Patent Publication Number: US-7896909-B2

Title: Method for treating intervertebral discs

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a divisional of U.S. patent application Ser. No. 08/881,693, filed Jun. 24, 1997, now U.S. Pat. No. 6,007,570, which is a continuation-in-part of (i) U.S. patent application Ser. No. 08/881,525, filed Jun. 24, 1997, now U.S. Pat. No. 6,122,549, (ii) U.S. patent application Ser. No. 08/881,692, filed Jun. 24, 1997, now U.S. Pat. No. 6,073,051, and (iii) U.S. patent application Ser. No. 08/881,694, filed Jun. 24, 1997, now U.S. Pat. No. 6,095,149, and which claims priority to U.S. provisional application Nos. 60/047,820, 60/047,841, 60/047,818, and 60/047,848, each filed May 28, 1997, provisional application No. 60/047,941, filed May 8, 1997, and provisional application Nos. 60/029,734, 60/029,735, 60/029,600, and 60/029,602, each filed Oct. 23, 1996. 
     This application is a continuation of U.S. patent application Ser. No. 10/712,006, filed Nov. 14, 2003, which is a continuation of U.S. patent application Ser. No. 10/388,609, filed Mar. 17, 2003, now U.S. Pat. No. 6,997,941, which is a continuation of U.S. patent application Ser. No. 09/707,627, filed, Nov. 6, 2000, now U.S. Pat. No. 6,547,810, which is a continuation of U.S. application Ser. No. 09/236,816, filed Jan. 25, 1999, now U.S. Pat. No. 6,290,715, which is a continuation of (i) U.S. application Ser. No. 09/162,704 filed Sep. 29, 1998, now U.S. Pat. No. 6,099,514, (ii) U.S. patent application Ser. No. 09/153,552 filed Sep. 15, 1998, now U.S. Pat. No. 6,126,682, and (iii) U.S. patent application Ser. No. 08/881,525, now U.S. Pat. No. 6,122,549, U.S. patent application Ser. No. 08/881,692, now U.S. Pat. No. 6,073,051, U.S. patent application Ser. No. 08/881,527, now U.S. Pat. No. 5,980,504, U.S. patent application Ser. No. 08/881,693, now U.S. Pat. No. 6,007,570, and U.S. patent application Ser. No. 08/881,694, now U.S. Pat. No. 6,095,149, each filed Jun. 24, 1997, claiming priority from provisional application Nos. 60/047,820, 60/047,841, 60/047,818, and 60/047,848, each filed May 28, 1997, provisional application No. 60/047,941, filed May 8, 1997, and provisional application Nos. 60/029,734, 60/029,735, 60/029,600, and 60/029,602, each filed Oct. 23, 1996. U.S. patent application Ser. No. 10/712,006 is also a continuation-in-part of U.S. patent application Ser. No. 09/876,833, now U.S. Pat. No. 6,726,685, Ser. No. 09/876,832, now U.S. Pat. No. 6,733,496 and Ser. No. 09/876,831, now U.S. Pat. No. 6,832,997 each filed Jun. 6, 2001. U.S. patent application Ser. No. 10/712,006 is a continuation-in-part of U.S. patent application Ser. No. 10/624,894, filed Jul. 23, 2003, which is a divisional of U.S. patent application Ser. No. 09/753,786, filed Jan. 2, 2001, now U.S. Pat. No. 6,645,203, which is a continuation-in-part of U.S. patent application Ser. No. 09/022,688, filed Feb. 12, 1998, now U.S. Pat. No. 6,168,593, which claims priority from provisional application No. 60/037,620, filed Feb. 12, 1997. U.S. patent application Ser. No. 10/712,006 is a continuation-in-part of U.S. patent application Ser. No. 10/242,777, filed Sep. 13, 2002, which is a divisional of U.S. patent application Ser. No. 09/340,065, filed Jun. 25, 1999, now U.S. Pat. No. 6,461,357, which is a continuation-in-part of U.S. patent application Ser. No. 09/022,612, filed Feb. 12, 1998, now U.S. Pat. No. 6,135,999, which claims priority from provisional application No. 60/037,782, filed Feb. 12, 1997. U.S. patent application Ser. No. 10/712,006 is a continuation-in-part of U.S. patent application Ser. No. 09/776,231, now U.S. Pat. No. 6,767,347 and Ser. No. 09/776,186, now U.S. Pat. No. 6,749,605, both filed Feb. 1, 2001, both of which are divisional of U.S. patent application Ser. No. 09/272,806, filed Mar. 19, 1999, now U.S. Pat. No. 6,258,086, which claims priority from provisional application No. 60/078,545, filed Mar. 19, 1998. U.S. patent application Ser. No. 10/712,006 is a continuation-in-part of U.S. patent application Ser. No. 09/884,859, filed Jun. 18, 2001, now U.S. Pat. No. 6,878,155, which is a continuation of U.S. patent application Ser. No. 09/792,628, filed Feb. 22, 2001, now U.S. Pat. No. 7,069,087, which claims priority from provisional application No. 60/185,221, filed Feb. 25, 2000. U.S. patent application Ser. No. 10/712,006 is a continuation-in-part of U.S. patent application Ser. No. 09/664,473, filed Sep. 18, 2000, which is a continuation of U.S. patent application Ser. No. 08/696,051, filed Aug. 13, 1996, now abandoned. 
     This application is a continuation U.S. patent application Ser. No. 10/898,671, filed Jul. 26, 2004, which is a continuation of U.S. patent application Ser. No. 09/776,231, filed Feb. 1, 2001, now U.S. Pat. No. 6,767,347, which is a divisional of U.S. patent application Ser. No. 09/272,806, filed Mar. 19, 1999, now U.S. Pat. No. 6,258,086, which claims priority to provisional application Ser. No. 60/078,545 filed on Mar. 19, 1998. U.S. patent application Ser. No. 09/272,806 is also a continuation-in-part of U.S. patent application Ser. No. 08/881,527, now U.S. Pat. No. 5,980,504, Ser. No. 08/881,525, now U.S. Pat. No. 6,122,549, Ser. No. 08/881,692, now U.S. Pat. No. 6,073,051, Ser. No. 08/881,693, now U.S. Pat. No. 6,007,570, and Ser. No. 08/881,694, now U.S. Pat. No. 6,095,149, each of which were filed on Jun. 24, 1997, and each of which claims priority to U.S. Provisional Application Nos. 60/047,820, 60/047,841, 60/047,818, and 60/047,848, each of which were filed on May 28, 1997, U.S. Provisional Application No. 60/047,941, filed May 8, 1997, and U.S. Provisional Application Nos. 60/029,734, 60/029,735, 60/029,600, and 60/029,602, each of which were filed on Oct. 23, 1996. Application Ser. Nos. 09/776,231, 09/272,806, 08/881,525, 08/881,692, 08/881,693, 08/881,694, 60/047,941, 60/078,545, and 60/029,734 are each hereby incorporated by reference as if fully set forth herein. 
     All of the above-mentioned applications are incorporated herein by reference in their entirety. 
    
    
     TECHNICAL FIELD 
     This document relates to methods and apparatuses for modifying intervertebral disc tissue and more particularly to the treatment of annular fissures and other conditions using percutaneous techniques to avoid major surgical intervention. 
     BACKGROUND 
     Intervertebral disc abnormalities have a high incidence in the population and may result in pain and discomfort if they impinge on or irritate nerves. Disc abnormalities may be the result of trauma, repetitive use, metabolic disorders and the aging process and include such disorders but are not limited to degenerative discs (i) localized tears or fissures in the annulus fibrosus, (ii) localized disc herniations with contained or escaped extrusions, and (iii) chronic, circumferential bulging disc. 
     Disc fissures occur rather easily after structural degeneration (a part of the aging process that may be accelerated by trauma) of fibrous components of the annulus fibrosus. Sneezing, bending or just attrition can tear these degenerated annulus fibers, creating a fissure. The fissure may or may not be accompanied by extrusion of nucleus pulposus material into or beyond the annulus fibrosus. The fissure itself may be the sole morphological change, above and beyond generalized degenerative changes in the connective tissue of the disc. Even if there is no visible extrusion, biochemicals within the disc may still irritate surrounding structures. Disc fissures can be debilitatingly painful. Initial treatment is symptomatic, including bed rest, painkillers and muscle relaxants. More recently spinal fusion with cages have been performed when conservative treatment did not relieve the pain. The fissure may also be associated with a herniation of that portion of the annulus. 
     With a contained disc herniation, there are no free nucleus fragments in the spinal canal. Nevertheless, even a contained disc herniation is problematic because the outward protrusion can press on the spinal nerves or irritate other structures. In addition to nerve root compression, escaped nucleus pulposus contents may chemically irritate neural structures. Current treatment methods include reduction of pressure on the annulus by removing some of the interior nucleus pulposus material by percutaneous nuclectomy. However, complications include disc space infection, nerve root injury, hematoma formation, instability of the adjacent vertebrae and collapse of the disc from decrease in height. 
     Another disc problem occurs when the disc bulges outward circumferentially in all directions and not just in one location. Over time, the disc weakens and takes on a “roll” shape or circumferential bulge. Mechanical stiffness of the joint is reduced and the joint may become unstable. One vertebra may settle on top of another. This problem continues as the body ages and accounts for shortened stature in old age. With the increasing life expectancy of the population, such degenerative disc disease and impairment of nerve function are becoming major public health problems. As the disc “roll” extends beyond the normal circumference, the disc height may be compromised, foramina with nerve roots are compressed. In addition, osteophytes may form on the outer surface of the disc roll and further encroach on the spinal canal and foramina through which nerves pass. This condition is called lumbar spondylosis. 
     It has been thought that such disc degeneration creates segmental instability which disturbs sensitive structures which in turn register pain. Traditional, conservative methods of treatment include bed rest, pain medication, physical therapy or steroid injection. Upon failure of conservative therapy, spinal pain (assumed to be due to instability) has been treated by spinal fusion, with or without instrumentation, which causes the vertebrae above and below the disc to grow solidly together and form a single, solid piece of bone. The procedure is carried out with or without discectomy. Other treatments include discectomy alone or disc decompression with or without fusion. Nuclectomy can be performed by removing some of the nucleus to reduce pressure on the annulus. However, complications include disc space infection, nerve root injury, hematoma formation, and instability of adjacent vertebrae. 
     These interventions have been problematic in that alleviation of back pain is unpredictable even if surgery appears successful. In attempts to overcome these difficulties, new fixation devices have been introduced to the market, including but not limited to pedicle screws and interbody fusion cages. Although pedicle screws provide a high fusion success rate, there is still no direct correlation between fusion success and patient improvement in function and pain. Studies on fusion have demonstrated success rates of between 50% and 67% for pain improvement, and a significant number of patients have more pain postoperatively. Therefore, different methods of helping patients with degenerative disc problems need to be explored. 
       FIGS. 1(   a ) and  1 ( b ) illustrate a cross-sectional anatomical view of a vertebra and associated disc and a lateral view of a portion of a lumbar and thoracic spine, respectively. Structures of a typical cervical vertebra (superior aspect) are shown in  FIG. 1(   a ):  104 —lamina:  106 —spinal cord:  108 —dorsal root of spinal nerve;  114 —ventral root of spinal nerve;  116 —posterior longitudinal ligament:  118 —intervertebral disc;  120 —nucleus pulposus;  122 —annulus fibrosus;  124 —anterior longitudinal ligament;  126 —vertebral body;  128 —pedicle;  130 —vertebral artery;  132 —vertebral veins;  134 —superior articular facet;  136 —posterior lateral portion of the annulus;  138 —posterior medial portion of the annulus; and  142 —spinous process. In  FIG. 1(   a ), one side of the intervertebral disc  118  is not shown so that the anterior vertebral body  126  can be seen.  FIG. 1(   b ) is a lateral aspect of the lower portion of a typical spinal column showing the entire lumbar region and part of the thoracic region and displaying the following structures:  118 —intervertebral disc;  126 —vertebral body;  142 —spinous process;  170 —inferior vertebral notch;  110 —spinal nerve;  174 —superior articular process;  176 —lumbar curvature; and  180 —sacrum. 
     The presence of the spinal cord and the posterior portion of the vertebral body, including the spinous process, and superior and inferior articular processes, prohibit introduction of a needle or trocar from a directly posterior position. This is important because the posterior disc wall is the site of symptomatic annulus tears and disc protrusions/extrusions that compress or irritate spinal nerves for most degenerative disc syndromes. The inferior articular process, along with the pedicle and the lumbar spinal nerve. form a small “triangular” window (shown in black in  FIG. 1(   c )) through which introduction can be achieved from the posterior lateral approach.  FIG. 1(   d ) looks down on an instrument introduced by the posterior lateral approach. It is well known to those skilled in the art that percutaneous access to the disc is achieved by placing an introducer into the disc from this posterior lateral approach, but the triangular window does not allow much room to maneuver. Once the introducer pierces the tough annulus fibrosus, the introducer is fixed at two points along its length and has very little freedom of movement. Thus, this approach has allowed access only to small central and anterior portions of the nucleus pulposus. Current methods do not permit percutaneous access to the posterior half of the nucleus or to the posterior wall of the disc. Major and potentially dangerous surgery is required to access these areas. 
     U.S. Pat. No. 5,433,739 (the “&#39;739 patent”) discloses placement of an RF electrode in an interior region of the disc approximately at the center of the disc. RF power is applied, and heat then putatively spreads out globally throughout the disc. The &#39;739 patent teaches the use of a rigid shaft which includes a sharpened distal end that penetrates through the annulus fibrosus and into the nucleus pulposus. In one embodiment the shaft has to be rigid enough to permit the distal end of the RF electrode to pierce the annulus fibrosus, and the ability to maneuver its distal end within the nucleus pulposus is limited. In another embodiment, a somewhat more flexible shaft is disclosed. However, neither embodiment of the devices of the &#39;739 patent permits access to the posterior, posterior lateral and posterior medial region of the disc, nor do they provide for focal delivery of therapy to a selected local region within the disc or precise temperature control at the annulus. The &#39;739 patent teaches the relief of pain by globally heating the disc. There is no disclosure of treating an annular tear or fissure. 
     U.S. Pat. No. 5,201,729 (the “&#39;729 patent”) discloses the use of an optical liber that is introduced into a nucleus pulposus. In the &#39;729 patent, the distal end of a stiff optical liber shaft extends in a lateral direction relative to a longitudinal axis of an introducer. This prevents delivery of coherent energy into the nucleus pulposus in the direction of the longitudinal axis of the introducer. Due to the constrained access from the posterior lateral approach, stiff shaft and lateral energy delivery, the device of the &#39;729 patent is unable to gain close proximity to selected portion(s) of the annulus (i.e., posterior, posterior medial and central posterior) requiring treatment or to precisely control the temperature at the annulus. No use in treating an annular fissure is disclosed. The device of the &#39;729 patent describes ablating the nucleus pulposus. 
     Accordingly, it is desirable to diagnose and treat disc abnormalities at locations previously not accessible via percutaneous approaches and without substantial destruction to the disc. It would further be desirable to be able to administer materials to a precise, selected location within the disc, particularly to the location of the annular fissure. It would be further desirable to provide thermal energy into collagen in the area of the fissure to strengthen the annulus and possibly fuse collagen to the sides of the fissure, particularly at the posterior, posterior lateral and the posterior medial regions of the inner wall of the annulus fibrosus. 
     SUMMARY 
     Accordingly, one aspect of the invention features a minimally invasive method and apparatus for diagnosing and treating fissures of discs at selected locations within the disc. 
     Another aspect features an apparatus which is advanceable and navigable at the inner wall of the annulus fibrosus to provide localized heating at the site of the annular fissure. 
     Another aspect features a method and apparatus to treat degenerative intervertebral discs by delivering thermal energy to at least a portion of the nucleus pulposus to reduce water content of the nucleus pulposus and shrink the nucleus pulposus. 
     Still a further aspect features a device which has a distal end that is inserted into the disc and accesses the posterior, posterior lateral and the posterior medial regions of the inner wall of the annulus fibrosus in order to repair or shrink an annular fissure at such a location. 
     Methods for manipulating a disc tissue with a fissure or tear in an intervertebral disc, the disc having a nucleus pulposus and an annulus fibrosus, the annulus having an inner wall of the annulus fibrosus, employ an externally guidable intervertebral disc apparatus, or catheter. The procedure is performed with a catheter having a distal end, a proximal end, a longitudinal axis, and an intradiscal section at the catheter&#39;s distal end on which there is at least one functional element. The catheter is advanced through the nucleus pulposus and around an inner wall of an annulus fibrosus by applying a force to the proximal end but the applied force is insufficient for the intradiscal section to puncture the annulus fibrosus. The next step is positioning the functional element at a selected location of the disc by advancing or retracting the catheter and optionally twisting the proximal end of the catheter. Then the functional unit treats the annular fissure. 
     A method of treating an intervertebral fissure includes placing an energy source adjacent to the fissure and providing sufficient energy to the fissure to raise the temperature to at least about 45-70° C. and for a sufficient time to cause the collagen to weld. 
     Yet another method of treating an intervertebral fissure includes placing a catheter with a lumen adjacent to the fissure and injecting sealant info the fissure via the catheter lumen to seal the fissure. 
     In addition to the methods, there is provided an externally guidable intervertebral disc apparatus for diagnosis or manipulation of disc tissue present at a selected location of an intervertebral disc, the disc having a nucleus pulposus, an annulus fibrosus, and an inner wall of the annulus fibrosus, the nucleus pulposus having a diameter in a disc plane between opposing sections of the inner wall. The apparatus comprises a catheter having a distal end, a proximal end, and a longitudinal axis, and an intradiscal section at the catheter&#39;s distal end, which is extendible into the disc, has sufficient rigidity to be advanceable through the nucleus pulposus and around the inner wall of the annulus fibrosus under a force applied longitudinally to the proximal end, has sufficient flexibility in a direction of the disc plane to be compliant with the inner wall, and has insufficient penetration ability to be advanceable out through the annulus fibrosus under the force; and a functional element located at the intradiscal section for adding sufficient thermal energy at or near the fissure. 
     The details of one or more embodiments are set forth in the drawings and the description below. Other features will be apparent from, the description and drawings, and from the claims. 
    
    
     
       DESCRIPTION OF DRAWINGS 
         FIG. 1(   a ) is a superior cross-sectional anatomical view of a cervical disc and vertebra. 
         FIG. 1(   b ) is a lateral anatomical view of a portion of a lumbar spine. 
         FIG. 1(   c ) is a posterior-lateral anatomical view of two lumbar vertebrae and illustration of the triangular working zone. 
         FIG. 1(   d ) is a superior cross-sectional view of the required posterior lateral approach. 
         FIG. 2  is a second cross-sectional view of an intervertebral disc illustrating a disc plane of the intervertebral disc and an inferior/superior plane. 
         FIG. 3(   a ) is a plan view of an introducer and an instrument of the invention in which solid lines illustrate the position of the instrument in the absence of bending forces and dotted lines indicate the position the distal portion of the instruments would assume under bending forces applied to the intradiscal section of the instrument. 
         FIG. 3(   b ) is an end view of the handle of the embodiment shown in  FIG. 3(   a ). 
         FIG. 4  is a cross-sectional view of an intervertebral disc with a portion of the intervertebral apparatus of the present invention inserted in the intervertebral disc. 
         FIG. 5(   a ) is a cross-sectional view of the intervertebral segment of the embodiment of the invention shown in  FIG. 3(   a ) taken along the line  5 ( a )- 5 ( a ) of  FIG. 3(   a ). 
         FIG. 5(   b ) is a cross-sectional view of the intervertebral segment of a second embodiment of the present invention having a combined wall/guiding mandrel. 
         FIG. 6  is a perspective view of an embodiment of an apparatus of the present invention with a resistive heating coil positioned around an exterior of an intradiscal section of the catheter. 
         FIG. 7  is a partial cross-sectional view of an embodiment an apparatus of the invention illustrating a sensor positioned in an interior of the intradiscal section of the catheter. 
         FIG. 8  is a partial cross-sectional view of an embodiment of the apparatus of the invention further including a sheath positioned around the resistive healing coil. 
         FIG. 9  is a partial cross-sectional view of an embodiment of the apparatus of  FIG. 6  with multiple resistive heating coils. 
         FIG. 10  is a plan view of an embodiment of the intradiscal section of a catheter of the invention with a helical structure. 
         FIG. 11  is a block diagram of an open or closed loop feedback system that couples one or more sensors to an energy source. 
         FIG. 12  is a block diagram of an embodiment illustrating an analog amplifier, analog multiplexer and microprocessor used with the feedback control system of  FIG. 11 . 
     
    
    
     DETAILED DESCRIPTION 
     The present invention provides a method and apparatus for diagnosing and treating intervertebral disc disorders, such as, for example, tears of fissures of the annulus fibrosus, herniations, and circumferential bulging, which may or may not be accompanied with contained or escaped extrusions. 
     In general, an apparatus of the invention is in the form of an externally guidable intervertebral disc apparatus for accessing and manipulating disc tissue present at a selected location of an intervertebral disc having a nucleus pulposus and an annulus fibrosus, the annulus having an inner wall. Use of a temperature-controlled energy delivery element, combined with the navigational control of the inventive catheter, provides preferential, localized heating to treat the fissure. For ease of reference to various manipulations and distances described below, the nucleus pulposus can be considered as having a given diameter in a disc plane between opposing sections of the inner wall. This nucleus pulposus diameter measurement allows instrument sizes (and parts of instruments) designed for one size disc to be readily converted to sizes suitable for an instrument designed for a different size of disc. 
     The operational portion of the apparatus of the invention is brought to a location in or near the disc&#39;s fissure using techniques and apparatuses typical of percutaneous interventions. For convenience and to indicate that the apparatus of the invention can be used with any insertional apparatus that provides proximity to the disc, including many such insertional apparatuses known in the art, the term “introducer” is used to describe this aid to the method. An introducer has an internal introducer lumen with a distal opening at a terminus of the introducer to allow insertion (and manipulation) of the operational parts of the apparatus into (and in) the interior of a disc. 
     The operational part of the apparatus comprises an elongated element referred to as a catheter, various parts of which are located by reference to a distal end and a proximal end at opposite ends of its longitudinal axis. The proximal end is the end closest to the external environment surrounding the body being operated upon (which may still be inside the body in some embodiments if the catheter is attached to a handle insertable into the introducer). The distal end of the catheter is intended to be located inside the disc under conditions of use. The catheter is not necessarily a traditional medical catheter (i.e., an elongate hollow tube for admission or removal of fluids from an internal body cavity) but is a defined term for the purposes of this specification. “Catheter” has been selected as the operant word to describe this part of the apparatus, as the inventive apparatus is a long, flexible tube which transmits energy and/or material from a location external to the body to a location internal to the disc being accessed upon, such as a collagen solution and heat to the annular fissure. Alternatively, material can be transported in the other direction to remove material from the disc, such as removing material by aspiration to decrease pressure which is keeping the fissure open and aggravating the symptoms due to the fissure. Material may be removed to decrease intradiscal pressure which maintains a herniation. 
     The catheter is adapted to slidably advance through the introducer lumen, the catheter having an intradiscal section at the distal end of the catheter, the intradiscal section being extendible through the distal opening at the terminus of the introducer into the disc. Although the length of the intradiscal portion can vary with the intended function as explained in detail below, a typical distance of extension is at least one-half the diameter of the nucleus pulposus, preferably in the range of one-half to one and one-half times the circumference of the nucleus pulposus. 
     In order that the functional elements of the catheter can be readily guided to the desired location within a disc, the intradiscal portion of the catheter is manufactured with sufficient rigidity to avoid collapsing upon itself while being advanced through the nucleus pulposus and navigated around the inner wall of the annulus fibrosus. The intradiscal portion, however, has insufficient rigidity to puncture the annulus fibrosus under the same force used to advance the catheter through the nucleus pulposus and around the inner wall of the annulus fibrosus. Absolute penetration ability will vary with sharpness and stiffness of the tip of the catheter, but in all cases a catheter of the present invention will advance more readily through the nucleus pulposus than through the annulus fibrosus. 
     In preferred embodiments, the intradiscal section of the catheter further has differential bending ability in two orthogonal directions at right angles to the longitudinal axis. This causes the catheter to bend along a desired plane (instead of at random). Also when a torsional (twisting) force is applied to the proximal end of the catheter to re-orient the distal end of the catheter, controlled advancement of the catheter in the desired plane is possible. 
     A further component of the catheter is a functional element located in the intradiscal section for diagnosis or for adding energy and adding and/or removing material at the selected location of the disc where the annular tear is to be treated, or some other therapeutic action is to be carried out. The apparatus allows the functional element to be controllably guided by manipulation of the proximal end of the catheter into a selected location for localized diagnosis and/or treatment of a portion of the disc, such as, for example, the annular fissure. 
     The method of the invention which involves manipulating disc tissue at the annular fissure or other selected location, is easily canned out with an apparatus of the invention. An introducer is provided that is located in a patient&#39;s body so that its proximal end is external to the body and the distal opening of its lumen is internal to the body and (1) internal to the annulus fibrosus or (2) adjacent to an annular opening leading to the nucleus pulposus, such as an annular tear or trocar puncture that communicates with the nucleus pulposus. The catheter is then slid into position in and through the introducer lumen so that the functional element in the catheter is positioned at the selected location of the disc by advancing or retracting the catheter in the introducer lumen and optionally twisting the proximal end of the catheter to precisely navigate the catheter. By careful selection of the rigidity of the catheter and by making it sufficiently blunt to not penetrate the annulus fibrosus, and by careful selection of the flexibility in one plane versus the orthogonal plane, the distal portion of the catheter will curve along the inner wall of the annulus fibrosus as it is navigated and is selectively guided to an annular tear or other selected location(s) in the disc. Energy is applied and/or material is added or removed at the selected location of the disc via the functional element. 
     Each of the elements of the apparatus and method will now be described in more detail. However, a brief description of disc anatomy is provided first, as sizes and orientation of structural elements of the apparatus and operations of the method can be better understood in some cases by reference to disc anatomy. 
     The annulus fibrosus is comprised primarily of tough fibrous material, while the nucleus pulposus is comprised primarily of an amorphous colloidal gel. There is a transition zone between the annulus fibrosus and the nucleus pulposus made of both fibrous-like material and amorphous colloidal gel. The border between the annulus fibrosus and the nucleus pulposus becomes more difficult to distinguish as a patient ages, due to degenerative changes. This process may begin as early as 30 years of age. For purposes of this specification, the inner wall of the annulus fibrosus can include the young wall comprised primarily of fibrous material as well as the transition zone which includes both fibrous material and amorphous colloidal gels (hereafter collectively referred to as the “inner wall of the annulus fibrosus”). Functionally, that location at which there is an increase in resistance to catheter penetration and which is sufficient to cause bending of the distal portion of the catheter into a radius less than that of the internal wall of the annulus fibrosus is considered to be the “inner wall of the annulus fibrosus”. 
     As with any medical instrument and method, not all patients can be treated, especially when their disease or injury is too severe. There is a medical gradation of degenerative disc disease (stages 1-5). See, for example, Adams et al., “The Stages of Disc Degeneration as Revealed by Discograms,” J. Bone and Joint Surgery, 68, 36-41 (1986). As these grades are commonly understood, the methods of instrument navigation described herein would probably not be able to distinguish between the nucleus and the annulus in degenerative disease of grade 5. In any case, most treatment is expected to be performed in discs in stages 3 and 4, as stages 1 and 2 are asymptomatic in most patients, and stage 5 may require disc removal and fusion. 
     Some of the following discussion refers to motion of the catheter inside the disc by use of the terms “disc plane” “oblique plane” and “cephalo-caudal plane.” These specific terms refer to orientations of the catheter within the intervertebral disc. Referring now to  FIG. 2  (which shows a vertical cross-section of a disc), a disc plane  30  of the intervertebral disc is generally a plane of some thickness  27  within the nucleus pulposus  120  orthogonal to the axis formed by the spinal column (i.e., such a disc plane is substantially horizontal in a standing human, corresponding to the “flat” surface of a vertebra). A oblique plane  31  extends along any tilted orientation relative to axial plane  30 ; however, when the plane is tilted 90°, such a plane would be substantially vertical in a standing human and is referred to as a cephalo-caudal plane. Reference is made to such planes to describe catheter movements with respect to the disc plane. In various embodiments, disc plane  30  has a thickness no greater than the thickness of the intervertebral disc, preferably a thickness no greater than 75% of a thickness of the intervertebral disc, and more preferably a thickness no greater than 50% of a thickness of the intervertebral disc. Movement of the intradiscal portion  16  of catheter  14  is confined within a disc plane by the physical and mechanical properties of the intradiscal portion  16  during advancement of the catheter when the bending plane of the catheter is aligned with the disc plane until some additional force is applied to the catheter by the physician. A twisting force (which can be applied mechanically, electrically, or by any other means) acting on the proximal end of the catheter changes the forces acting on the distal end of the catheter so that the plane of the catheter bend can be angled relative to the disc plane as the catheter is advanced. Thus, the physician can cause the distal end of the catheter to move up or down, depending on the direction of the twist. 
     Turning now to the introducer, a detailed description of an entire apparatus should not be necessary for those skilled in the art of percutaneous procedures and the design of instruments intended for such use. The method of the invention can also be carried out with endoscopic instruments, and an endoscopic apparatus having structural parts that meet the descriptions set forth in this specification would also be an apparatus of the invention. 
     In general, a device of the invention can be prepared in a number of different forms and can consist (for example) of a single instrument with multiple internal parts or a series of instruments that can be replaceably and sequentially inserted into a hollow fixed instrument (such as a needle) thai guides the operational instruments to a selected location, such as, for example, an annular fissure, in or adjacent to an intervertebral disc. Because prior patents do not fully agree on how to describe parts of percutaneous instruments, terminology with the widest common usage will be used. 
     The introducer, in its simplest form, can consist of a hollow needle-like device (optionally fitted with an internal removable obturator or trocar to prevent clogging during initial insertion) or a combination of a simple exterior cannula that fits around a trocar. The result is essentially the same: placement of a hollow tube (the needle or exterior cannula after removal of the obturator or trocar, respectively) through skin and tissue to provide access into the annulus fibrosus. The hollow introducer acts as a guide for introducing instrumentation. More complex variations exist in percutaneous instruments designed for other parts of the body and can be applied to design of instruments intended for disc operations. Examples of such obturators are well known in the art. A particularly preferred introducer is a 17- or 18-gauge, thin-wall needle with a matched obturator, which alter insertion is replaced with a catheter of the present invention. 
     Referring now to the figures,  FIGS. 3(   a ) and  3 ( b ) illustrate one embodiment of a catheter  14  of the invention as it would appear inserted into an introducer  12 . The apparatus shown is not to scale, as an exemplary apparatus (as will be clear from the device dimensions below) would be relatively longer and thinner; the proportions used in  FIG. 3(   a ) were selected for easier viewing by the reader. The distal portion of an intervertebral apparatus operates inside an introducer  12  having an internal introducer lumen  13 . A flexible, movable catheter  14  is at least partially positionable in the introducer lumen  13 . Catheter  14  includes a distal end section  16  referred to as the intradiscal section, which is designed to be the portion of the catheter that will be pushed out of the introducer lumen and into the nucleus pulposus, where movement of the catheter will be controlled to bring operational portions of the catheter into the selected location(s) within the disc, such as, for example, the annular tear. In  FIG. 3(   a ), clashed lines are used to illustrate bending of the intradiscal portion of the catheter as it might appear under use, as discussed in detail later in the specification.  FIG. 3(   b ) shows an end view of handle  11  at the proximal end of the catheter, with the handle  11  having an oval shape to indicate the plane of bending, also discussed in detail later in the specification. Other sections and properties of catheter  14  are described later. 
     For one embodiment suitable for intervertebral discs, the outer diameter of catheter  14  is in the range of 0.2 to 5 mm, the total length of catheter  14  (including the portion inside the introducer) is in the range of 10 to 60 cm, and the length of introducer  12  is in the range of 5 to 50 cm. For one preferred embodiment, the catheter has a diameter of 1 mm, an overall length of 30 cm, and an introduced length of 15 cm (for the intradiscal section). With an instrument of this size, a physician can insert the catheter for a distance sufficient to reach selected location(s) in the nucleus of a human intervertebral disc. 
       FIG. 4  illustrates the anatomy of an intervertebral disc and shows an apparatus of the invention inserted into a disc. Structures of the disc are identified and described by these anatomical designations: the posterior lateral inner annulus  136 , posterior medial inner annulus  138 , annulus fibrosus  122 /nucleus pulposus  120  interface, the annulus/dural interface  146 , annulus/posterior longitudinal ligament interface  148 , anterior lateral inner annulus  150 , and the anterior medial inner annulus  152 . 
     Referring again to  FIG. 4 , the mechanical characteristics of intradiscal section  16  of catheter  14  are selected to have (1) sufficient column strength along the longitudinal axis of the catheter to avoid collapse of the catheter and (2) different flexural strengths along the two axes orthogonal to the longitudinal axis to allow controlled bending of the catheter. These parameters make the catheter conformable and guidable along inner wall  22  of an annulus fibrosus  122  to reach selected location(s), such as the posterior medial annulus  138 . 
     Specific mechanical characteristics of particular designs will be described later in the examples that follow. Generally, however, the necessary design features can be selected (in an interrelated fashion) by first providing the intradiscal section of the catheter with sufficient column strength to be advanceable through normal human nucleus pulposus and around the inner wall of the annulus fibrosus without collapse. Here “collapse” refers to bending sufficient to inhibit further advancement at the tip. Advancement of the tip is restricted by 1) sliding through the normal gelatinous nucleus pulposus, 2) contacting denser clumps of nucleus pulposus and 3) curving and advancing along the inner wall of the annulus. Column strength can be increased in many ways known in the art, including but not limited to selecting materials (e.g., metal alloy or plastic) with a high resistance to bending from which to form the catheter, forming the structure of the catheter with elements that add stiffening (such as bracing), and increasing the thickness of the structural materials. Column strength can be decreased to favor bending by selecting the opposite characteristics (e.g., soft alloys, hinging, and thin structural elements). 
     When the catheter collapses, the physician feels an abrupt decrease in resistance. At that time, the catheter forms one or more loops or kinks between the tip of the introducer and the distal tip of the catheter. 
     Particularly preferred for locations, such as, for example, annular tears, at the posterior of the annulus, the tip  28  of intradiscal section  16  is biased or otherwise manufactured so that it forms a pre-bent segment prior to contact with the annulus fibrosus as shown in  FIG. 3(   a ). The bent tip will cause the intradiscal section to tend to continue to bend the catheter in the same direction as the catheter is advanced. This enhanced curving of a pre-bent catheter is preferred for a catheter that is designed to reach a posterior region of the nucleus pulposus; however, such a catheter must have sufficient column strength to prevent the catheter from collapsing back on itself. 
     The intradiscal section not only must allow bending around the relatively stronger annulus fibrosus in one direction, but also resist bending in the orthogonal direction to the plane in which bending is designed to occur. By twisting the proximal end of a catheter and thus controlling the orientation of the plane of bending while concurrently controlling the advancement of the catheter through the nucleus, a physician can navigate the catheter and its instrumentation within the disc. 
     The bending stiffness of the intradiscal section as measured in Taber stiffness units (using a length of the inventive catheter as the test strip rather than the standard dimension, homogeneous-material test strip) should be in the range of 2-400 units (in a 0-10,000 unit range) in the desired bending plane, preferably 3-150 units. In preferred embodiments, stiffness is in the range of 4-30 units in the desired bending plane. In all cases, the bending stiffness preferably is 2-20 times higher for bending in the orthogonal direction. 
     The column or compressive strength of the intradiscal section (force required to buckle a segment whose length is 25 or more times its diameter) is in the range of 0.05 to 4 kg, preferably 0.05 to 2 kg. In the most preferred embodiments, it is in the range of 0.1 to 1 kg. In the proximal shall section (i.e., the part of the catheter proximal to the intradiscal section), this strength is in the range of 0.1 to 25 kg, preferably 0.2 to 7 kg. In the most preferred embodiments, it is in the range of 0.7 to 4 kg. 
     Returning now to  FIG. 4 , intradiscal section  16  is guidable and can reach the posterior, the posterior lateral, and the posterior medial regions of the posterior wall of the annulus fibrosus, as well as other selected section(s) on or adjacent to inner wall  22 . In order to move the functional section of the catheter into a desired nucleus location, intradiscal section  16  is first positioned in the nucleus pulposus  120  by means of the introducer. 
     In most uses, introducer  12  pierces annulus fibrosus  122  and is advanced through the wall of the annulus fibrosus into the nucleus pulposus. In such embodiments, introducer  12  is then extended a desired distance into nucleus pulposus  120 . Catheter  14  is advanced through a distal end of introducer  12  into nucleus pulposus  120 . Advancement of the catheter  14 , combined with increased resistance to advancement at the annulus fibrosus, causes the tip of the intradiscal section to bend relative to the longitudinal axis of introducer  12  when the intradiscal section contacts the inner wall of the annulus fibrosus  122 . Catheter  14  is navigated along inner wall  22  of annulus fibrosus  122  to selected site(s) of inner wall  22  or within nucleus pulposus,  120 . For example, intradiscal section  16  can be positioned in or adjacent to a fissure or tear  44  of annulus fibrosus  122 . 
     The distal portion  28  of intradiscal section  16  is designed to be incapable of piercing the annulus fibrosus  122 . The inability of distal portion  28  to pierce the annulus can be the result of either shape of the tip  29  or flexibility of distal portion  28 , or both. The tip  29  is considered sufficiently blunt when it does not penetrate the annulus fibrosus but is deflected back into the nucleus pulposus or to the side around the inner wall of the annulus when the tip  29  is advanced. The tip can be made with a freely rotating ball. This embodiment provides not only a blunt surface but also a rolling contact to facilitate navigation. 
     Many percutaneous and endoscopic instruments designed for other purposes can be adapted for use in this invention. This permits other functions at the desired location after the catheter is advanced to that position. For example, cutting edges and sharp points can be present in the distal portion  28  if they can be temporarily masked by a covering element. However, such devices must be sufficiently flexible and thin to meet the design characteristics described in this specification. 
     In another embodiment an introducer  12  pierces the skin and reaches an exterior of annulus fibrosus  122 . A rigid and sharp trocar is then advanced through introducer  12 , to pierce annulus fibrosus  122  and enter the disc. The trocar is then removed and catheter  14  is advanced through a distal end of introducer  12 , following the path created by the trocar in annulus fibrosus  122  beyond the end of the introducer. In such cases, the introducer is outside the annulus fibrosus  122  and only the catheter with its guidable distal portion  16  is present inside the disc. The physician can manipulate the proximal portion  15  of the catheter to move the distal portion of the catheter to a selected location for diagnosing or treating the nucleus pulposus  120  or the inner wall  22  of the annulus fibrosus  122 , such as, for example, a fissure of the annulus fibrosus  122 . 
     Catheter  14  is not always pre-bent as shown in  FIG. 3(   a ), but optionally can include a biased distal portion  28  if desired. “Pre-bent” or “biased” means that a portion of the catheter (or other structural element under discussion) is made of a spring-like material that is bent in the absence of external stress but which under selected stress conditions (for example, while the catheter is inside the introducer), is linear. Such a biased distal portion can be manufactured from either spring metal or superelastic memory material (such as Tinel® nickel-titanium alloy, Raychem Corp., Menlo Park Calif.). The introducer (at least in the case of a spring-like material for forming the catheter) is sufficiently strong to resist the bending action of the bent tip and maintain the biased distal portion in alignment as it passes through the introducer. Compared to unbiased catheters, a catheter with a biased distal portion  28  encourages advancement of intradiscal section  16  substantially in the direction of the bend relative to other lateral directions as shown by the bent location of intradiscal section  16  indicated by dashed lines in  FIG. 3(   a ). That is, biased distal portion  28  permits advancement of intradiscal section  16  substantially in only one lateral direction relative to the longitudinal axis of introducer  12 . More generally, embodiments of the intradiscal section may resist bending in at least one direction. Biasing the catheter tip also further decreases likelihood that the tip  29  will be forced through the annulus fibrosus under the pressure used to advance the catheter. 
     In addition to biasing a catheter tip prior to insertion into an introducer, a catheter tip can be provided that is deflected by mechanical means, such as a wire attached to one side of the tip that deflects the tip in the desired direction upon application of force to the proximal end of the deflection wire. Any device in which bending of the tip of a catheter of the invention is controlled by the physician is “actively steerable.” In addition to a tip that is actively steerable by action of a wire, other methods of providing a bending force at the tip can be used, such as hydraulic pressure and electromagnetic force (such as heating a shaped memory alloy to cause it to contract). Any of a number of techniques can be used to provide selective bending of the catheter in one lateral direction. 
     Referring now to  FIG. 5(   a ), a guiding mandrel  32  can be included both to add rigidity to the catheter and to inhibit movement of catheter  14  in the inferior and superior directions while positioned and aligned in the disc plane of a nucleus pulposus  120 . This aids the functions of preventing undesired contact with a vertebra and facilitating navigation. The mandrel can be flattened to encourage bending in a plane (the “plane of the bend”) orthogonal to the “flat” side of the mandrel. “Flat” here is a relative term, as the mandrel can have a D-shaped cross-section, or even an oval or other cross-sectional shape without a planar face on any part of the structure. Regardless of the exact configuration, bending will preferentially occur in the plane formed, by the principal longitudinal axis of the mandrel and a line connecting the opposite sides of the shortest cross-sectional dimension of the mandrel (the “thin” dimension). To provide sufficient resistance to the catheter bending out of the desired plane while encouraging bending in the desired plane, the minimum ratio is 1.25:1 (“thickest” to “thinnest” cross-sectional dimensions along at least a portion of the intradiscal section). The maximum ratio is 20:1, with the preferred ratio being between 1.5:1 and 16:3, more preferably between 2:1 and 3.5:1. These ratios are for a solid mandrel and apply to any material, as deflection under stress for uniform solids is inversely proportional to the thickness of the solid in the direction (dimension) in which bending is taking place. For other types of mandrels (e.g., hollow or non-uniform materials), selection of dimensions and/or materials that provide the same relative bending motions under stress are preferred. 
     A catheter of the present invention is designed with sufficient torsional strength (resistance to twisting) to prevent undesired directional movement of the catheter. Mandrels formed from materials having tensile strengths in the range set forth in the examples of this specification provide a portion of the desired torsional strength. Other materials can be substituted so long as they provide the operational functions described in the examples and desired operating parameters. 
     While the mandrel can provide a significant portion of the column strength, selective flexibility, and torsional strength of a catheter, other structural elements of the catheter also contribute to these characteristics. Accordingly, it must be kept in mind that it is the characteristics of the overall catheter that determine suitability of a particular catheter for use in the methods of the invention. For example, a mandrel that does not have sufficient torsional strength when acting alone can be combined with another element, such as anti-twisting outer sheath  40  or inserting/advancing a second mandrel, to provide a catheter of the invention. Similarly, components inside the catheter, such as a heating element or potting compound, can be used to strengthen the catheter or provide directional flexibility at the locations of these elements along the catheter. 
     It is not necessary that the guiding mandrel  32  be flattened along its entire length. Different mandrels can be designed for different sized discs, both because of variations in disc sizes from individual to individual and because of variations in size from disc to disc in one patient. The bendable portion of the mandrel is preferably sufficient to allow intradiscal portion  16  of the catheter to navigate at least partially around the circumference of the inner wall of the annulus fibrosus (so that the operational functions of the catheter can be carried out at desired location(s) along the inner wall of the annulus fibrosus). Shorter bendable sections are acceptable for specialized instruments. In most cases, a flattened distal portion of the mandrel of at least 10 mm, preferably 25 mm, is satisfactory. The flattened portion can extend as much as the entire length of the mandrel, with some embodiments being flattened for less than 15 cm, in other cases for less than 10 cm, of the distal end of the guide mandrel. 
     In preferred embodiments the guide mandrel or other differential bending control element is maintained in a readily determinable orientation by a control element located at the proximal end of the catheter. The orientation of the direction of bending and its amount can be readily observed and controlled by the physician. One possible control clement is simply a portion of the mandrel that extends out of the proximal end of the introducer and can be grasped by the physician, with a shape being provided that enables the physician to determine the orientation of the distal portion by orientation of the portion in the hand. For example, a flattened shape can be provided that mimics the shape at the distal end (optionally made larger to allow better control in the gloved hand of the physician, as in the handle  11  of  FIG. 3(   b )). More complex proximal control elements capable of grasping the proximal end of the mandrel or other bending control element can be used if desired, including but not limited to electronic mechanical, and hydraulic controls for actuation by the physician. 
     The guide mandrel can also provide the function of differential flexibility by varying the thickness in one or more dimensions (for example, the “thin” dimension, the “thick” dimension, or both) along the length of the mandrel. A guide mandrel that tapers (becomes gradually thinner) toward the distal tip of the mandrel will be more flexible and easier to bend at the tip than it is at other locations along the mandrel. A guide mandrel that has a thicker or more rounded tip than more proximal portions of the mandrel will resist bending at the tip but aid bending at more proximal locations. Thickening (or thinning) can also occur in other locations along the mandrel. Control of the direction of bending can be accomplished by making the mandrel more round, i.e., closer to having 1:1 diameter ratios; Hatter in different sections of the mandrel; or by varying the absolute dimensions (increasing or decreasing the diameter). Such control over flexibility allows instruments to be designed that minimize bending in some desired locations (such as the location of connector of an electrical element to avoid disruption of the connection) while encouraging bending in other locations (e.g., between sensitive functional elements). In this manner, a catheter that is uniformly flexible along its entire length, is variably flexibility along its entire length, or has alternating more flexible and less flexible segment(s), is readily obtained simply by manufacturing the guide mandrel with appropriate thickness at different distances and in different orientations along the length of the mandrel. Such a catheter will have two or more different radii of curvature in different segments of the catheter under the same bending force. 
     In some preferred embodiments, the most distal 3 to 40 mm of a guide mandrel is thinner relative to central portions of the intradiscal section to provide greater flexibility, with the proximal 10 to 40 mm of the intradiscal section being thicker and less flexible to add column strength and facilitate navigation. 
     The actual dimensions of the guide mandrel will vary with the stiffness and tensile strength of the material used to form the mandrel. In most cases the mandrel will be Conned from a metal (elemental or an alloy) or plastic that will be selected so that the resulting catheter will have characteristics of stiffness and bending that fall within the stated limits. Additional examples of ways to vary the stiffness and tensile strength include transverse breaks in a material, advance of the material so that it “doubles up,” additional layers of the same or different material, tensioning or relaxing tension on the catheter, and applying electricity to a memory metal. 
     As illustrated in  FIG. 5(   b ), in some embodiments of an apparatus of the invention, guiding mandrel is combined with at least a portion of the catheter  14  to form a structure which provides the functions of both, a wall/mandrel  41 . In this figure, the wall/mandrel  41  of catheter  14  can be varied in dimensions as described in the previous section of this specification directed to a separate mandrel, with the same resulting changes in function. For example, changing the thickness of the wall/mandrel  41  that functions as the mandrel portion change, the flexibility and preferred direction of bending of the catheter. In many cases, the wall/mandrel  41  will be thinner than other portions of the catheter wall  33  so that wall/mandrel  41  controls bending. Alternatively, wall/mandrel  41  can be formed of a different material than the other portions  33  of the catheter walls (i.e., one with a lower tensile and/or flexural strength) in order to facilitate bending. 
     Returning now to  FIG. 5(   a ), the guiding mandrel  32  is generally located in the interior of catheter  14 , where it shares space with other functional elements of the catheter. For example and as shown in  FIG. 5(   a ), thermal energy delivery device lumen  34  can receive any of a variety of different couplings from an energy source  20  to a thermal energy delivery device (functional element) further along the catheter, including but not limited to a wire or other connector between thermal energy elements. Alternatively or concurrently, hollow lumen(s)  36  for delivery and/or removal of a fluid or solid connectors for application of a force to a mechanical element can be present, so no limitation should be placed on the types of energy, force, or material transporting elements present in the catheter. These are merely some of the possible alternative functional elements that can be included in the intradiscal portion of the catheter. Accordingly, a general description will now be given of some of the possible functional elements. 
     To facilitate a catheter in performing some function on disc or nearby tissue, such as, for example, applying electromagnetic energy to controllably heat disc tissue at selected location(s) inside the disc, or repairing tears or fissures in a disc by operation of the instrument at the tear location adjacent to or inside the disc, a functional element is provided in or on the catheter. 
     Non-limiting examples of functional elements include any element capable of aiding diagnosis, delivering energy, or delivering or removing a material from a location adjacent the element&#39;s location in the catheter, such as an opening in the catheter for delivery of a fluid (e.g., dissolved collagen to seal the fissure) or for suction, a thermal energy delivery device (heat source), a mechanical grasping tool for removing or depositing a solid, a cutting tool (which includes all similar operations, such as puncturing), a sensor for measurement of a function (such as electrical resistance, temperature, or mechanical strength), or a functional clement having a combination of these functions. 
     The functional clement can be at varied locations in the intradiscal portion of the catheter, depending on its intended use. Multiple functional elements can be present such as multiple functional elements of different types (e.g., a heat source and a temperature sensor) or multiple functional elements of the same type (e.g., multiple heat sources, such as RF elements, spaced along the intradiscal portion). 
     One of the possible functional elements present on intradiscal section  16  is a thermal energy delivery device  18 . A variety of different types of thermal energy can be delivered including but not limited to resistive heat, radiofrequency (RF), coherent and incoherent light, microwave, ultrasound and liquid thermal jet energies. In one embodiment, thermal energy delivery device  18  is positioned proximal to the distal portion of intradiscal section  16  so that there is no substantial delivery of energy at the distal portion, which can then perform other functions without being constrained by being required to provide energy (or resist the resulting heat). 
     Some embodiments have an interior infusion lumen  36 . Infusion lumen  36  is configured to transport a variety of different media including but not limited to electrolytic solutions (such as normal saline), contrast media (such as Conray meglumine iothalamate), pharmaceutical agents, disinfectants, filling or binding materials such as collagens or cements, chemonucleolytic agents and the like, from a reservoir exterior to the patient to a desired location within the interior of a disc (i.e., the fissure). Further, infusion lumen  36  can be used as an aspiration lumen to remove nucleus material or excess liquid or gas (naturally present, present as the result of a liquefying operation, or present because of prior introduction) from the interior of a disc. When used to transport a fluid for irrigation of the location within the disc where some action is taking place (such as ablation, which generates waste materials), the infusion lumen is sometimes referred to as an irrigation lumen. Infusion lumen  36  can be coupled to medium reservoir  21  through the catheter (see  FIG. 3(   a )). 
     Included in the particular embodiment shown in  FIG. 5(   a ) is one or more sensor lumens  42 . An example is a wire connecting a thermal sensor at a distal portion of the catheter to control elements attached to a connector in the proximal handle  11  of the catheter. 
     Also included in the embodiment shown in  FIG. 5(   a ) is an optional energy directing device  43  including but not limited to a thermal reflector, an optical reflector, thermal insulator, or electrical insulator. Energy directing device  43  is configured to limit thermal and/or electromagnetic energy delivery to a selected site of the disc and to leave other sections of the disc substantially unaffected. Energy directing device  43  can be positioned on an exterior surface of catheter intradiscal section  16  and/or catheter  14  as well as in an internal portion of the catheter intradiscal section  16  and/or catheter  14 . For example, the energy can be directed to the walls of the fissure to cauterize granulation tissue and to shrink the collagen component of the annulus, while the nucleus is shielded from excess heat. 
     In one embodiment, catheter intradiscal section  16  and/or distal portion  28  are positionable to selected site(s) around and/or adjacent to inner wall  22  of annulus fibrosus  122  for the delivery of therapeutic and/or diagnostic agents including but not limited to, electromagnetic energy, electrolytic solutions, contrast media, pharmaceutical agents, disinfectants, collagens, cements, chemonucleolytic agents and thermal energy. Intradiscal section  16  is navigational and can reach the posterior, the posterior lateral, the posterior medial, anterior lateral, and anterior medial regions of the annulus fibrosus, as well as selected section(s) on or adjacent to inner wall  22 . 
     In a preferred embodiment, intradiscal section  16  is positioned adjacent to the entire posterior wall of the disc. Sufficient thermal energy can then be delivered, for example, to selectively heat the posterior annulus to cauterize granulation tissue and shrink the collagen component of the wail around and adjacent to fissure  44  without undue damage to other portions of the intervertebral disc, particularly the nucleus. These actions help close the fissure in the annulus. 
     In the preferred embodiment of  FIG. 5(   a ), markings  38  are visible on the portion of the catheter that is located during normal operation outside the body being acted upon, particularly for embodiments in which the proximal end of the catheter is designed to be directly manipulated by the hand of the physician. Advancement of the catheter into the introducer will advance the markings into the introducer thereby showing how far the catheter has been advanced into the nucleus. Such a visible marking  38  can be positioned on an exterior surface of the catheter or can be present on an interior surface and visible through a transparent outer covering or sheath. Preferred are visible markings every centimeter to aid the physician in estimating the catheter tip advancement. 
     If desired, visible markings can also be used to show twisting motions of the catheter to indicate the orientation of the bending plane of the distal portion of the catheter. It is preferred, however, to indicate the distal bending plane by the shape and feel of the proximal end of the catheter assembly. The catheter can be attached to or shaped into a handle  11  that fits the hand of the physician and also indicates the orientation of the distal bending plane. Both the markings and the handle shape thus act as control elements to provide control over the orientation of the bending plane; other control elements, such as plungers or buttons that act on mechanical, hydrostatic, electrical, or other types of controls, can be present in more complex embodiments of the invention. 
     Additionally, a radiographically opaque marking device can be included in the distal portion of the catheter (such as in the tip or at spaced locations throughout the intradiscal portion) so that advancement and positioning of the intradiscal section can be directly observed by radiographic imaging. Such radiographically opaque markings are preferred when the intradiscal section is not clearly visible by radiographic imaging, such as when the majority of the catheter is made of plastic instead of metal. A radiographically opaque marking can be any of the known (or newly discovered) materials or devices with significant opacity. Examples include but are not limited to a steel mandrel sufficiently thick to be visible on fluoroscopy, a tantalum/polyurethane tip, a gold-plated tip, bands of platinum, stainless steel or gold, soldered spots of gold and polymeric materials with radiographically opaque filler such as barium sulfate. A resistive heating element or an RF electrode(s) may provide sufficient radio-opacity in some embodiments to serve as a marking device. 
     A sheath  40  can optionally be positioned around catheter  14 . Sheath  40  provides a flexible surface that is smooth and provides for easy introduction into a selected area within the disc. Sheath  40  can be made of a variety of different materials including but not limited to polyester, rayon, polyimide, polyurethane, polyethylene, polyamide and silicone. When visible markings are present to indicate the advancement of the catheter, either the sheath carries the markings, or the sheath is clear to reveal markings underneath. 
     In one preferred embodiment, thermal energy delivery device  18  is a resistive heating device. As illustrated in  FIG. 6  a heating coil  46  is positioned around an exterior of catheter  14 . The heating element  46  need not be in the shape of a coil. For instance, the healing element can be in the form of a thin flexible circuit which is mountable on or in substantially one side of the intradiscal portion of the catheter. Heating element  46  is powered by a direct current source  20  (and less preferably a source of alternating current). Heating element is made of a material that acts as a resistor. Suitable materials include but are not limited to stainless steel, nickel/chrome alloys, platinum, and the like. 
     Preferably, the heating element is inside the intradiscal section of catheter  14  ( FIG. 8 ). The resistive material is electrically insulated and substantially no current escapes into the body. With increasing levels of current, element  46  heats to greater temperature levels. Additionally, a circuit can be completed substantially entirely at intradiscal section  16  and a controllable delivery of thermal energy is achieved. In one embodiment, 2 watts pass through heating element  46  to produce a temperature of about 55° C. in a selected target such as fissure  44 , 3 watts produces 65° C., 4 watts produces 75° C. and so on. 
     In another embodiment, thermal energy delivery device  18  is a radiofrequency electrode, such as a band or coil. As illustrated in  FIG. 6 , RF electrode  46  is positioned on an exterior of catheter  14 . RF electrode  46  is powered by an RF generator. The electrode is made of suitable materials including but not limited to stainless steel or platinum. The RF electrode is located on intradiscal section of catheter  14 . Increasing levels of current conducted into disc tissue heat that tissue to greater temperature levels. A circuit can be completed substantially entirely at intradiscal section  16  (bipolar device) or by use of a second electrode attached to another portion of the patient&#39;s body (monopolar device). In either case, a controllable delivery of RF energy is achieved. 
     In another embodiment sufficient energy is delivered to the intervertebral disc to heat and shrink the collagen component of the annulus but not ablate tissue adjacent to catheter  14 . 
     With a resistive heating device, the amount of thermal energy delivered to the tissue is a function of (i) the amount of current passing through heating element  46 , (ii) the length, shape, and/or size of healing element  46 , (iii) the resistive properties of heating element  46 , (iv) the gauge of heating element  46 , and (v) the use of cooling fluid to control temperature. All of these factors can be varied individually or in combination to provide the desired level of heat. Power supply  20  associated with heating element  46  may he battery based. Catheter  14  can be sterilized and may be disposable. 
     Referring now to  FIG. 7 , a thermal sensor  48  may be positioned in an interior location of catheter  14 . In another embodiment, thermal sensor  48  is positioned on an exterior surface of catheter  14 . A thermal sensor can be used to control the delivery of energy to thermal energy delivery device  18 . A potting material can be used to fix the position of thermal sensor  48  and provide a larger area from which to average the measured temperature. Thermal sensor  48  is of conventional design, including but not limited to a thermistor; T type thermocouple with a copper constant an junction; J type, E type, and K type thermocouples; fiber optics; resistive wires; IR detectors; and the like. Optionally, there may be a lumen  42  for the thermal sensor connection. 
     As illustrated in  FIG. 8 , sheath  40  may be used to cover resistive heating element  46 . A plurality of resistive heating elements  46  can be used ( FIG. 9 ) in a catheter of the invention. 
     Referring now to the embodiment shown in  FIG. 10 , thermal energy delivery device  18  comprises one or more resistive heating elements  46  coupled to a resistive heating energy source. Resistive heating elements  46  are positioned along intradiscal section  16  at locations where they controllably deliver thermal energy to selected structures, including granulation tissue in a fissure  44  and the annulus surrounding the fissure. Resistive heating elements  46  can be segmented and multiplexed so that only certain resistive heating elements, or combinations of resistive heating elements are activated at any one particular time. Thermal sensor  48  can be positioned between resistive heating elements  46  and/or at an exterior or interior location of catheter  14 . In the embodiment illustrated in  FIG. 10 , catheter  14  can be prepared with a wound helical structure element  49  to increase flexibility and minimize kinking. However, other structures and geometries are suitable for catheter  14 , including but not limited to a substantially smooth surface (and specifically including the device using an internal guide mandrel as previously described). For example, a sheath can be provided over the heating element, and the guiding mandrel inside the coil can be encapsulated in silicone potting material. The tubing flexibility and the silicone potting material prevent kinking. Additionally, sheath  40  can be positioned around catheter  14  and also around resistive heating elements  46  to afford a substantially smooth surface. Resistive heating element  46  can be at least partially covered by a thermally insulating material, for example, along one side of the catheter, to selectively heat disc tissue on the opposite side. 
     Referring now to  FIGS. 11 and 12 , an open or closed loop feedback system  52  couples sensors  48  to energy source  20 . As illustrated in  FIG. 10 , thermal energy delivery device  18  is a resistive heating element  46 . It will be appreciated that the embodiments illustrated in  FIGS. 10 and 11  are readily adaptable to other thermal energy delivery sources (e.g., for radiofrequency energy, the resistive heating clement is replaced with insulated RF probe(s) and the energy source is an RF generator). 
     The temperature of the tissue or of element  46  ( FIG. 10 ) is monitored by sensors  48 , and the output power of energy source  20  adjusted accordingly. The physician can, if desired, override control system  52 . A microprocessor can be included and incorporated in the closed or open loop system to switch power on and off, as well as to modulate the power. The closed loop system utilizes a microprocessor to serve as a controller  54  which acts to monitor the temperature and adjust the power accordingly. Alternatives to the microprocessor are, for example, analog control circuitry and a logic controller. 
     With the use of sensors  48  and feedback control system  52 , a tissue adjacent to resistive heating elements  46  can be maintained at a desired temperature for a selected period of time without aberrant high temperature fluctuations. Each resistive heating clement  46  can be connected to separate control and power supply resources, which generate an independent output for each resistive heating element  46 . For example, a desired thermal output can be achieved by maintaining a selected energy at resistive heating elements  46  for a selected length of time. 
     When a resistive heating element  46  is used, current delivered through resistive heating element  46  can be measured by current sensor  56 . Voltage can be measured by voltage sensor  58 . Resistance and power are then calculated at power calculation device  60 . These values can then be displayed at user interface and display  62 . Signals representative of power and resistance values are received by a controller  54 . 
     A control signal is generated by controller  54  that is related to the current and voltages. The control signal is used by power circuits  66  to adjust the power output in an appropriate amount in order to maintain the desired power delivered at respective resistive heating elements  46 . 
     In a similar manner, temperatures detected at sensors  48  provide feedback for maintaining a selected power. The actual temperatures are measured at temperature measurement device  68 , and the temperatures are displayed at user interface and display  62 . A control signal is generated by controller  54  that is related to the actually measured temperature and a desired temperature. The control signal is used by power circuits  66  to adjust the power output in an appropriate amount in order to maintain the desired temperature delivered at the respective sensor  48 . A multiplexer can be included to measure current, voltage, and temperature at the sensors  48 ,  56  and  58 , so that appropriate energy can be delivered to resistive heating elements  46 . 
     Controller  54  can be a digital or analog controller or a computer with software. When controller  54  is a computer, it can include a CPU coupled through a system bus. Included in this system can be a keyboard, a disc drive or other non-volatile memory system, a display, and other peripherals, as are known in the art. Also coupled to the bus can be a program memory and a data memory. 
     User interface and display  62  includes operator controls and a display. Controller  54  can be coupled to imaging systems well known in the art. 
     The output of current sensor  56  and voltage sensor  58  is used by controller  54  to maintain a selected power level at resistive heating elements  46 . A predetermined profile of power delivered can be incorporated in controller  54 , and a preset amount of energy to be delivered can also be profiled. 
     Circuitry, software, and feedback to controller  54  result in process control and in the maintenance of the selected power that is independent of changes in voltage or current. Control can include (i) the selected power and (ii) the duty cycle (wattage and on-off times). These process variables are controlled and varied while maintaining the desired delivery of power independent of changes in voltage or current, based on temperatures monitored at sensors  48 . 
     In the embodiment shown, current sensor  56  and voltage sensor  58  are connected to the input of an analog amplifier  70 . Analog amplifier  70  can be a conventional differential amplifier circuit for use with sensors  48 ,  56  and  58 . The output of analog amplifier  70  is sequentially connected by an analog multiplexer  72  to the input of A/D converter  74 . The output of analog amplifier  70  is a voltage which represents the respective sensed parameters. Digitized amplifier output voltages are supplied by A/D converter  74  to microprocessor  54 . Microprocessor  54  may be a type 68HCII available from Motorola. However, it will be appreciated that any suitable microprocessor or general purpose digital or analog computer can be used to the parameters of temperature, voltage or current. 
     Microprocessor  54  sequentially receives and stores digital representations of temperature. Each digital value received by microprocessor  54  corresponds to different parameters. 
     Calculated power and temperature values can be indicated on user interface and display  62 . Alternatively, or in addition to the numerical indication of power, calculated power values can be compared by microprocessor  54  with power limits. When the values exceed predetermined power or temperature values, a warning can be given on user interface and display  62 , and additionally, the delivery of electromagnetic energy can be reduced, modified or interrupted. A control signal from microprocessor  54  can modify the power level supplied by energy source  20 . 
     In preferred embodiment of the invention, the materials that make up the various parts of an apparatus of the invention have the following characteristics: 
     
       
         
           
               
               
               
               
               
               
               
             
               
                   
               
               
                   
                 Tensile 
                   
                   
                   
                   
                   
               
               
                   
                 Strength 
                 % 
                 Conductivity 
                 Resistivity 
                 Melt 
                 Geometry (height, 
               
               
                 Component 
                 in MPa 
                 Elongation 
                 cal/cm 2 /cm · sec° C. 
                 nΩ*m 
                 temp. ° C. 
                 width, and/or dia.) in min 
               
               
                   
               
             
            
               
                 Mandrel 
                 600-2000 
                 5-100 
                 N/A 
                 N/A 
                 N/A 
                 height 0.2-2.3 
               
               
                   
                   
                   
                   
                   
                   
                 width 0.05-0.5 
               
               
                 Heating Element 
                 300 min. 
                 20 (min.) 
                 .025-0.2 
                 500-1500* 
                 N/A 
                 .05-0.5 dia. 
               
               
                 Conductor wire 
                 N/A 
                 N/A 
                  0.2-1.0 
                 150 max.* 
                 N/A 
                 0.1-0.5 dia. 
               
               
                 Plastic sheath 
                 N/A 
                 25 (min.) 
                 N/A 
                 N/A 
                 80* 
                 0.05-0.2 thickness 
               
               
                   
                   
                   
                   
                   
                 (min.) 
               
               
                   
               
            
           
         
       
     
     Another preferred characteristic is that the minimum ratio of heating element resistivity to conductor wire resistivity is 6:1; the preferred minimum ratio of guiding mandrel height to guiding mandrel width is 2:1. Tensile strength and % elongation can be measured according to ASTME8 (tension test of metallic materials). Conductivity and resistivity can be determined by procedures to be found in ASTM Vol. 2.03 for electrothermal properties. 
     A particularly preferred embodiment of a catheter of the invention can be prepared using a covering sheath of polyimide with an outside diameter of 1 mm and a wall thickness of 0.05 mm. Such a sheath provides a significant fraction of the stiffness and torsional strength appropriate for the catheter. Internal to the polyimide sheath and in the intradiscal section of the catheter is a heating coil of insulated nickel/chromium wire that has an outside diameter that matches the interior diameter of the polyimide sheath. This heating coil provides both heat and additional stiffness to the assembly. Also internal to the polyimide sheath on each side of the coil (longitudinally) is a 0.1 mm-walled, 304 stainless-steel, metallic band whose outer diameter matches the inner diameter of the sheath, the distal band having a hemispherical end that exits the end of the polyimide sheath and creates a blunt tip  29  at the end of the catheter. These bands provide enhanced radio-opacity for fluoroscopic visualization, as well as some of the stiffness of the assembled apparatus. Proximal to the proximal metallic band and internal to the sheath is an additional polyimide tube  47  that increases the stiffness of the catheter in the region that transitions from the intradiscal section containing the coil to the rigid proximal section. Proximal to the second polyimide tube and internal to the sheath is a 304 stainless steel (fully hard) hypodermic tube with an outside diameter matching the inside diameter of the polyimide sheath and a wall thickness of 0.1 mm. This combination provides the rigidity needed for a physician to advance the distal portion of the device inside a nucleus pulposus and provides tactile force feedback from the lip to the physician. 
     In some embodiments, inside the bands, coil, hypodermic lube, and both the polyimide sheath and internal polyimide tube is a guiding mandrel that extends from a proximal handle to tip. In one embodiment, this mandrel is 0.15 mm by 0.5 mm and formed from 304 stainless steel. In another embodiment, it is a 0.3 mm diameter 304 stainless steel wire, with the distal 2.5 cm flattened to 0.2 mm by 0.5 mm. 
     Inside the center of the heating coil is a T-type thermocouple potted with cyanoacrylate adhesive into a polyimide sheath and located alongside the mandrel. The thermocouple wire travels through the coil and hypodermic tube to the handle at the proximal end of the apparatus. Two copper conductor wires (36 gauge-insulated with polyimide) are soldered to the heating coil and pass through the hypodermic tube and handle to the proximal handle&#39;s electrical connector, which allows a power supply and feedback controls to be connected to electrical elements in the catheter. One embodiment has the handle fitted with a 1-3 meter cable extension ending in an electrical connector to eliminate the need for a connector in the handle. This design reduces weight (from connector elements) on the proximal end and increases the physician&#39;s tactile feedback during device manipulation. 
     The entire inside of the catheter in one embodiment is encapsulated with a silicone material which removes air (which would insulate the heat created by the heating coil) and helps support the polyimide sheath to prevent collapse (i.e., increases stiffness). Instead of the silicone, another embodiment uses an epoxy which remains flexible after curing. Strain relief is provided between the catheter body and the handle with an elastomeric boot. The distal end of the catheter is pre-bent 15-30° off the longitudinal axis of the catheter at about 5-10 mm from the distal tip. 
     The catheter in one embodiment carries visible markings  38  on the hypodermic tube (with the markings being visible through the polyimide sheath) to indicate distance of insertion of the catheter into an introducer and/or distance that the distal end of the catheter extends out of the introducer into a disc. The catheter is also marked both visually and with tactile relief on its handle to indicate the direction of bending of the pre-bent tip and biased stiffness. 
     The guidable apparatus described herein can be used in any of a number of methods to treat annular fissures. Specific methods that can be carried out with an apparatus of the invention will now be described. 
     Discs with fissures can be treated non-destructively with or without the removal of nucleus tissue other than limited desiccation of the nucleus pulposus which reduces its water content. Fissures can also be ameliorated by shrinking the collagen component of the surrounding annulus to bring the sides closer to their normal position. Thermal shrinkage of collagen also facilitates ingrowth of collagen which increases annular stiffness. Fissures can also be repaired with sealants such as a tiller (non-adhesive material that blocks the opening) and/or bonding material (adhesives or cements) which help seal the tear. The fissure can also be treated with global heating of the disc. Most of the heat will be directed toward the fissure, but the remainder of the disc will also receive some heat. 
     In some methods of the invention, bonding materials such as collagen, albumin, and a mixture of fibrinogen and thrombin are delivered to the fissure. Collagen from a variety of sources can be used (e.g., bovine extracted collagen from Semex Medical, Frazer Pa., or human recombinant collagen from Collagen Corp., Palo Alto, Calif). The collagen is injected dissolved or as a fine slurry, after which it is gradually thickens (or may be heated) in the fissure, where the injected collagen provides a matrix for collagen disposition by the body. 
     A variety of different materials can also be delivered to the disc, such as, for example, to the fissure, including but not limited to electrolyte solutions (i.e. normal saline), contrast media (e.g., Conray meglumine iothalamate), pharmaceutical agents (such as the steroid methylprednisolone sodium succinate available from Pharmacia &amp; Upjohn. Kalamazoo, Mich., and nonsteroidal anti-inflammatory drugs), chemonucleolytic enzyme (e.g., chymopapain), hydrogel (such as disclosed in U.S. Pat. No. 4,478,822), osteoinductive substances (e.g., BMP, see U.S. Pat. No. 5,364,839), chondrocyte inductive substance (e.g., TGF-.beta.) and the like. The materials are delivered via the catheter and/or introducer to the disc. Preferably, however, when precision placement of the material (as in a fissure) is necessary or desired, the delivery method uses the apparatus described above, especially when delivery to the posterior, posterior lateral, or posterior medial region of the disc is desired. The materials may be administered simultaneously or sequentially, such as beginning with an electrolytic solution (which helps the physician view the pathology) and following with products to seal a fissure. 
     The materials are delivered in an amount sufficient to decrease the extent of the fissure at least partially, preferably to fill the fissure completely. The delivered material can be fixed in position with an adhesive, with a hydrogel that is liquid at room temperature gels at body temperature, with naturally occurring processes (such as interaction of fibrinogen and thrombin) within the disc, or by heating the disc as described in more detail below. 
     To seal a fissure, a combination of thrombin and fibrinogen is injected at the fissure, after which it coagulates and forms a seal over the fissure. A kit with appropriate syringes and other equipment is available from Micromedics, Inc., Eagan, Minn. Frozen fibrinogen solution is thawed in its plastic bag and then dispensed to a small med cup. Thrombin is reconstituted with sterile water in the “slow gel” concentration (100 units/ml) for tissue bonding. For example, 100 ml is added to a vial containing 10,000 units. Thrombin solution is withdrawn from the vial and dispensed to a second med cup. The two syringes are filled equally, one with each solution. Then the syringe tips are each twisted into an applicator that mixes the solutions before passing them to an administration tube. The syringes are fitted into the dual syringe holder and the plunger link, which helps the practitioner administer equal amounts of thrombin and fibrinogen. Then the practitioner connects the administration tube to the proximal end of the inventive catheter, depresses the plungers and dispenses the sealant solution to the fissure. The thrombin and fibrinogen react and form a natural seal over the fissure. 
     Chymopapain can be injected through the subject catheter, particularly near a herniation of the disc. Chymopapain splits side chains off proteoglycan molecules, thereby decreasing their ability to hold water and their volume. The disc gradually loses water and decreases in size. A typical dose is 0.75 to 1.0 ml (2000 pKat/ml). 
     In some embodiments, thermal energy is delivered to a selected section of the disc in an amount that does not create a destructive lesion to the disc, other than at most a change in the water content of the nucleus pulposus. In one embodiment there is no removal and/or vaporization of disc material positioned adjacent to an energy delivery device positioned in a nucleus pulposus. Sufficient thermal energy is delivered to the disc to change its biochemical and/or biomechanical properties without structural degradation of tissue. 
     Thermal energy is used to, e.g., cauterize granulation tissue which is pain sensitive and forms in a long-standing tear or fissure, and/or ablate granulation tissue. Additionally or alternatively, thermal energy is used to seal at least a part of the fissure. To do that, the disc material adjacent to the fissure is typically heated to a temperature in the range of 45-70° C. which is sufficient to shrink and weld collagen. In one method, tissue is heated to a temperature of at least 50° C. for times of approximately one, two, three minutes, or longer, as needed to shrink the tissue back into place. 
     Delivery of thermal energy to the nucleus pulposus removes some water and permits the nucleus pulposus to shrink. This reduces a “pushing out” effect that may have contributed to the fissure. Reducing the pressure in the disc and repairing the fissure may help stabilize the spine and reduce pain. 
     Global heating of the disc also can be used to cauterize the granulation tissue and seal the fissure. In this embodiment of the method, the heating element is positioned away from the annulus but energy radiates to the annulus to raise the temperature of the tissue around the fissure. This global heating method can help seal a large area or multiple fissures simultaneously. 
     All publications and patent applications mentioned in this specification are herein incorporated by reference to the same extent as if each individual publication or patent application was specifically and individually indicated to be incorporated by reference. 
     The foregoing description of preferred embodiments of the invention has been presented for purposes of illustration and description. It is not intended to be exhaustive or to limit the invention to the precise forms disclosed. Many modifications and variations will be apparent to practitioners skilled in this art. It is intended that the scope of the invention be defined by the following claims and their equivalents. 
     A number of embodiments have been described. Nevertheless, it will be understood that various modifications may be made. Accordingly, other embodiments are within the scope of the following claims.