Patent Publication Number: US-2022218417-A1

Title: Surgical system and method

Description:
TECHNICAL FIELD 
     The present disclosure generally relates to medical devices for the treatment of spinal disorders, and more particularly to a surgical system and a method for correction of a spinal disorder. 
     BACKGROUND 
     Spinal disorders such as degenerative disc disease, disc herniation, osteoporosis, spondylolisthesis, stenosis, scoliosis, kyphosis, and other curvature abnormalities, tumor, and fracture may result from factors including trauma, disease and degenerative conditions caused by injury and aging. Spinal disorders typically result in symptoms including pain, nerve damage, and partial or complete loss of mobility. 
     Non-surgical treatments, such as medication, rehabilitation and exercise can be effective, however, may fail to relieve the symptoms associated with these disorders. Surgical treatment of these spinal disorders includes correction, ligamentotaxy, corpectomy, discectomy, laminectomy, fusion, fixation and implantable prosthetics. Correction treatments used for positioning and alignment of vertebrae may employ spinal implants including spinal constructs and interbody devices for stabilization of a treated section of a spine. In some cases, the spinal implants may be manipulated with surgical instruments for compression and distraction of vertebrae. This disclosure describes an improvement over these prior technologies. 
     SUMMARY 
     In one embodiment, a method for treating a spine is disclosed. The method comprises the steps of: imaging a patient anatomy for registration of anatomical image data and positional tracking of the patient anatomy; selecting an implant strategy for at least one bone fastener; selecting a manipulation strategy for the patient anatomy; determining a post-correction orientation of the patient anatomy according to the implant strategy and the manipulation strategy; imaging the post-correction orientation of the patient anatomy; engaging the at least one bone fastener with vertebral tissue of the patient anatomy according to the implant strategy; and connecting a first implant support to the at least one bone fastener, the first implant support including an adaptor that is movable relative to the first implant support to releasably engage a surgical instrument to distract and/or compress the vertebral tissue according to the manipulation strategy. In some embodiments, surgical systems, instruments, constructs and implants are disclosed. 
     In one embodiment, the method for treating a spine comprises the steps of: attaching a reference marker to the patient anatomy; imaging a patient anatomy for registration of anatomical image data and positional tracking of the patient anatomy; selecting an implant strategy for at least one bone fastener; selecting a manipulation strategy for the patient anatomy; determining a post-correction orientation of the patient anatomy according to the implant strategy and the manipulation strategy; imaging the post-correction orientation of the patient anatomy; connecting the at least one bone fastener with a surgical driver having a navigation component and engaging the at least one bone fastener with vertebral tissue of the patient anatomy according to the implant strategy; injecting cement through the at least one bone fastener into a vertebra of the patient anatomy; connecting a first implant support to the at least one bone fastener, the first implant support including an adaptor that is movable relative to the first implant support to releasably engage a surgical instrument to distract and/or compress the vertebral tissue according to the manipulation strategy; and comparing an actual correction orientation of the patient anatomy according to the manipulation strategy with the determined post-correction orientation. 
     In one embodiment, a surgical system is provided. The surgical system comprises at least one implant support includes a first implant support that is engageable with a receiver of a first fastener having a shaft fixed with vertebral tissue. The receiver includes at least one tab extender. The shaft includes a proximal portion and a closed distal tip. The shaft further includes an outer surface engageable with a first cortical surface and a second cortical surface. The proximal portion includes an inner surface that defines a longitudinal cavity and at least one fenestration in communication therewith. The first implant support includes a connector releasably engageable with the at least one tab extender. The first implant support further includes an adaptor. At least a portion of the adaptor is movable relative to the first implant support to releasably engage a surgical instrument to distract and/or compress the vertebral tissue. An image guide is oriented relative to a sensor for registration of anatomical image data and positional tracking of the patient anatomy. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The present disclosure will become more readily apparent from the specific description accompanied by the following drawings, in which: 
         FIG. 1  is a perspective view of components of one embodiment of a surgical system in accordance with the principles of the present disclosure disposed with vertebrae; 
         FIG. 2  is a perspective view of components of one embodiment of a surgical system in accordance with the principles of the present disclosure disposed with vertebrae; 
         FIG. 3  is a perspective view of components, disposed with vertebrae, of one embodiment of a surgical system in accordance with the principles of the present disclosure; 
         FIGS. 4 and 5  are flow diagrams illustrating representative steps of embodiments of a method and a surgical system in accordance with the principles of the present disclosure; 
         FIG. 6  is a perspective view of components of one embodiment of a surgical system in accordance with the principles of the present disclosure disposed with vertebrae; 
         FIG. 7  is a plan view of one embodiment of an implant strategy in accordance with the principles of the present disclosure; 
         FIGS. 8 and 9  are graphical representations of a computer showing components of one embodiment of a spinal implant system in accordance with the principles of the present disclosure; 
         FIG. 10  is a perspective view of one embodiment of a manipulation strategy in accordance with the principles of the present disclosure; 
         FIG. 11  is a side view of one embodiment of a manipulation strategy in accordance with the principles of the present disclosure; and 
         FIG. 12  is a side view of one embodiment of a manipulation strategy in accordance with the principles of the present disclosure. 
     
    
    
     DETAILED DESCRIPTION 
     The exemplary embodiments of the system and related methods of use disclosed are discussed in terms of medical devices for the treatment of musculoskeletal disorders and more particularly, in terms of a surgical system and method for correction of a spine disorder. In some embodiments, the present surgical system includes one or more surgical instruments that allow vertebral manipulation to treat spinal disorders, as described herein, for managing lordosis and/or kyphosis restoration. In some embodiments, the present surgical system includes one or more surgical instruments that allow for parallel distraction and/or compression of vertebral tissue. 
     In some embodiments, the present surgical system can be employed with fracture reduction. In some embodiments, the present surgical system includes a fracture reduction system that employs surgical navigation and instrumentation to provide measurement capability. In some embodiments, the instrumentation includes fenestrated bone screws, for example, cement-augmented screws. In some embodiments, the fracture reduction system allows restoration of an angle during ligamentotaxy at a level of an implant, such as, for example, a head of a screw disposed at a surgical site to facilitate a more precise reduction of the trauma. 
     In some embodiments, the fracture reduction system facilitates burst fracture reduction and/or deformity correction procedures. In some embodiment, to treat burst fractures, the fracture reduction system utilizes fenestrated bone screws including a sagittal adjusting screw (SAS), a fixed angle screw (FAS) and/or a multi-axial screw (MAS) for treating tumor, trauma and/or deformity disorders with instrumentation. 
     In some embodiments, the present surgical system includes a cement delivery system for fenestrated screws before and after a selected manipulation strategy including a procedure for correction. In some embodiments, the present surgical system includes a multi-level percutaneous fixation system and other features such as integrated extensions, and a low profile configuration. In some embodiments, the present surgical system includes a cement delivery system that delivers cement and/or other materials to one or more fenestrated screws to achieve various desired characteristics such as strength, rigidity, elasticity, compliance, biomechanical performance, durability and radiolucency or imaging preference on the implanted screws. In some embodiments, the present surgical system includes measurement capability that allows measurement and calculation of screw positions, relative correction and/or geometric parameters associated with the implanted screws. In some embodiments, the measurement capability is enabled by a computer through navigation software to quantify ligamentotaxy or kyphosis correction. In some embodiments, the present surgical system includes measurement capability that facilitates navigation of screws during a surgical procedure, which minimizes the exposure to radiation or other radioactive scanning devices. 
     In some embodiments, the present surgical system can be employed with a fracture reduction method including the steps of attaching a navigation reference marker with a patient anatomy, imaging the patient anatomy for registration of anatomical image data and positional tracking of the patient anatomy, implanting screws with driver that has a navigation component attached, imaging screws and vertebrae with a driver having a navigation component such that the navigation system projects and/or reproduces an image of the implant disposed with vertebrae on a computer screen. The image may include pre and post-correction orientation of the patient anatomy. In some embodiments, the method further includes the steps of selecting an implant strategy for at least one bone fastener; selecting a manipulation strategy for the patient anatomy prior or post the correction of vertebrae or other surgical process performed; a computer calculating a preferred correction based on screw orientation with vertebrae-pre correction; attaching a distractor to screws and/or employ other surgical instruments, selectively injecting cement with fractured vertebrae with a tool through fenestrated screws; performing correction with the distractor; imaging screws with vertebrae-post correction, comparing and/or evaluating calculated correction with actual correction on the navigation system. 
     In some embodiments, the present surgical system includes a surgical trauma instrument. In some embodiments, the present surgical system is utilized with a method to correct complex spinal deformities. In some embodiments, the present surgical system is utilized with a method to treat degenerative spinal disorders and/or employed with transforaminal lumbar interbody fusion procedures. In some embodiments, the present surgical system comprises a plurality of compressor/distractors, such as, for example, two distractors disposed along a side of vertebrae to perform a ligamentotaxy procedure. In some embodiments, the present surgical system comprises a single distractor to treat degenerative spinal disorders, for example, for disposal along a side of vertebrae oriented for decompression and/or interbody cage insertion. 
     In some embodiments, the present surgical system includes a percutaneous surgical system for use in a ligamentotaxy of a traumatic thoracic lumbar spine. In some embodiments, the present surgical system includes a surgical system that allows restoration of an angle during ligamentotaxy at a level of an implant, such as, for example, a head of a screw disposed at a surgical site to facilitate a more precise reduction of the trauma. 
     In some embodiments, the present surgical system includes a surgical instrument connected with an adaptor, which is utilized with a bone screw having extender tabs attached thereto. In some embodiments, the present surgical system includes an implant support including a connector and an adaptor. In some embodiments, the connector includes an outer sleeve configured for connection with extenders. In some embodiments, the connector is connected with extenders for insertion of an implant, such as for example, a spinal rod. In some embodiments, the adaptor includes an arm having a pivot hinge that connects the connector with a compressor/retractor. In some embodiments, the pivot hinge allows movement of the components to provide surgical-site visibility for inter-operative imaging. In some embodiments, a compressor/distractor is utilized for parallel distraction. In some embodiments, the surgical instrument includes a compressor/distractor having a reversible ratchet with a neutral, freely moveable position. In some embodiments, the present surgical system is employed with a procedure for implantation of a bone fastener percutaneously. 
     In some embodiments, the present surgical system includes a surgical instrument configured to compress or distract and restore curvature of a spine. In some embodiments, the present surgical system includes instruments and tools for correcting a sagittal deformity and rebalancing a spine of a body. In some embodiments, the present surgical system is employed to treat degenerative deformities of a spine in a sagittal plane, for example, degenerative kyphosis. In some embodiments, the present surgical system is employed to treat hyper-kyphosis, flat lumbar back, including disorders that create an unbalance of a body and loss of alignment between body parts. In some embodiments, the present surgical system provides a selected amount of correction to apply a selected balance to a spine and provides control and adjustment to the amount of correction. In some embodiments, the present surgical system includes a series of tools and instruments that allow formulation of a type of correction applied and can control the correction stabilization using posterior instrumentation. 
     In some embodiments, one or all of the components of the surgical system are disposable, peel-pack, pre-packed sterile devices used with a spinal construct. One or all of the components of the surgical system may be reusable. The surgical system may be configured as a kit with multiple sized and configured components. 
     In some embodiments, the present disclosure may be employed to treat spinal disorders such as, for example, degenerative disc disease, disc herniation, osteoporosis, spondylolisthesis, stenosis, scoliosis, kyphosis, and other curvature abnormalities, tumor and fractures. In some embodiments, the present disclosure may be employed with other osteo and bone related applications, including those associated with diagnostics and therapeutics. In some embodiments, the disclosed surgical system and methods may be alternatively employed in a surgical treatment with a patient in a prone or supine position, and/or employ various surgical approaches to the spine, including posterior and/or posterior mid-line and in other body regions. The present disclosure may also be alternatively employed with procedures for treating the lumbar, cervical, thoracic, sacral and pelvic regions of a spinal column. The system and methods of the present disclosure may also be used on animals, bone models and other non-living substrates, such as, for example, in training, testing and demonstration. 
     The present disclosure may be understood more readily by reference to the following detailed description of the embodiments taken in connection with the accompanying drawing figures, which form a part of this disclosure. It is to be understood that this application is not limited to the specific devices, methods, conditions or parameters described and/or shown herein, and that the terminology used herein is for the purpose of describing particular embodiments by way of example only and is not intended to be limiting. In some embodiments, as used in the specification and including the appended claims, the singular forms “a,” “an,” and “the” include the plural, and reference to a particular numerical value includes at least that particular value, unless the context clearly dictates otherwise. Ranges may be expressed herein as from “about” or “approximately” one particular value and/or to “about” or “approximately” another particular value. When such a range is expressed, another embodiment includes from the one particular value and/or to the other particular value. Similarly, when values are expressed as approximations, by use of the antecedent “about,” it will be understood that the particular value forms another embodiment. It is also understood that all spatial references, such as, for example, horizontal, vertical, top, upper, lower, bottom, left and right, are for illustrative purposes only and can be varied within the scope of the disclosure. For example, the references “upper” and “lower” are relative and used only in the context to the other, and are not necessarily “superior” and “inferior”. 
     As used in the specification and including the appended claims, “treating” or “treatment” of a disease or condition refers to performing a procedure that may include administering one or more drugs to a patient (human, normal or otherwise or other mammal), employing implantable devices, and/or employing instruments that treat the disease, such as, for example, microdiscectomy instruments used to remove portions bulging or herniated discs and/or bone spurs, in an effort to alleviate signs or symptoms of the disease or condition. Alleviation can occur prior to signs or symptoms of the disease or condition appearing, as well as after their appearance. Thus, treating or treatment includes preventing or prevention of disease or undesirable condition (e.g., preventing the disease from occurring in a patient, who may be predisposed to the disease but has not yet been diagnosed as having it). In addition, treating or treatment does not require complete alleviation of signs or symptoms, does not require a cure, and specifically includes procedures that have only a marginal effect on the patient. Treatment can include inhibiting the disease, e.g., arresting its development, or relieving the disease, e.g., causing regression of the disease. For example, treatment can include reducing acute or chronic inflammation; alleviating pain and mitigating and inducing re-growth of new ligament, bone and other tissues; as an adjunct in surgery; and/or any repair procedure. Also, as used in the specification and including the appended claims, the term “tissue” includes soft tissue, ligaments, tendons, cartilage and/or bone unless specifically referred to otherwise. 
     The following discussion includes a description of a surgical system and related methods of employing the surgical system in accordance with the principles of the present disclosure. Alternate embodiments are disclosed. Reference is made to the exemplary embodiments of the present disclosure, which are illustrated in the accompanying figures. Turning to  FIGS. 1-3 , there are illustrated components of a surgical system  10 . 
     The components of surgical system  10  can be fabricated from biologically acceptable materials suitable for medical applications, including metals, synthetic polymers, ceramics and bone material and/or their composites. For example, the components of surgical system  10 , individually or collectively, can be fabricated from materials such as stainless steel alloys, commercially pure titanium, titanium alloys, Grade 5 titanium, super-elastic titanium alloys, cobalt-chrome alloys, superelastic metallic alloys (e.g., Nitinol, super elasto-plastic metals), ceramics and composites thereof such as calcium phosphate (e.g., SKELITE™), thermoplastics such as polyaryletherketone (PAEK) including polyetheretherketone (PEEK), polyetherketoneketone (PEKK) and polyetherketone (PEK), carbon-PEEK composites, PEEK-BaSO 4  polymeric rubbers, polyethylene terephthalate (PET), fabric, silicone, polyurethane, silicone-polyurethane copolymers, polymeric rubbers, polyolefin rubbers, hydrogels, semi-rigid and rigid materials, elastomers, rubbers, thermoplastic elastomers, thermoset elastomers, elastomeric composites, rigid polymers including polyphenylene, polyamide, polyimide, polyetherimide, polyethylene, epoxy, bone material including autograft, allograft, xenograft or transgenic cortical and/or corticocancellous bone, and tissue growth or differentiation factors, partially resorbable materials, such as, for example, composites of metals and calcium-based ceramics, composites of PEEK and calcium based ceramics, composites of PEEK with resorbable polymers, totally resorbable materials, such as, for example, calcium based ceramics such as calcium phosphate, tri-calcium phosphate (TCP), hydroxyapatite (HA)-TCP, calcium sulfate, or other resorbable polymers such as polyaetide, polyglycolide, polytyrosine carbonate, polycaroplaetohe and their combinations. 
     Various components of surgical system  10  may have material composites, including the above materials, to achieve various desired characteristics such as strength, rigidity, elasticity, compliance, biomechanical performance, durability and radiolucency or imaging preference. The components of surgical system  10 , individually or collectively, may also be fabricated from a heterogeneous material such as a combination of two or more of the above-described materials. The components of surgical system  10  may be monolithically formed, integrally connected or include fastening elements and/or instruments, as described herein. 
     Surgical system  10  is employed, for example, with a minimally invasive procedure, including percutaneous techniques, mini-open and open surgical techniques to deliver and introduce instrumentation and/or components of spinal constructs at a surgical site within a body of a patient, for example, a section of a spine. In some embodiments, one or more of the components of surgical system  10  are configured for engagement with spinal constructs attached with vertebrae to manipulate tissue and/or correct a spinal disorder, such as, for example, a sagittal deformity, as described herein. In some embodiments, surgical system  10  may be employed with surgical procedures, such as, for example, corpectomy, discectomy and/or fracture/trauma treatment and may include fusion and/or fixation that employ implants to restore the mechanical support function of vertebrae. 
     Surgical system  10  includes a surgical instrument, such as, for example, an implant support  14  and an implant support  14   a,  similar to implant support  14 , as show in  FIG. 2 . Implant supports  14 ,  14   a  are each connectable with a bone fastener  16  having a receiver  18  and a screw shaft  20 , as shown in  FIGS. 1-3 . Screw shaft  20  is fixed with tissue. Receiver  18  is connectable with implant support  14  to releasably engage a surgical instrument, such as, for example, a compressor/distractor  300  to distract and/or compress tissue. 
     Receiver  18  includes a pair of spaced apart arms  30 ,  32  that define an implant cavity configured for disposal of a component of a spinal construct, such as, for example, a spinal rod. Receiver  18  includes an inner surface having a thread form located disposed with arms,  30 ,  32 . Screw shaft  20  is configured to penetrate tissue, such as, for example, bone, of a patient. 
     Arm  30  includes a break away tab  34  that is frangibly connected to arm  30  such that manipulation of tab  34  relative to arm  30  can fracture and separate tab  34  from arm  30  at a predetermined force and/or torque limit. Arm  32  includes a break away tab  36  that is frangibly connected to arm  32  such that manipulation of tab  36  relative to arm  32  can fracture and separate tab  36  from arm  32  at a predetermined force and/or torque limit, as described herein. In some embodiments, as force and/or torque is applied to tabs  34 ,  36  and resistance increases, for example, the predetermined torque and force limit is approached. 
     Implant support  14  includes extender tabs  40 ,  42  that are connectable with bone fastener  16 , as shown in  FIG. 1 . Each extender tab  40 ,  42  extends between a proximal end  44  and a distal end  46 . Distal ends  46  are configured for slidable disposal of a portion of bone fastener  16 , such as, for example, tabs  34 ,  36 . In some embodiments, tabs  34 ,  36  are configured to releasably fix extender tabs  40 ,  42  with bone fastener  16  for connection with implant support  14 , as described herein. In some embodiments, bone fastener  16  includes at least one extender tab. For embodiments lacking tabs  34 ,  36 , the extender tabs  40 ,  42  can connect directly to the arms  30 ,  32 . 
     In some embodiments, connection of implant supports  14 ,  14   a  facilitates correction of a vertebral angle of vertebrae, for example, to achieve a selected lordosis and/or kyphosis, via manipulation of implant supports  14 ,  14   a,  as described herein. In some embodiments, implant supports  14 ,  14   a  are connected with compressor/distractor  300  to maintain a corrected vertebral angle of vertebrae during distraction and/or compression, as described herein. In some embodiments, the compressor/distractor has direct connection to extender (top-loading) and the screws such that the system provides direct control ligamentotaxy/kyphosis correction and at a reduced profile. In some embodiments, the present surgical system also provides ergonomic instrumentation that connects the implant, implant support and other rack and lordosis module assembly. In some embodiments, the present surgical system is configured for open and/or mini-open approach and configured as a pre-assembled single block top loading. In some embodiments, the surgical system includes an angulation module to facilitate compression/distraction. In some embodiments, an angulation module is configured for connection with the extenders  40 ,  42 . For example, an angulation module may move the extenders close together in a compression process as shown in  FIG. 3 . In some embodiments, the angulation module is monolithic with the at least one implant support  14 . 
     In assembly, operation and use, surgical system  10 , similar to the systems and methods described herein, is employed with a surgical procedure, for treatment of a spine of a patient including vertebrae V. Surgical system  10  may also be employed with surgical procedures, such as, for example, discectomy, lam inectomy, fusion, laminotomy, laminectomy, nerve root retraction, foramenotomy, facetectomy, decompression, spinal nucleus or disc replacement and bone graft and implantable prosthetics including plates, rods, and bone engaging fasteners. 
     In various embodiment, as shown by way of examples in  FIGS. 4-12 , spinal implant system  10 , similar to the systems and methods described herein, is employed in connection with one or more surgical procedures, as described herein. Initially, spinal implant system  10  is employed with a method for treating a spine that includes a preparation and/or a pre-operative procedure  400 , as shown in  FIG. 4 . Surgical method  500 , as shown in  FIG. 5 , includes use of components and/or surgical instruments for delivery of components of spinal implant system  10 , which, such as, for example, drivers, extenders, reducers, spreaders, distractors, blades, clamps, forceps, elevators and drills, any of which may be alternately sized and dimensioned, and any of which may be arranged as a kit. 
     In preparation and/or a pre-operative procedure  400 , step  402  includes attaching a  3 D reference marker  600 , as shown in  FIG. 6 , to the patient. Marker  600  is visible by surgical navigation system  216 , shown in  FIGS. 8 and 9 . Marker  600  is utilized to obtain images bone fastener  16  in a coronal, cephalad and/or caudal space during angulation, distraction and/or derotation. In some embodiments, markers  600  can be utilized with two or a plurality of bone fasteners  16  at multiple vertebral levels. For example, prior to manipulation of the vertebral segment, a machine can overlay bone fasteners  16  to vertebrae V. 
     Step  404  includes imaging vertebrae V for registration of anatomical image data and positional tracking of vertebrae V, for example, a CT scan or MRI scan. In some embodiments, the images include taking C-arm images of the patient anatomy. The images are calibrated such that a three-dimensional image of the selected vertebrae is generated. In some embodiments, fluoroscopic images are taken from different angles, such as, 0, 45, and 90 degrees. In some embodiments, multiple C-arm images are taken. For example, step  404  may include imaging the vertebrae V by performing a three-dimensional scan of the selected vertebrae V. In some embodiments, step  404  includes utilizing O-Arm® imaging device in the operating room to obtain the three-dimensional images of the patient anatomy intra-operatively and/or prior to surgery  500  for calibration and registration. 
     During a registration process, the three-dimensional scans from step  404  are transferred to a control unit. See, for example, the registration systems and methods, as described in U.S. Pat. No. 8,571,638, the contents of which being hereby incorporated by reference herein in its entirety. The C-arm images from step  404  are transferred to the control unit. A pseudo three-dimensional image of the selected vertebrae V is generated for patient anatomy registration,  FIG. 8 . For example, at pre-correction, the relative angle between a first bone fastener  16  is about 51 degrees relative to a second bone fastener  16  and a distance is about 41 mm. 
     In step  406 , a surgeon reviews three-dimensional the images captured in step  404  and formulates and selects an implant strategy according to three-dimensional scans. 
     Step  406  includes selecting an implant strategy for bone fasteners  16 . For example, step  406  includes selecting a plurality of trajectories, such as, for example, trajectories T 1 , T 2 , T 3  and T 4  for bone fasteners  16  for positioning and engaging with vertebrae V, as shown in  FIG. 7 . In some embodiments, step  406  utilizes pre-operative analytics software including anatomy recognition and vertebral segmentation algorithms for surgical visualization based on a patient&#39;s images, which facilitates formulating the implant strategy including implant and trajectory placement planning. 
     Step  408  includes selecting a manipulation strategy for bone fasteners  16 . Step  408  includes forming a strategy for manipulating a first bone fastener  16  a selected angular orientation relative to a second bone fastener  16  to decompress the vertebral tissue of vertebrae V 1 , V 2 . 
     Step  410  includes determining a post-correction orientation of vertebrae V 1 , V 2  according to the implant strategy from step  406  and the manipulation strategy from step  408 . In various embodiments, step  410  includes calculating or otherwise determining the post-correction orientation using a specially configured computing system having a processor. In various embodiments, calculating the post-correction orientation is done by a specially configured computing device (e.g., a processor executing software customized for the present purpose). 
     Step  412  includes imaging the calculated post-correction orientation, as shown in  FIG. 9 . For example, the calculated post correction would manipulate bone fasteners  16  such that the relative angle between the first bone fastener  16  is about 7 degrees relative to the second bone fastener  16  and a distance is about 27 mm. 
     In contemplated embodiments, any of the steps of the methods described herein can be performed by a specially configured computing system—e.g., a processor executing instructions, stored on a tangible, non-transitory, computer-readable storage device, customized for the present purpose. 
     During surgery  500 , step  502  includes engaging bone fasteners  16  with vertebrae V 1 , V 2  (see e.g.,  FIGS. 8 and 9 ) along trajectories T 1 , T 2 , T 3  and T 4  (see e.g.,  FIG. 7 ) according to the implant strategy developed in step  406 . Bone fasteners  16  are connected with a surgical instrument, such as, for example, a driver  218  including a navigation component  258 , as shown in  FIG. 10 . Navigation component  258  generates a signal representative of a position of each bone fastener  16  relative to vertebrae V 1 , V 3  based on the actual correction orientation. 
     Navigation component  258  transmits a signal and communicates with a processor of computer  264  of a navigation system  216 , as shown in  FIG. 10 . In various embodiments, navigation component  258  includes an emitter array. The emitter array is configured for generating a signal to a sensor array  260  of surgical navigation system  16 . In some embodiments, the signal generated by emitter array  262  represents a position of bone fastener  16  relative to driver  218  and relative to tissue, such as, for example, bone. In some embodiments, the signal generated by emitter array  262  represents a three-dimensional position of bone fastener  16  relative to tissue. 
     In some embodiments, sensor array  260  receives signals from emitter array  262  to provide a three-dimensional spatial position and/or a trajectory of bone fastener  16  relative to driver  218  and/or tissue. Emitter array  262  communicates with a processor of computer  264  of navigation system  216  to generate data for display of an image on a monitor  266 . In some embodiments, sensor array  260  receives signals from emitter array  262  to provide a visual representation of a position of bone fastener  16  relative to driver  218  and/or tissue. See, for example, similar surgical navigation components and their use as described in U.S. Pat. Nos. 6,021,343, 6,725,080, 6,796,988, the entire contents of each of these references being incorporated by reference herein. 
     Surgical navigation system  216  is configured for acquiring and displaying medical imaging, such as, for example, x-ray images appropriate for a given surgical procedure. In some embodiments, pre-acquired images of a patient are collected. In some embodiments, surgical navigation system  216  can include an O-arm® imaging device  268  sold by Medtronic Navigation, Inc., having a place of business in Louisville, Colo., USA. Imaging device  68  may have a generally annular gantry housing that encloses an image capturing portion  270 . 
     In some embodiments, image capturing portion  270  includes an x-ray source or emission portion and an x-ray-receiving, or other image-receiving, portion located generally, or as practically possible, 180 degrees from each other and mounted on a rotor (not shown in detail) relative to a track of image-capturing portion  270 . Image-capturing portion  270  can be operable to rotate 360 degrees during image acquisition. Image-capturing portion  270  may rotate around a central point or axis, allowing image data of the patient to be acquired from multiple directions or in multiple planes. Surgical navigation system  216  can include those disclosed in U.S. Pat. Nos. 8,842,893, 7,188,998; 7,108,421; 7,106,825; 7,001,045; and 6,940,941; the entire contents of each of these references being incorporated by reference herein. 
     The images, e.g., fluoroscopic images, taken are transmitted to computer  264 , which may further forward them toto a computer  276 . Image transfer may be performed using any channel, wireless or wired, such as over a standard video connection or a digital link including wired and wireless. In various embodiments, computer  276  provides the ability to display, via monitor  266 , as well as save, digitally manipulate, or print a hard copy of the received images. In some embodiments, images may also be displayed to the surgeon through a heads-up display. In a contemplated embodiment, one computer is employed, here, instead of the two computers  264 ,  276 . 
     In some embodiments, in step  504  a surgical instrument, such as, for example, a cement delivery device  590 , as shown in  FIGS. 11 and 12 , is connected with bone fasteners  16  to inject cement through bone fasteners  16  into vertebrae V 1 , V 2 . In some embodiments, bone fasteners  16  includes fenestrated bone fasteners  160 , as shown in  FIGS. 11 and 12 . In some embodiments, bone fastener  600  includes a shaft  602  including a proximal portion and a closed distal tip  603 . Shaft  602  includes an outer surface engageable with a first cortical surface and a second cortical surface of bone. The proximal portion includes an inner surface  604  that defines a longitudinal cavity  606 . Shaft  602  includes at least one opening, such as, for example, a fenestration  608  in communication with cavity  606  for dispersing the cement into vertebrae V. In some embodiments, bone fasteners  16  include sagittally adjustable screws. The bone fasteners  16  can in any way be like those described in U.S. patent Ser. No. 16/047,590, which is in its entirety incorporated herein. 
     In step  506  implant supports  14 ,  14   a  are connected with bone fasteners  16 . For example, implant supports  14 ,  14   a  are connected with extenders  40 ,  42 , as described herein. 
     In step  508 , compressor/distractor  300  is mounted with adaptors  100 , as described herein, to allow for manipulation via distraction and/or compression of vertebrae V 1 , V 2  for the actual correction based on the manipulation strategy developed at step  408 . 
     Step  510  includes comparing the actual correction from step  508  of vertebrae V 1 , V 2  with the post-correction determined in steps  410  and  412 . 
     In some embodiments, in step  512 , cement delivery device  590  is connected with bone fasteners  160 , as described herein, to inject cement through bone fasteners  160  into vertebral space S of vertebrae V 1 , V 2 . 
     Upon completion of one or more surgical procedures, the surgical instruments and non-implanted components of spinal implant system  10  are removed and the incision(s) are closed. One or more of the components of spinal implant system  10  can be made of radiolucent materials such as polymers. In some embodiments, spinal implant system  10  includes an agent, which may be disposed, packed, coated or layered within, on or about the components and/or surfaces of spinal implant system  10 . In some embodiments, the agent may include bone growth promoting material, such as, for example, bone graft to enhance fixation of the fixation elements with vertebrae. In some embodiments, the agent may be HA coating. In some embodiments, the agent may include one or a plurality of therapeutic agents and/or pharmacological agents for release, including sustained release, to treat, for example, pain, inflammation and degeneration. 
     It will be understood that various modifications may be made to the embodiments disclosed herein. Therefore, the above description should not be construed as limiting, but merely as exemplification of the various embodiments. Those skilled in the art will envision other modifications within the scope and spirit of the claims appended hereto.