or more such components could be used per device in this and other embodiments of the invention taught in this application. 
         [0170]      FIG. 2F  is an oblique view of another alternative embodiment of the invention drawn in  FIG. 1A . The intra-aperture component has a single fold. Two, three, four, five, six or more folds may be used in alternative embodiments of the invention. However, as drawn in  FIGS. 2C and 2D , the folds are preferably oriented generally perpendicular to the lamellae of the AF so as to create large transverse passageways between the folds of the intra-aperture component that facilitate NP extrusion from the IVD before connective tissue in-growth across of into the aperture prevents such NP extrusion. Such passageways preferably have surface areas of 16 to  288 or more  mm squared and volumes of 16 to  576 or more  mm cubed. Passageways with larger or smaller surface areas could be used in alternative embodiments of the invention. 
         [0171]      FIG. 3A  is a lateral view of the embodiment of the invention drawn in  FIG. 1A  and a novel instrument  300  that may be used to pass the ends of the flexible longitudinal fixation component through the AF. The first end  302  of the flexible longitudinal fixation component is pressed into a releasable fastening feature at the tip  304  of the footplate  306  at the distal end of the tool. The first arm of the flexible longitudinal fixation component also passes through a slot like opening  310  on the bottom and posterior portions to the footplate of the instrument and wraps around a projection  312  on the handle  316  of the instrument  300 . The first arm of the flexible longitudinal fixation component is then pressed into a releasable fastening feature  314  on the handle of the instrument. 
         [0172]    The intra-aperture component  100  and the second arm  303  of the flexible longitudinal fixation component are seen hanging from the handle  316  of the instrument  300 . The first arm of the flexible longitudinal fixation component is released with less force from the fastening component on the footplate of the instrument than the fastening component on the handle of the instrument. A needle-like component  320  passes through a cannulated shaft through the instrument. The tip of the needle preferably has a tapered point rather than a cutting point. A hook-like opening  322  is seen on the side of the needle component near the distal end of the component. 
         [0173]      FIG. 3B  is a lateral view of the embodiment of the invention drawn in  FIG. 3A . The hook-like opening  322  is seen on the side of the distal end of the needle. The distal end of the first arm of the flexible longitudinal fixation component is seen in the releasable fastening feature at the end of the footplate of the instrument. For example, the flexible longitudinal fixation component may be press fit into a slot on the end of the footplate. 
         [0174]      FIG. 3C  is a lateral view of the embodiment of the invention drawn in  FIG. 3B . The needle component  320  was advanced through the shaft of the tool. The needle component preferably has a feature that prevents axial rotation of the needle relative to the shaft of the tool. For example, the shaft of the tool may have a projection that cooperates with a slot in the side of the cannulated portion of the tool to prevent such axial rotation. The feature keeps the hook-like opening in the side of the needle parallel with the portion of the flexible longitudinal fixation component within the footplate portion of the instrument. 
         [0175]    The needle component is preferably actuated by a compressible pistol grip mechanism in an alternative embodiment of the invention. Squeezing the pistol grip advances the needle component in the cannulated component in the alternative embodiment of the invention. The distal portion of the needle forces the flexible longitudinal fixation component to the side as the needle passes by the flexible longitudinal component. Tension on the flexible longitudinal fixation component causes the flexible longitudinal component to migrate into the hook-like opening in the needle-like component of the tool. 
         [0176]      FIG. 3D  is lateral view of the embodiment of the invention drawn in  FIG. 3C  with the needle partially retracted. The distal portion of the first end of the flexible longitudinal fixation component was captured in the hook-like opening in the side of the needle. Retraction of the needle pulls the distal end of the flexible longitudinal fixation component through the releasable fastening feature at the end of the footplate. The stronger releasable fastening feature on the handle of the instrument preferably prevents advancement of the proximal portion of the first arm of the flexible longitudinal fixation component as the needle is retracted. 
         [0177]      FIG. 3E  is view of the bottom of the footplate of the embodiment of the invention drawn in  FIG. 3C . The distal portion of the first arm of the flexible longitudinal fixation component is seen within the slot in the bottom of the footplate and in the releasable fastening feature in the footplate. 
         [0178]      FIG. 3F  is the opposite lateral view of the distal portion of the embodiment of the invention drawn in  FIG. 3A . The hook-like opening is on the opposite side of the needle. The taper point of the needle slides by the flexible longitudinal fixation component as the needle is advanced through the cannula of the instrument. The instrument is preferably manufactured in various sizes. For example, instruments with 3 mm, 6 mm and 9 mm long footplates could be manufactured. The space between the footplate and the distal portion of the cannula portion of the instrument, where the tip of the needle component exits, is preferably 5 to 25 mm long or longer. 
         [0179]      FIG. 3G  is a posterior view of the distal portion of the embodiment of the invention drawn in  FIG. 3A . The distal portion of the first arm of the flexible longitudinal fixation component is seen in a slot-like opening in the back of the tool. Tension on the first arm of the flexible longitudinal fixation component holds the first arm of the flexible longitudinal fixation component in the slot-like openings of the instrument. Tension on such component is achieved by fastening the distal end of the first arm of the flexible longitudinal fixation component in the releasable fastening feature at the top of the footplate and pulling in the proximal portion of the first arm of the flexible longitudinal fixation component as such component is wrapped around the projection from the handle and temporarily locked into the releasable fastening component. 
         [0180]      FIG. 3H  is a bottom view of an alternative embodiment of the invention drawn in  FIG. 3A . The flexible longitudinal fixation component was not included in the drawing to better illustrate the bottom of the instrument. The groove  324  in the footplate  326  that receives the distal portion of the first arm of the flexible longitudinal fixation component is seen on the bottom of the tool. 
         [0181]      FIG. 3I  is a lateral view of the distal end of the needle of the embodiment of the invention drawn in  FIG. 3H .  FIG. 3J  is a lateral view of the embodiment of the invention drawn in  FIG. 3I  and a portion of a flexible longitudinal fixation component. The sides of the distal portion of the needle preferably have recesses that provide space for the flexible longitudinal fixation component. The hook-like feature in the needle is on the opposite side of the drawing, and not visible in this view. 
         [0182]      FIG. 3K  is lateral view of an alternative footplate of the embodiment of the invention drawn in  FIG. 3A . A slot-like releasable fastening feature  328  is on the top of the distal end of the footplate.  FIG. 3L  is a lateral view of an alternative embodiment of the footplate drawn in  FIG. 3K . The slot-like releasable fastening feature  329  is on the bottom of the distal end of the footplate. The slot-like releasable fastening feature or other releasable fastening feature could be located in other areas of the tool in alternative embodiments of the invention. 
         [0183]      FIG. 3M  is a view of the bottom of an alternative embodiment of the invention drawn in  FIG. 3E . Two releasable fastening features  330 ,  332  hold the distal end of the first arm of the flexible longitudinal fixation component  302 . The captured distal portion of the first arm of the flexible longitudinal fixation component generally takes a transverse course relative the handle of the instrument and is generally perpendicular to such portion of the flexible longitudinal fixation component drawn in  FIG. 3E . 
         [0184]      FIG. 3N  is a view of the bottom of the embodiment of the invention drawn in  FIG. 3M . The tip of the needle  340  was advanced by the captured portion of the flexible longitudinal fixation component. The segment of the captured portion of the flexible longitudinal sits within the hook-like opening on the side of the needle component.  FIG. 3O  is a view of the bottom of the embodiment of the invention drawn in  FIG. 3N . The needle  340  was partially retracted into the shaft of the instrument. Such movement of the needle pulled the distal end of the first arm of the flexible longitudinal fixation component from the releasable fastening feature  332 . 
         [0185]      FIG. 4A  is a superior view of an axial cross section of an IVD and a lateral view of the embodiment of the invention drawn in  FIG. 3A . The footplate  306  of the invention drawn in  FIG. 3A  was placed through an aperture  402  in the IVD, generally rotated  90  degrees and pressed against the inner portion of the AF.  FIG. 4B  is a superior view of an axial cross section of an IVD and a lateral view of the embodiment of the invention drawn in  FIG. 4A . The tip  320 ′ of needle  320  of the instrument was advanced the AF and by the distal portion of the first arm of the flexible longitudinal fixation component  302 . The taper tip of the needle preferably separates rather cuts the fibers of the AF. Tension on the first arm of the flexible longitudinal fixation component causes the component to slip into the hook-like opening in the side of the needle. 
         [0186]      FIG. 4C  is a superior view of an axial cross section of an IVD and a lateral view of the embodiment of the invention drawn in  FIG. 4B . The needle  302  of the instrument was withdrawn from the IVD which pulls the distal portion of the first arm of the flexible longitudinal fixation component  302  through the opening the AF created by the needle. The distal portion of the first arm of the flexible longitudinal fixation component advanced partially through the releasable fastening feature in the footplate. 
         [0187]      FIG. 4D  is a superior view of an axial cross section of an IVD and a lateral view of the embodiment of the invention drawn in  FIG. 4C . The needle of the instrument was retracted further along the shaft of the instrument. The distal portion of the first arm of the flexible longitudinal fixation component was pulled through the releasable fastening feature in the footplate. 
         [0188]      FIG. 4E  is a superior view of an axial cross section of an IVD and a lateral view of the embodiment of the invention drawn in  FIG. 4D . The device  100  drawn in  FIG. 1B  was released from the instrument and the instrument drawn in  FIG. 3A  was removed from IVD. The ends of the arms of the flexible longitudinal fixation component  102  could be passed through vertebral fixation component as described in FIG. 29Q of my co-pending U.S. patent application Ser. No. 12/263,753. 
         [0189]      FIG. 4F  is a superior view of an axial cross section of an IVD and a lateral view of the embodiment of the invention drawn in  FIG. 4C . The second arm of the flexible longitudinal fixation component was loaded into the instrument as described in the text of  FIGS. 3A-4E .  FIG. 4G  is a superior view of an axial cross section of an IVD and a lateral view of the embodiment of the invention drawn in  FIG. 4F . The second arm of the flexible longitudinal fixation component was passed through the AF as described in the text of  FIGS. 3A-4F  and the instrument was removed from the IVD. 
         [0190]      FIG. 4H  is a superior view of an axial cross section of the IVD and the embodiment of the invention drawn in  FIG. 4G . The intra-aperture component was pulled into the aperture of the IVD by pulling on the ends of the arms of the flexible longitudinal fixation component. Intra-aperture components used in the inventions taught in this and my co-pending application U.S. patent application Ser. No. 12/263,753 are narrower than the widths of the apertures in the AF or shorter than the heights of the apertures or both narrower or shorter than the apertures. The cross sectional areas of the intra-aperture components including pores in the material used to manufacture the components are preferably 5 to 25 percent smaller than the cross sectional areas of the apertures to be treated. 
         [0191]    Alternatively, the cross sectional areas of the intra-aperture components including pores in the material can be 1, 2, 3, 4, 26, 27, 28, less than 1, or more than 28 percent smaller than the cross sectional areas of the apertures to be treated. That is, the intra-aperture components leave 5 to 25 percent of the cross sectional areas of the apertures unfilled. Alternatively, the intra-aperture components leave 1, 2, 3, 4, 26, 27, 28, less than 1, or more than 28 percent of the cross sectional areas of the apertures unfilled. Preferably no dimension of the intra-aperture components, other than length, is larger than the corresponding dimension of the apertures to be treated. 
         [0192]    The intra-aperture components preferably do not dilate the apertures in any direction. Alternatively, intra-aperture components could be larger than the apertures to be treated in one or more direction as long as such components are smaller than such apertures in on or more alternative directions so as to facilitate NP extrusion around the device in alternative embodiments of the invention. Alternatively, the outer portion the device could dilate the aperture so long as the transverse passageways remain open and allow NP tissue extrusion in alternative embodiments of the invention. 
         [0193]      FIG. 4I  is a superior view of an axial cross section of the IVD and the embodiment of the invention drawn in  FIG. 4H . Tension on the ends of the arms of the flexible longitudinal fixation component preferably decreases the width of the aperture from the inlet to the outlet of the aperture in the AF. The arms of the flexible longitudinal fixation component were welded at  440  while tension was maintained on the arms of the flexible longitudinal component. 
         [0194]    The invention taught in this embodiment and other embodiments of the invention taught in this application and my co-pending U.S. patent application Ser. No. 12/263,753 narrow apertures by tension on the flexible longitudinal fixation components and use of intra-aperture components that are substantially more narrow or shorter than the apertures in the AF. Tension on the arm or arms of the flexible longitudinal fixation component that passes across the aperture at or near the inlet narrows the inlet of the aperture and tension on the arm or arms of the flexible longitudinal fixation that passes across the aperture at or near the outlet narrows the outlet of the aperture. The central portion of the aperture is narrowed by tension on the portions of the flexible longitudinal fixation components that lie adjacent to the central portion of the aperture. Intra-aperture components used in this invention preferably do not swell or expand in situ and thus do not enlarge the aperture in the AF following insertion of the device into the spine. 
         [0195]      FIG. 4J  is a superior view of an axial cross section of the IVD and the embodiment of the invention drawn in  FIG. 4I . An anti-adhesion sleeve  450  as described in FIGS. 38A-39B of my co-pending U.S. patent application Ser. No. 12/263,753 was applied over the arms of the flexible longitudinal fixation component before the flexible longitudinal components were welded. 
         [0196]      FIG. 5A  is an oblique view of an alternative embodiment of the invention drawn in  FIG. 1F . Pores  502  extend through the proximal portion of a tube-like component  500 . A pair of transverse holes  504  extend through the distal portion of the component  500 . The device is preferably composed of ePTFE, and supplied in sizes described in the text of  FIG. 1A . The device could be made of the other materials listed in the text of  FIG. 1A  in alternative embodiments of the invention. The pores in the proximal portion of the device are preferably 0.001 to 2.0 mm in diameter. The pores may be circular, square, rectangular, diamond, or other shape. 
         [0197]      FIG. 5B  is an oblique view of an alternative embodiment of the invention drawn in  FIG. 5A . A flexible longitudinal fixation hoop  506  was inserted through two of the components drawn in  FIG. 5A . The flexible longitudinal fixation component is made of the materials and lengths described in the text of  FIG. 1A  and other portions of this application. One, 3, 4, 5, 6, or more intra-apertures per flexible longitudinal component could be used in alternative embodiments of the invention. 
         [0198]      FIG. 6A  is view of the bottom of an alternative embodiment of the invention drawn in  FIG. 3E . The distal portion of first loop-like arm of the flexible longitudinal fixation component drawn in  FIG. 5B  is releasably fastened to the footplate  604  of the instrument. A portion of the loop is held in a slot-like releasable fastening feature in the side of the distal end of the footplate similar to the configuration drawn in  FIG. 3F . The proximal portion of the first loop-like arm of the flexible longitudinal fixation component extends along the back of the instrument similar to the configuration drawn in  FIG. 3F . The device drawn in  FIG. 5B  is temporarily fastened, under tension, to the handle of an instrument similar to the handle drawn in  FIG. 3A . 
         [0199]      FIG. 6B  is a lateral view of the distal portion of the embodiment of the invention drawn in  FIG. 6A . The needle component  606  with a hook-like opening  608  in the side of the needle is seen above the distal portion of the first loop-like arm of the flexible longitudinal fixation component drawn in  FIG. 5B . 
         [0200]      FIG. 6C  is a superior view of a transverse cross section of an IVD and the embodiment of the invention drawn in  FIG. 5B . The instrument drawn in  FIGS. 6A and 6B  was used to pull the distal portions of the loop-like arms of the flexible longitudinal fixation component through AF tissue on either side of the aperture. The tool works similar to the tool drawn in  FIG. 3A-O , but pulls a flexible longitudinal fixation loop, rather than the end of a flexible longitudinal fixation component through the AF. Alternatively, the instrument may be used to create a loop shape of a flexible longitudinal fixation component by pulling a segment of the distal portion of a flexible longitudinal fixation component through the AF, but not pulling the distal end of the flexible longitudinal fixation component through the AF. The second loop-like arms of the flexible longitudinal fixation component are released from the fastening feature on the handle of the instrument as the needle is retracted into the shaft of the instrument. Tension on the two loop-like arms of the flexible longitudinal fixation component pulls the intra-aperture component into the aperture in the AF. 
         [0201]      FIG. 6D  is a posterior view of an IVD and the embodiment of the invention drawn in  FIG. 6C . The proximal ends of the intra-aperture components drawn in  FIG. 5B  are seen in the aperture in the AF. The ends of the loop-like flexible longitudinal fixation component were cut and removed leaving two separate flexible longitudinal fixation components that pass through AF tissue on either side of the aperture and through the intra-aperture components. If the loop-like flexible longitudinal fixation component has a weak area, for example an area where two ends of a single flexible longitudinal fixation component were welded to create the loop shown in  FIG. 5B , the weakened area should be included in one of the two portions of the loop removed to create two separate longitudinal components. 
         [0202]    The ends of the flexible longitudinal fixation components were welded or otherwise fastened at  640  after placing tension on the flexible longitudinal fixation components. An anti-adhesion sleeve, such as drawn in FIGS. 38E and 40B of my co-pending U.S. patent application Ser. No. 12/263,753 could have been threaded over the ends of the flexible longitudinal fixation component before welding such flexible longitudinal components in alternative embodiments of the invention. 
         [0203]      FIG. 7A  is a lateral view of an alternative embodiment of the invention drawn in  FIG. 5B . The flexible longitudinal fixation component passes through two intra-aperture components  500  drawn in  FIG. 5A . One, 3, 4, 5, 6, or more intra-aperture components per flexible longitudinal fixation component could be used in alternative embodiments of the invention. The ends of the flexible longitudinal fixation component were passed through vertebral fixation member  720 . Co-pending application U.S. Ser. No. 12/263,753 describes suitable vertebral fixation members, intra-aperture components, and flexible longitudinal fixation component for this embodiment of the invention and other embodiments taught in this application. 
         [0204]      FIG. 7B  is a lateral view of a partial sagittal cross section of a spinal segment and the embodiment of the invention drawn in  FIG. 7A . The loop-like arm of the flexible longitudinal fixation component was passed through AF tissue cranial to the aperture using the instrument taught in  FIGS. 6A and 6B . 
         [0205]      FIG. 7C  is a lateral view of a partial sagittal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 7B . The vertebral fixation component  720 , intra-aperture components  500  and most of the flexible longitudinal fixation component were passed through the loop in the first arm of the flexible longitudinal component. A drill  710  was placed into the caudal vertebra. The position of the drill bit may be verified with x-ray or fluoroscopy. 
         [0206]      FIG. 7D  is a lateral view of a partial sagittal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 7D . The vertebral fixation component  720  was inserted, preferably by impaction, into the vertebra. A knot-pusher surgical instrument (not shown) could be used to tighten the flexible longitudinal fixation component before inserting the intra-aperture components  500  into the aperture and the vertebral fixation component into the vertebra. Tension on the ends of the flexible longitudinal fixation components provides the final tightening of the construct. The vertebral fixation member preferably has a cinch-like mechanism to permit tightening and locking of the arms of the flexible longitudinal fixation component. 
         [0207]      FIG. 7E  is a posterior view of a coronal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 7D . The device tightens during spinal flexion, the position most likely to expulse anulus repair devices and NP tissue. 
         [0208]      FIG. 8A  is an oblique view of an alternative embodiment of the inventions drawn in  FIGS. 2F and 7A . The loop-like end  802  of the flexible longitudinal fixation component  804  extends through a hole in the superior portion of the intra-aperture component  700 . The ends of the flexible longitudinal fixation component were passed through a vertebral fixation component  720  as described in the text of  FIG. 7A . Portions of the flexible longitudinal fixation component also pass through a fold  711  in the intra-aperture component  700 . Alternative intra-aperture components, such as those drawn in  FIGS. 1A-7A , could be used in this embodiment of the invention, the embodiment of the invention drawn in  FIG. 5B ,  7 A and other embodiments of the invention. 
         [0209]      FIG. 8B  is a lateral view of a coronal cross section of a spinal segment and the embodiment of the invention drawn in  FIG. 8A . The device  700  was inserted into the spine using the method taught in  FIG. 7B-D . Tension is applied to the ends of the flexible longitudinal fixation component in the next step of the method. 
         [0210]      FIG. 8C  is posterior view of a coronal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 8B . The invention was used to treat a transverse aperture in the AF near a vertebra. Vertebral fixation components may be placed into the vertebrae caudal or cranial to the defective IVD in this embodiment of the invention and other embodiments taught in this application. 
         [0211]      FIG. 8D  is an oblique view of an alternative embodiment of the invention drawn in  FIG. 8A . The ends of the flexible longitudinal fixation component were threaded through holes in an anti-adhesion patch  810  before they were passed through the vertebral fixation component. 
         [0212]      FIG. 8E  is a posterior view of a coronal cross section of a spinal segment and the embodiment of the invention drawn in  FIG. 8D . The device was inserted into the spine using the method taught in  FIGS. 8B and 8C . The anti-adhesion component is preferably made of ePTFE or other material described in this and my co-pending my co-pending application U.S. patent application Ser. No. 12/263,753. The patch component covers the intra-aperture component, the aperture in the AF, and the loop-like portion of the flexible longitudinal fixation component. 
         [0213]      FIG. 8F  is an oblique view of an alternative embodiment of the invention drawn in  FIG. 8D . The ends of the flexible longitudinal fixation component were threaded through holes in an anti-adhesion component  820  before they were passed through the vertebral fixation component. The anti-adhesion component was previously described  FIG. 39A  of my co-pending application U.S. patent application Ser. No. 12/263,753. The vertebral fixation component extends from the shaft of an insertion instrument  822 . The fully assembled or pre-coupled device is applied to the spine using the method taught in  FIGS. 7A to 7D . The loop of the flexible longitudinal fixation component is pulled through the anulus using the tool described in  FIGS. 6A and 6B . Then insertion instrument  822 , the anchor extending from the insertion instrument and ends of the flexible longitudinal fixation component, which pass through the anchor, and the anti-adhesion component are passed through the loop of the flexible longitudinal fixation component. The mesh component is placed into the aperture in the anulus and the anchor is impacted into the vertebra in the next step of the procedure. Fully pre-coupled devices taught in this and other embodiments of the invention do not require intra-operative assembly by surgeons. The invention saves surgeons time and eliminates the risk of improperly coupling components during surgical procedures. 
         [0214]      FIG. 8G  is a posterior view of a coronal cross section of a spinal segment and the embodiment of the invention drawn in  FIG. 8F . The device was inserted into the spine using the method taught in  FIGS. 8B and 8C . The anti-adhesion component is preferably made of ePTFE or other material described in this or my other pending applications. The patch component  820  covers the intra-aperture component, the aperture in the AF, and the flexible longitudinal fixation component, and the hole in the vertebra through which the vertebral fixation component was inserted. 
         [0215]      FIG. 9A  is a lateral view of a partial sagittal cross section of a spinal segment and an alternative embodiment if the invention drawn in  FIG. 8A . The device does not have an intra-aperture component. The flexible longitudinal fixation and vertebral fixation components were inserted into the spine using the method taught in  FIGS. 8B and 8C . Portions of the flexible longitudinal fixation component pass through the aperture in the IVD. 
         [0216]      FIG. 9B  is a posterior view of a partial coronal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 9B . The anti-adhesion patch component drawn in  FIG. 8D  could be added to alternative embodiments of the invention. 
         [0217]      FIG. 10A  is a posterior view of a partial coronal cross section of a spinal segment and an alternative embodiment of the inventions drawn in  FIGS. 6C and 8C . The first loop-like arm of the flexible longitudinal fixation component was passed through AF tissue cranial to the aperture and the second loop-like arm was passed through AF tissue caudal to the aperture using the method taught in  FIGS. 8B and 8C . The second loop-like are of the flexible longitudinal fixation component was passed through the first loop-like arm of the component. 
         [0218]    The end of the second loop-like arm of the flexible longitudinal fixation component was cut and removed leaving two ends that were threaded through a vertebral fixation component  720 . As described in the text of  FIG. 6D , if the loop-like flexible longitudinal fixation component has a weak area, for example an area where two ends of a single flexible longitudinal fixation component were welded to create the loop, the weakened area should be included in the portion of the loop removed to create two ends of the longitudinal component. The vertebral fixation component was impacted into the caudal vertebra. Two intra-aperture components  1002  are seen within a horizontal aperture in the AF. 
         [0219]      FIG. 10B  is a posterior view of a partial coronal cross section of a spinal segment and the embodiment of the invention drawn in  FIG. 10A . The invention was used to treat a vertical aperture in the AF. The invention treats apertures similar to those treated in the embodiment of the invention drawn in  FIG. 6D , but does not require welding technology. In alternative embodiments of the invention as well as other embodiments of the invention taught in this application and my co-pending application U.S. patent application Ser. No. 12/263,753, more or fewer of the intra-aperture components  1002  may be used, and/or different components could be substituted from other embodiments of the invention or deleted. For example, the intra-aperture components  1004  in this embodiment of the invention could be deleted and the anti-adhesion component taught in  FIG. 8F  added to the device. 
         [0220]      FIG. 11A  is a lateral view of an alternative embodiment of the invention drawn in  FIG. 3A . The instruments drawn in this embodiment of the invention and the embodiment drawn in  FIG. 3A  are preferably made of metal and plastic. The instrument is used to pass flexible longitudinal fixation components through bone. For example, the instrument may be used to pass an arm of the flexible longitudinal fixation component through a vertebra as illustrated in FIG. 42 of my co-pending U.S. patent application Ser. No. 12/263,753. 
         [0221]      FIG. 11B  is a lateral view of the embodiment of the invention drawn in  FIG. 11A . The proximal and distal portions of a first arm of a flexible longitudinal fixation component were temporarily fastened to the handle of the tool. Only the tip  1106  of the distal portion of first arm of the flexible longitudinal fixation component is seen near the handle of the tool. A large segment of the distal portion of the first flexible longitudinal fixation component is hidden behind the shaft  1104  of the tool  1102 . 
         [0222]    The intra-aperture components  1110  and the second arm  1112  of the flexible longitudinal fixation component are seen hanging from the handle  1114  of the tool. A drill bit  1116  extends through holes in the distal portion of the tool. The first arm of the flexible longitudinal fixation component is temporarily held in a slot or recess in the distal portion of the instrument or tool. Such position prevents damaging the flexible longitudinal fixation component while the hole is drilled in bone. The L-shaped portion of the distal portion of the tool is preferably placed over the junction of vertebral endplates and the posterior portion of vertebrae. The horizontal component of the L-shaped portion of the tool is preferably 4 to 15 mm long, 3 to 8 mm wide and 1 to 4 mm thick. Such portion of the tool is preferably inserted through apertures in the AF and placed on the VEP. 
         [0223]    The vertical portion of the L-shaped distal portion of the tool is preferably 4 to 15 mm long, 3 to 8 mm wide and 1 to 4 mm thick. Such portion of the tool is preferably placed over the posterior portion of vertebrae. The drill bit has a depth-limiting feature that stops advancement of the drill bit once the bit has passed through the hole in the horizontal portion of the L-shaped feature of the tool. For example, the shaft of the drill bit may have a larger diameter than the diameter of the hole in the vertical portion of the L-shaped feature of the tool. The feature preferably allows the tip of the drill bit advance 1 to 5 mm beyond the VEP. The drill bit is preferably 1 to 4 mm in diameter, but may be larger or smaller in other embodiments of the invention. 
         [0224]      FIG. 11C  is a lateral view of the distal end of a hook-like tool  1120 . The diameter of the tool is preferably slightly smaller than the diameter of the drill bit described in  FIG. 11B . For example, the diameter of the shaft of the hook-like tool could be 1 to 2 mm smaller than the diameter of the drill bit.  FIG. 11D  is a superior view of the distal end of the embodiment of the invention drawn in  FIG. 11C . The hook portion of the tool is preferably narrower than the shaft of the tool in the direction transverse to the hook. 
         [0225]      FIG. 11E  is a lateral view of the embodiments of the invention drawn in  FIGS. 11B and 11C . The hook-like tool was inserted into the hole drilled through bone. The shaft of the hook-like tool has a depth-limiting feature, such as a widened area. The depth-limiting feature enables the hook to pass beyond the flexible longitudinal fixation component. 
         [0226]      FIG. 11F  is a lateral view of the embodiment of the invention drawn in  FIG. 11E . Tension was applied to the distal and proximal portions of the first arm of the flexible longitudinal fixation component to advance the flexible longitudinal component in a proximal direction within the slot at the tip of the horizontal portion of the L-shaped feature in the tool. The distal portion of the first arm of the flexible longitudinal fixation component was then released from the handle of the tool.  FIG. 11G  is a lateral view of the embodiment of the invention drawn in  FIG. 11F . The hook-like tool was pulled through the holes in the tool and the hole in the bone. Such action pulls the distal portion of the first arm of the flexible longitudinal fixation component through the bone. 
         [0227]      FIG. 11H  is a view of the proximal end of the vertical portion of the L-shaped feature of the tool. A cross section of the shaft of the tool is seen near the top of the drawing. The slot  1130  in the circular opening  1132  in the vertical portion of the L-shaped feature in the tool enables the flexible longitudinal fixation component to escape from the tool. 
         [0228]      FIG. 11I  is a superior view of a transverse cross section through the horizontal portion of the L-shaped feature of the tool and a portion of the first arm of the flexible longitudinal fixation component. The tool has features, such as projections  1140 ,  1142 , that hold the flexible longitudinal fixation component in a first position near the distal portion of the tool. Such position prevents damaging the flexible longitudinal fixation component by the drill bit. 
         [0229]      FIG. 11J  is a superior view of a transverse cross section of the embodiment of the invention drawn in  FIG. 11I . The flexible longitudinal fixation component was advanced over the hole in the tool by pulling on proximal and distal portion of the first arm of the flexible longitudinal fixation component. Such position enables capture of the flexible longitudinal fixation component with the hook-like tool. 
         [0230]      FIG. 11K  is a lateral view of a spinal segment and an alternative embodiment of the invention drawn in  FIG. 2D . The distal portion of the first arm of the flexible longitudinal fixation component was passed through a hole in the vertebra using the embodiment of the invention taught in  FIGS. 11A-11J . The distal portion of the second arm of the flexible longitudinal fixation component was passed through AF tissue cranial to an aperture in the AF. Tension on the ends of the flexible longitudinal fixation component pulls the intra-aperture components into the aperture. The intra-aperture components  1110  cover the hole drilled  1160  through the vertebra  1162 . The ends of the flexible longitudinal fixation component are preferably threaded into a vertebral fixation member (not shown), which is then impacted into the vertebra in the next step in the method. Alternatively, the ends of the flexible longitudinal fixation component could be welded together or otherwise fastened to each other. 
         [0231]      FIG. 12A  is a posterior view of a spinal segment and an embodiment of the invention which may use some of the components drawn in  FIG. 8F . Two flexible longitudinal fixation components  1202 ,  1204  are looped around the spinous process  1206  of a first vertebra  1208  and anchored to the vertebral body of a second vertebra  1210 . An anti-adhesion/connective tissue ingrowth sleeve, similar to the embodiment of the sleeve drawn in  FIG. 26B  of my co-pending U.S. patent application Ser. No. 12/263,753, surrounds at least a portion of each flexible longitudinal fixation element in the final device. Such sleeves were not included in the drawing to better illustrate the configuration of the flexible longitudinal fixation elements. 
         [0232]      FIG. 12B  is a lateral view of a partial sagittal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 12A . The ends of each flexible longitudinal fixation element were passed through the loop of the same flexible longitudinal fixation element after such flexible component was wrapped around the spinous process. Each anchor member  1220 ,  1222  through which the ends of a flexible longitudinal fixation pass, was impacted through a pedicle into the vertebra body of the second vertebra. 
         [0233]    The anchors  1220 ,  1222  are preferably impacted into the vertebrae through pilot holes in the vertebrae. The pilot holes are preferably 10 to 20 mm long and 2 to 4 mm in diameter and pass through the at least the majority of the pedicles. The anchors preferably pass through pedicles, may expand the pilot holes, and preferably lie completely within the vertebral body. As previously described the anchors, such as the Piton anchor (Tornier, Edina, Minn.) have a suture-locking component. 
         [0234]    The flexible longitudinal fixation components are preferably made of multi-filament polyester or ultra high molecular weight polyethylene, and have a tensile strength of at least 75 lbs. in the preferred embodiment of the invention. The anchors are preferably at least 3.5 mm in diameter and 10 to 15 mm long. The ends of the flexible longitudinal fixation component are pulled at the end of the procedure to apply tension to and to shorten the flexible longitudinal fixation component proximal to the anchor. The locking feature of the anchor maintains the tension on the flexible longitudinal fixation component. The ends of the flexible longitudinal fixation components that extend from the holes in the vertebrae are cut and removed in the last step of the procedure. 
         [0235]      FIG. 12C  is a posterior view of the spinal segment and embodiment of the invention drawn in  FIG. 12A . The drawing shows application of the first device to the spinal segment. The anchor will be inserted into the pilot hole in the next step of the procedure. The anchors could be impacted directly into the vertebrae, without pilot holes, in alternative embodiments of the invention. 
         [0236]      FIG. 12D  is a posterior view of the spinal segment and the embodiment of the invention drawn in  FIG. 12A . Anti-adhesion/connective tissue ingrowth sleeves  1230 ,  1232  surround a portion of each flexible longitudinal fixation component. A portion of each sleeve is preferably microporous, with approximately 4 micron pores to prevent connective tissue ingrowth and a portion of each sleeve has approximately 0.5 to 2 mm pores that promote connective tissue ingrowth. Microporous portions of the sleeves preferably lie over the dura to prevent adhesions to dura and the portions of the sleeves with large pores preferably lie over the vertebrae, facet capsules, and spinal muscles. For example, such microporous sections of the sleeve are preferably located along medial and anterior portions of the sleeves and the portions of the sleeve with large pores are preferably located along the lateral and posterior portions of the sleeves. 
         [0237]    The locations of the large and micro pores could be located in different areas of the sleeves in alternative embodiments of the invention. The sleeves are preferably made of ePTFE. Similar to the embodiment illustrated in  FIG. 8F , the device is preferably fully assembled with the sleeve, before the flexible longitudinal fixation component is passed around the spinous process. Connective tissue grows into the sleeves forming ligament-like structures that also limit spinal flexion. 
         [0238]    The devices described with respect to  FIG. 12  limit spinal flexion.  FIG. 13A  is a posterior view of a spinal segment and an alternative embodiment of the invention drawn in  FIG. 12A  which also limits spinal movement  FIG. 13B  is a lateral view of a partial sagittal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 13A . The flexible longitudinal fixation components  1302 ,  1304  were looped around the laminae of a first vertebra and anchored at  1320 ,  1322  to the body of a second vertebra. Anti-adhesion/connective tissue ingrowth sleeves, such as the sleeves drawn in  FIG. 12D , preferably surround a portion of each flexible longitudinal fixation component in the fully assembled devices. Such sleeves were not included in the drawing to better illustrate the configuration of the flexible longitudinal fixation components. 
         [0239]      FIG. 14A  is a posterior view of a spinal segment and an alternative embodiment of the invention drawn in  FIG. 13A .  FIG. 14B  is a lateral view of a partial sagittal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 14A . Spinal rods  1440 ,  1442  connect pedicle screws  1444 ,  1446 ,  1448 ,  1450  that were placed into the two caudal vertebrae. Flexible longitudinal fixation components  1402 ,  1404  were looped around the spinal rods and anchored to the body of a third vertebra  1408 . Anti-adhesion/connective tissue ingrowth sleeves, such as the sleeves drawn in  FIG. 12D , preferably surround a portion of each flexible longitudinal fixation component in fully assembled devices. Such sleeves were not included in the drawing to better illustrate the configuration of the flexible longitudinal fixation components. 
         [0240]      FIG. 14C  is posterior view of the spinal segment and embodiment of the invention drawn in  FIG. 14A . Porous sleeves  1430 ,  1432  surround portions of the flexible longitudinal fixation components. Such sleeves preferably have large pores,  0 . 5  to 2 mm in diameter, width, or length to promote connective tissue ingrowth. The sleeves do not necessarily have microporous sections. The sleeves are preferably made of polyester, polypropylene, ePTFE, or similar material. 
         [0241]      FIG. 15A  is a posterior view of a spinal segment and an alternative embodiment of the invention drawn in  FIG. 14C .  FIG. 15B  is a lateral view of a partial sagittal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 15A . The drawings illustrate a laminectomy, surgical removal of the lamina, of the intermediate vertebrae  1510 . Flexible longitudinal fixation components  1502 ,  1504 ,  1506 ,  1508  were looped around the spinous process and laminae  1506  of a first vertebra  1508  and anchored between the rods and pedicle screws of the second and third vertebrae. Anti-adhesion/connective tissue ingrowth sleeves, such as the sleeves drawn in  FIG. 12D , preferably surround a portion of each flexible longitudinal fixation component in fully assembled devices. Such sleeves were not included in the drawing to better illustrate the configuration of the flexible longitudinal fixation components. 
         [0242]      FIG. 15C  is a view of the proximal end of a pedicle screw such as  1544  and the ends of flexible longitudinal fixation component such as  1502  drawn in  FIG. 15A . The flexible longitudinal fixation component  1502  preferably passes through the central portion of the connector component of the pedicle screw. Such location assures the flexible longitudinal fixation component is compressed between the rod and the pedicle screw as the set-screw is tightened in the connector. The flexible longitudinal fixation component preferably passes from the lateral portion of the first opening for the rod in the connector portion of the screw to the medial portion of the second opening for the rod in the connector portion of the screw. The flexible longitudinal fixation component most preferably passes from the medial portion of the caudal opening for the rod in the connector portion of the screw to the lateral portion of the cranial opening for the rod in the connector portion of the screw. The edges of the connector component are preferably rounded to prevent cutting of the flexible longitudinal fixation component. 
         [0243]      FIG. 15D  is an exploded lateral view of the embodiment of the invention drawn in  FIG. 15C . The arms of the flexible longitudinal fixation component  1502  pass between the rod such as  1540  and the connector portion  1544  of the pedicle screw. Set screw  1560  forces rod  1540  against the arms of the flexible longitudinal fixation component  1502 , which are forced against pedicle screw  1544 .  FIG. 15E  is lateral view of the embodiment of the invention drawn in  FIG. 15D  in assembled form. 
         [0244]      FIG. 16  is a posterior view of a spinal segment and an alternative embodiment of the invention drawn in  FIG. 15A . Flexible longitudinal fixation components  1602 ,  1604  were looped around the laminae of a first vertebra  1608  and around rods  1640 ,  1642 . The ends of the flexible longitudinal fixation components were then welded together at  1644 ,  1646 . The welding systems supplied by Axya Medical (Beverly, Mass.) could be used to weld the flexible longitudinal fixation components. Anti-adhesion/connective tissue ingrowth sleeves, such as the sleeves drawn in  FIG. 12D , preferably surround a portion of each flexible longitudinal fixation component in fully assembled devices. Such sleeves were not included in the drawing to better illustrate the configuration of the flexible longitudinal fixation components. 
         [0245]      FIG. 17A  is posterior view of spinal segment and an alternative embodiment of the invention drawn in  FIG. 16A .  FIG. 17B  is a lateral view of a partial sagittal cross section of the spinal segment and embodiment of the invention drawn in  FIG. 17C . Four suture anchors  1702 ,  1704 ,  1706 ,  1708  fasten two flexible longitudinal fixation components  1710 ,  1712  to the bodies of two vertebrae  1720 ,  1722 . Medial and lateral arms of the flexible longitudinal fixation components extend from the anchors in the cranial vertebrae. Each caudal anchor contains a medial arm of a first flexible longitudinal fixation component and a lateral arm of the second flexible longitudinal fixation component. Such configuration is similar to the invention taught in my U.S. Pat. No. 6,248,106. An anti-adhesion/connective tissue ingrowth sleeve or sleeves, such as the sleeves drawn in  FIGS. 12D and 17D , preferably surround portions of each flexible longitudinal fixation component in fully assembled devices. Such sleeve or sleeves were not included in the drawing to better illustrate the configuration of the flexible longitudinal fixation components. 
         [0246]      FIG. 17C  is a posterior view of the embodiment of the invention drawn in  FIG. 17A . The shafts of insertion tools hold the anchors in the collapsed configuration shown in the drawing. The device is preferably fully assembled as shown for immediate use by a surgeon with the flexible longitudinal fixation components passing through all the anchors and including one or more anti-adhesion/connective tissue ingrowth sleeves before the first anchor is impacted into the first vertebra. 
         [0247]      FIG. 17D  is an oblique view of a connective tissue ingrowth sleeve  1730  that surrounds portions of the flexible longitudinal fixation components drawn in  FIG. 17A . The sleeve is preferably 1.5 to 5 cm tall, 0.5 to 5 cm wide, and 3 to 30 cm long. Alternatively the sleeve could be 1, 1.1, 1.2, 1.3, 1.4, 5.1, 5.2, 5.3, 5.4, 5.5, less than 1 or more than 5.5 cm tall, 0.2, 0.3, 0.4, 5.1, 5.2, 5.3, 5.4, 5.5, or more than 5.5 cm wide and 1, 1.5, 2, 2.5, 31, 32, 33, 34, or more than 34 cm long. One or more sutures pull the central portions of the walls of the component together. Alternative methods or devices, such as adhesives, could pull the central portions of the walls of the sleeve together in alternative embodiments of the invention. The inferior or anterior surface of the sleeve is preferably microporous to prevent connective tissue growth between the sleeve and the dura. The remaining portions of the sleeve preferably have 0.5 to 2 mm pores to promote connective tissue ingrowth from the spinal ligaments, bone, and muscles. The sleeve is preferably made of ePTFE. Alternatively, the entire sleeve may have 0.5 to 2 mm pores and could be made of polyester, polypropylene, or similar material. 
         [0248]      FIG. 17E  is a view of the end of the component drawn in  FIG. 17D .  FIG. 17F  is a lateral view of the component drawn in  FIG. 17D . The inferior- or anterior-most portion of the component is preferably 1.5 to 10 cm long. 
         [0249]      FIG. 17G  is a posterior view of a spinal segment and the embodiments of the invention drawn in  FIGS. 17A and 17D . The medial arms of the flexible longitudinal fixation components preferably pass through the lumen of the sleeve. The sleeve is preferably inserted over the flexible longitudinal fixation components before the anchors are impacted into the vertebrae. Separate ingrowth sleeves could also surround portions of the lateral arms of the flexible longitudinal fixation components in alternative embodiments of the invention. 
         [0250]      FIG. 17H  is a lateral view of a partial sagittal cross section of a spinal segment and the embodiment of the invention drawn in  FIG. 17G . Sutures  1740 ,  1742 ,  1744  were passed through the native interspinous ligaments  1750 , which attach to vertebrae adjacent to the vertebrae with the device and the sutures pass through the sleeve. The sleeve  1730  serves as a scaffold for connective tissue to grow between the native supraspinous and interspinous ligaments caudal and cranial to the device. The dimensions of the sleeve preferably provide as much or more surface area for tissue ingrowth as the surface area of portions of native interspinous and supraspinous ligaments removed during surgical procedures to the spinal segment. 
         [0251]      FIG. 17I  is lateral view of an alternative embodiment of the invention drawn in  FIG. 17H . The ingrowth sleeve  1760  is smaller than the ingrowth sleeve drawn in  FIG. 17H . One wall of the sleeve has micropores to prevent connective tissue ingrowth. Anchor inserters  1 ,  2 ,  3 ,  4  hold the anchors  1770 ,  1772 ,  1774 ,  1776  in the compressed shape. The anchor inserters are numbered to help surgeons place the anchors in the desired locations in the spine. A suture passes  1780  through one of the walls of the sleeve. Such suture is preferably 20 to 80 cm long and 0.5 to 1.5 mm in diameter. Alternatively, such suture could be longer, shorter, thinner, or thicker in alternative embodiments of the invention. The suture is preferably made of multiple filaments of materials such as polyester or polyethylene. 
         [0252]    The flexible longitudinal fixation components pass through the lumen of the sleeve. The sleeve is preferably 0.8 to 4 mm tall, 1 to 6 cm wide, and 1 to 30 cm long. Alternatively, the sleeve could be 0.4, 0.5, 0.6, 0.7, 4.1, 4.2, 4.3, 4.4, less than 0.4 or more than 4.4 mm tall, 0.5, 0.6, 0.7, 0.8, 0.9, 6.1, 6.2, 6.3, 6.4, less than 0.5, or more than 6.4 cm wide and less than 1 or more than 30 cm long in alternative embodiments of the invention. The sleeve is preferably made of ePTFE. The flexible longitudinal fixation components are preferably between 70 and 120 cm long. Alternatively the flexible longitudinal fixation components could be 50, 60, 130, 140, less than 50 or more than 140 cm long in alternative embodiments of the invention. The anchors contained by the 1 st  and 2 nd  inserters do not contain a locking feature and are preferably 2.5 to 6 mm in diameter. The anchors in the 3 rd  and 4 th  inserters contain a locking feature and are preferably 3.0 to 6.5 mm in diameter. As previously described 2.8 and 3.5 mm Piton anchors (Tornier, Edina, Minn.) could be used for the first and second set of anchors respectively. 
         [0253]      FIG. 17J  is a view of the top of the embodiment of the invention drawn in  FIG. 17I .  FIG. 17K  is a view of the top of the embodiment of the invention drawn in  FIG. 17J , however the sleeve was not included in the drawing to better illustrate the configuration of the flexible longitudinal fixation components.  FIG. 17L  is an anterior view of a spinal segment and the embodiment of the invention drawn in  FIG. 17I . The suture was removed from the wall of the sleeve  1760  after the device was applied to the spine.  FIG. 17M  is lateral view of a partial sagittal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 17L . 
         [0254]      FIG. 17N  is a view of the top of a novel device  1802  used to hold the components of the embodiment of the invention drawn in  FIG. 17J  in their proper positions. 
         [0255]      FIG. 17O  is a view of the top of the embodiments of the invention drawn in  FIGS. 17J and 17N . Projections such as  1810  from the sides of the inserter handles fit between projections from the holding tool drawn in  FIG. 17N  to prevent rotation of the inserters relative to the holding tool. The ends of the suture that passes through the wall of the sleeve is fastened to the side of the holding tool. For example, the ends of the suture may be press fit into a notch on the side of the holding tool. 
         [0256]      FIG. 17P  is a lateral view of the embodiments of the invention drawn in  FIG. 17O . The embodiment of the invention drawn in  FIG. 17N  is preferably 4 to 8 cm wide and long and 1 to 5 cm tall. The holding tool may be 1, 2, 3, 9, 10, 11 or more than 11 cm wide and long and 0.5, 0.75, 6, 7, less than 0.5 and more than 7 cm tall in alternative embodiments of the invention. The inserters are releasably attached to the holding tool. For example, the shafts of the inserters may be press fit into notches along the side of the holding tool. In such case, the widths of the notches in the holding tool are preferably smaller than the diameter of the shafts of the inserters. For example, the shafts of the inserters could be 4 mm in diameter and the width of the notches could be 3.9 mm, or less, wide. The holding tool is preferably made of an elastic material such as plastic, Styrofoam, polyethylene, polypropylene, or other similar material. The holding tool could fasten to other portions of the inserters, such as the handles of the inserters, in alternative embodiments of the invention. 
         [0257]      FIG. 17Q  is an anterior view of a spinal segment and the embodiment of the invention drawn in  FIG. 17P . The 1 st  anchor was partially inserted into a pilot hole in the cranial vertebra. The holding tool holds the remaining portions of the device outside the surgical wound. The holding tool prevents twisting and tangling of the flexible longitudinal fixation components. 
         [0258]      FIG. 17R  is an anterior view of the spinal segment and the embodiment of the invention drawn in  FIG. 17Q . The first three anchors were inserted into pilot holes in the vertebrae. The suture that passes through the sleeve is used to maneuver the sleeve. For example, tension on the suture pulls the sleeve from the 4 th  pilot hole, thus improving the view of the 4 th  pilot hole. The suture also holds the sleeve in a position with the anterior surface of the sleeve facing in an anterior direction. The 4 th  anchor is inserted into the last pilot hole in the next step of the procedure. Then the ends of the flexible longitudinal fixation component are pulled to apply tension on the flexible longitudinal fixation components. The locking feature in the 3 rd  and 4 th  anchors maintains tension on the flexible fixation components. The suture is removed after insertion of the anchors in the vertebrae by pulling on one end of the suture. The ends of the flexible longitudinal fixation components are cut and removed in the last step in the procedure. 
         [0259]      FIG. 17S  is an anterior view of a spinal segment and an alternative embodiment of the invention drawn in  FIG. 17L . The anti-adhesion/connective tissue ingrowth sleeve was not drawn to better illustrate the configuration of the flexible longitudinal fixation components. The device includes  4  anchors that do not have locking features. The ends of two flexible longitudinal fixation components were welded at  1820  over the caudal vertebra. 
         [0260]      FIG. 17T  is a lateral view of the embodiment of the invention drawn in  FIG. 17S . The ends of a flexible longitudinal fixation component pass from anchors in inserters  1  and  2 , through the anti-adhesion/connective tissue ingrowth sleeve and through anchors in inserters  3  and  4 . The embodiment of the invention drawn in  FIG. 17N  is used to hold the components of the device in proper position. 
         [0261]      FIG. 17U  is an anterior view of a spinal segment and the embodiment of the invention drawn in  FIG. 17S . The ends of one of the flexible longitudinal fixation components are welded at  1822  within the shaft of the welding tool shown in the bottom of the drawing. The ends of the flexible component are cut lateral to the weld in the next step of the procedure. 
         [0262]      FIG. 18A  is posterior view of a spinal segment and an alternative embodiment of the invention drawn in  FIG. 17A . Flexible longitudinal fixation components  1830 ,  1832  extend from anchors  1834 ,  1836  in the body of a first vertebra  1850  around threaded portions of two pedicle screws  1840 ,  1842 . The pedicle screws are preferably passed through portions of the facet joints and anchor the ends of the flexible longitudinal fixation components to the second vertebra  1852 . An anti-adhesion/connective tissue ingrowth sleeve or sleeves, such as the sleeves drawn in  FIG. 12D , preferably surround portions of each flexible longitudinal fixation component in fully assembled devices. Such sleeve or sleeves were not included in the drawing to better illustrate the configuration of the flexible longitudinal fixation components. 
         [0263]      FIG. 18B  is a lateral view of a partial sagittal cross section of the spinal segment and the embodiment of the invention drawn in  FIG. 18A . The nut  1844  of the pedicle screw is tightened to compress the flexible longitudinal fixation component into a second portion of the screw. The pedicle screws causes spinal flexion and limits spinal extension, lateral bending and axial rotation. The flexible longitudinal fixation components limit spinal flexion. The invention may facilitate fusion of vertebrae. 
         [0264]      FIG. 18C  is an exploded lateral view of an alternative embodiment of the invention drawn in  FIG. 18B . A washer sits between the flexible longitudinal fixation component and the nut. The distal end of the washer has projections that help capture the flexible longitudinal fixation component. Large projections around the periphery of the distal end of the washer extend over the head of the screw. 
         [0265]      FIG. 18D  is an exploded lateral view of an alternative embodiment of the invention drawn in  FIG. 18C . Flexible longitudinal fixation components  1830  pass between a washer  1850  that is contained in the pedicle screw  1841  and a set-screw  1852 . The set-screw forces the washer into the flexible longitudinal fixation component and into a second portion of the pedicle screw, thus fastening the flexible longitudinal fixation component to the pedicle screw. 
         [0266]      FIG. 19A  is an exploded view of a partial transverse cross section of a vertebra  1900 , anchors  1902 ,  1904  and flexible longitudinal fixation components  1906 ,  1908  used in preferred embodiments of the invention and sleeves  1910 ,  1912  that fit over the flexible longitudinal fixation components and into holes in the vertebra. 
         [0267]      FIG. 19B  is a view of the partial transverse cross section of the vertebra and the embodiment of the invention drawn in  FIG. 19A . The sleeves are preferably made of plastic, polyethylene, polypropylene, polyurethane, metal or ceramic and help prevent the flexible longitudinal fixation components from cutting into the vertebra. 
         [0268]      FIG. 20A  is lateral view of an alternative embodiment of the flexible longitudinal fixation components  2002  drawn in preferred embodiments of the invention. The central portion of the flexible longitudinal fixation component has a U-shaped sleeve  2004  or a coating. The sleeve is preferably made of plastic, polyethylene, polypropylene, polyurethane, metal or ceramic and helps prevent abrasion between portions of the flexible longitudinal fixation components. Alternatively such portion of the flexible longitudinal fixation components could be coated with plastic, polyethylene, polypropylene, polyurethane, or other material to help prevent abrasion between portions of the flexible longitudinal fixation components. 
         [0269]      FIG. 20B  is a lateral view of the embodiment of the invention drawn in  FIG. 20A . The ends of the flexible longitudinal fixation component were passed over the sleeve or over the coating thus creating a lasso. The invention prevents the abrasive sides of the flexible longitudinal fixation component from sawing through itself. 
         [0270]      FIG. 21A  is the view of the distal end of a suture-passing tool  2102 . The U-shaped distal end of the tool is preferably 2 to 4 cm long and 0.5 to 1.5 cm wide. Alternatively, such portion of the tool could be 0.5, 1, 1.5, 4.5, 5, 5.5, less than 0.5 or more than 5.5 cm long and 0.3, 0.4, 1.6, 1.7, or more than 1.7 cm wide in alternative embodiments of the invention. A wire loop  2104  is seen extending through the lumen of the tool. The lumen of the shaft of the tool is preferably 0.5 to 3 mm in diameter. The distal tip of the tool is preferably beveled with the face of the bevel directed medially. 
         [0271]      FIG. 21B  is a lateral view of the embodiment of the invention drawn in  FIG. 21A . The proximal end of the wire loop extends through handle  2106  of the instrument. The distal end of the same wire loop extends through the distal end of the tool. The instrument is preferable 12 to 24 cm long. 
         [0272]      FIG. 21C  is a posterior view of spinous processes  2110 ,  2012 ,  2114 , interspinous ligaments  2116 ,  2118 , and the embodiment of the invention drawn in  FIG. 21A . The U-shaped end  2102  of the tool was passed around one side of spinous process  2112 . A portion of flexible longitudinal fixation component (not shown) is placed into the wire loop  2104 , then the proximal end of the wire loop is pulled to pull the distal end of the wire loop and a portion of the flexible longitudinal fixation component around the spinous process. The invention is used to pass flexible members around spinous processes or other structures in the spine. 
         [0273]      FIG. 22A  is a lateral view of an alternative embodiment of the invention drawn in  FIG. 21A . The U-shaped distal end  2202  of the tool is preferably 1 to 4 cm long and 0.5 to 1.5 cm tall. Otherwise, the tool is similar in size to the tool drawn in  FIG. 21A . The distal tip of the tool is preferably beveled with the face of the bevel directed inferiorly or anteriorly. The tip of the distal end of the bevel is preferably rounded to help prevent lacerating the dura. 
         [0274]      FIG. 22B  is a lateral view of a partial sagittal cross section of three spinal laminae  2210 ,  2212 ,  2214 , the ligamentum flavum  2216 ,  2218  between the laminae, and the embodiment of the invention drawn in  FIG. 22A . The U-shaped end of the tool was passed around one side of a lamina. A portion of flexible longitudinal fixation component is placed into the wire loop (not shown), then the distal end of the wire loop and a portion of the flexible longitudinal fixation component are pulled around the lamina by pulling on the proximal end of the wire loop. The invention is used to pass flexible members around laminae or other structures in the spine. 
         [0275]      FIG. 23A  is a view of the top of an alternative embodiment of the invention drawn in  FIG. 12A . The loop  2302  of a flexible longitudinal fixation component  2304  extends through a porous device  2310 . The ends of the flexible fixation component extend through an anchor  2312  with a locking feature. A wire loop  2320  extends through the porous device. 
         [0276]      FIG. 23B  is a posterior view of two spinous processes and the embodiment of the invention drawn in  FIG. 23A . The flexible longitudinal fixation component loop was passed around a portion of a spinous process, then passed into one end of the wire loop. The porous device was inserted between spinous processes of adjacent vertebrae. 
         [0277]      FIG. 23C  is a posterior view of the spinous processes and embodiment of the invention drawn in  FIG. 23B . The flexible longitudinal fixation component loop  2302  was pulled through the porous device by pulling the wire loop out of the porous device  2310 . The anchor was passed through the loop in the flexible longitudinal fixation component. 
         [0278]      FIG. 23D  is a posterior view of a spinal segment and the embodiment of the invention drawn in  FIG. 23C . Two flexible longitudinal fixation components  2330 ,  2332  were passed around the first spinous process  2340  and through the porous device using the method taught in  FIG. 23C . The anchors were then impacted into the vertebral body. Tension was applied on the ends of the flexible longitudinal fixation components followed by cutting and removing the distal ends of the flexible fixation components. 
         [0279]      FIG. 24A  is a posterior view of a portion of the spine and an alternative embodiment of the ingrowth sleeve drawn in  FIG. 17D . The ends of a mesh component  2402  were sutured at  2404 ,  2406  to native interspinous ligaments. Retracted muscles  2410  are seen at the periphery of the device. 
         [0280]      FIG. 24B  is lateral view of a spinal segment and the embodiment of the invention drawn in  FIG. 24A . An anti-adhesion component  2420  was fastened to the anterior side of the central portion of the mesh device  2402 . For example, the mesh and anti-adhesion components could be sutured together. The anti-adhesion component, preferably made of microporous ePTFE minimizes growth of connective tissues between the mesh and the dura. The mesh is preferably made of polyester, polypropylene, nylon or similar material and preferably has pores 0.5 to 2.0 mm in diameter or width. 
         [0281]      FIG. 24C  is a view of a transverse cross section of a vertebra and the embodiment of the invention drawn in  FIG. 24B . The mesh  2402  extends over the top and the sides of the spinous process  2400 . 
         [0282]      FIG. 25A  is an end view of an alternative embodiment of the inventions drawn in  FIG. 17E and 24B .  FIG. 25B  is a lateral view of the embodiment of the invention drawn in  FIG. 25A . The embodiment of the invention, like the embodiment of the invention drawn in  FIG. 24B , has an anti-adhesion component  2520  fastened to the anterior surface of the connective in-growth device  2502 . 
         [0283]      FIG. 25C  is a posterior view of a spinal segment and the embodiment of the invention drawn in  FIG. 25A . Flexible longitudinal fixation components  2510 ,  2512  pass from anchors  2520 ,  2522  in the first vertebra, through lumens in the lateral portions of the in-growth component and through anchors  2524 ,  2526  in the second vertebra. The ends of the flexible longitudinal fixation components could be passed from the anchors in the first vertebra under the skin and between muscle fibers to the second set of anchors using the invention taught in my co-pending patent application U.S. Ser. No. 11/945,998. For example, the ends of the flexible longitudinal fixation components could be manipulated under or between soft tissue structures using tool 60 of the &#39;998 application. The ends of the flexible longitudinal fixation components could then be treaded into the second set of anchors, which are then impacted into the second vertebra. 
         [0284]    Alternatively, as taught in the embodiment of the invention drawn in  FIG. 17I , the device could be fully assembled before the anchors are impacted into the vertebrae. These embodiments of the invention (a fully assembled spinal device that restricts spinal motion in-part because such device lies outside the disc space, where the center of vertebral rotation lies), unlike prior art spinal fusion devices that must be assembled in-situ, such as rods and screws and plates and screws, is easier to insert and disrupts the spinal tissues less than such prior art motion restricting spinal devices that are assembled in-situ. The criss-cross configuration of the flexible longitudinal fixation components as shown in  FIG. 17G  could be used in alternative embodiments of the invention. The lateral vertical flexible longitudinal fixation components would preferably pass through the in-growth component and the criss-crossing medial flexible longitudinal fixation components would preferably pass under the in-growth component and possibly between the in-growth and anti-adhesion components in such alternative embodiments of the invention.