Patent Publication Number: US-2021169504-A1

Title: Surgical targeting systems and methods

Description:
CROSS REFERENCE TO RELATED APPLICATIONS 
     This application is a continuation-in-part (CIP) of commonly owned U.S. Ser. No. 15/330,875, filed Nov. 9, 2016; 
     which is a CIP of commonly owned U.S. Ser. No. 14/659,497, filed Mar. 16, 2015; 
     which further claims benefit of U.S. Provisional Ser. No. 61/954,250, filed Mar. 17, 2014; 
     the entire contents of each of which is hereby incorporated by reference. 
    
    
     BACKGROUND 
     Field of the Invention 
     The present invention relates to a system and method to aid the placement of surgical devices under radiographic image guidance. More particularly, embodiments of the invention relate to a system utilizing radiopaque markers, an external light source and targets. Light is projected onto the skin or surgical site over a target in conjunction with a radiographic line marker superimposed on a fluoroscopic image to identify bone landmarks and angles so that skin entry points can be identified. This can be augmented by the use of a target system that is held in place by a bedside rail mounted mechanical arm that can hold any position desired. This allows rigid guidance of guide wire to facilitate the accurate placement of surgical implant or devices. An exemplary system utilizes a radiopaque marker, external laser markers and a target to determine intraoperative angles, trajectories and positioning coordinates to facilitate placement of needles, guide wires, trocars and cannulae for the surgical placement of orthopedic implantation devices. 
     Description of the Related Art 
     Many fluoroscopy systems, whether analog or digital, on the market possess a laser “aimer” or pointer that is used in conjunction with the imaging source. One example is the Smart Laser Aimer from GE OEC (GE Healthcare, Salt Lake City, Utah). The laser pointer is mounted on the Image Intensifier of the C-arm and is used as a line-of-sight pointer. The laser light illuminates the center point on the surgical site where the x-ray beam will image if activated, giving the user a more accurate location of the image. It does not accurately place the image in global 3-dimensional space, nor does it provide an accurate location with respect to anatomical landmarks. The user must rely on more complex image guidance systems intraoperatively, or 3-D image reconstruction software preoperatively in order to obtain more accurate information for precise instrument placement. One example of intraoperative guidance systems is the StealthStation from Medtronic. Such systems require a dedicated piece of equipment to transmit and receive signals and markers on the surgical instruments to track the position and orientation of each instrument. Dedicated software and image storage are also required to incorporate guidance system information into preoperative or intraoperative images. Such systems do not have the benefit of the present invention of being compatible with any commercially available imaging equipment and surgical instruments. 
     There are many targeting or aiming apparatus for making bores in bones as described in U.S. Pat. No. 5,031,2013 which utilizes a laser and a fixed target in combination with x-rays. More recently, there have been articles focusing on targeting with a complex computer aided technique such as, “Percutaneous Lumbar Pedicle Screw Placement Aided by Computer-Assisted Fluoroscopy-based Navigation” by Benson P. Yang, MD, Melvin Wahl, MD, CARY S. Idler MD, Spine: 37(24):2055-2060. There have also been other publications such as, “Accuracy of Fluoroscopically assisted laser targeting of the cadaveric thoracic and lumbar spine to place transpedicular screws” by Schwend, R M, Dewire P J, Kowalski T M; J Spinal Disord. 2000 October; 13 (5): 412-8; “Pedicle Guide for Thoracic Pedicle Screw Placement” by Kingsley O. Abode-Iyamah M D; Luke Stemper B S; Shane Rachman B S; Kelly Schneider B S; Kathryn Sick B S Patrick W. Hilton MD, University of Iowa Hospitals and Clinics; and the work of C. Grady McBride at the Orlando Orthopaedic Center, where reduction of fluoroscope times resulted in the use of a targeting device in parallel for insertion of a guide wire. 
     The fluoroscopy systems operate on either a continuous or pulsing system for x-rays to permit continuous or near continuous monitoring of the medical procedure involved. In either situation there is still a need to reduce or limit the exposure of patients to the exposure of the x-ray radiation. Timing is critical, but in the surgeries utilizing today&#39;s fluoroscopy systems there is somewhat a hit and miss approach to finding the landmarks need for the attachment of screws for spinal surgery, as the procedure follows a general methodology of measurement and a grid pattern that often does not consider the thickness of a patient&#39;s soft tissue and muscle from the area of attachment, such as the pedicles of the spine. The use of Jamshidi needles, trocars and cannulae for certain surgeries help limit wound size and openings, but the degree of precision desired is still not met using the current methods, even with complex software and robotics. The degree of precision has greatly improved, but the accuracy of the puncture for attaching screws in the body still relies on an estimate of the location of the incision without an exemplar or marker to follow or a more accurate place in which to make the incision. For example, in spine surgery the standardized methodology will be to measure from the midline to a fixed distance to make an incision with limited regard to the angle of entry and if the landmark is not hit on the first attempt there are continued attempts and the need for dealing with tissue and muscle as the trocar or cannula is being positioned to find the pedicle landmark. This increases unnecessary exposure to x-rays and the increased chance of injury to tissue and muscle. 
     Also, the focus is minimally invasive surgery is to limit the need for opening the body and increase the risk of infection and healing. In the use of robotics, for instance, sections of the spine still need to be exposed to attach the rail for the robotic system to be used during spine surgery. While this may be an improvement over opening the entire area of the spine, it still creates issues around infection and healing of the wounds. While the methodologies used to get towards minimally invasive surgery have improved there is significant opportunity for an increase in accuracy to go along with the increase in precision. 
     SUMMARY OF THE INVENTION 
     The disclosure concerns a system and method used in conjunction with fluoroscopic imaging systems to identify bone landmarks and angles, skin entry points and trajectories and a target guide holder in order to aid the placement of surgical instruments, such as guide pins, needles, trocars, fixation hardware and cannulae. The system&#39;s utility is not limited to a particular anatomical location, and thus can be used in a wide range of variety of surgical applications. In addition to the spine surgery application detailed below, it can be used in human, veterinary, or training models for cranial, hip, knee, and wrist surgery, for example. 
     The system comprises an adjustable radiopaque bar marker mounted below external light sources, such as visible light sources or lasers, the associated mounting hardware on the imaging system and a separate targeting guide holder. The mounting hardware allows the radiopaque marker to translate around and across the circumference and face 360° around the image intensifier. The radiopaque bar is able to rotate 90° along the axis parallel to the image intensifier allowing the marker to be effectively radiolucent. Additionally, the radiopaque marker is centered on the intensifier which eliminates the issue of beam divergence. The system is used in conjunction with commonly available preoperative images and commercially available intraoperative radiography equipment. A preoperative image of the intended surgical site is taken using computed tomography (CT) or magnetic resonance Imaging (MRI). It should be noted that the image is already taken to judge the surgical candidacy. 
     On this image, the anatomy of the intended surgical site is seen and used to preoperatively plan the angles, trajectories and positioning of the surgical instruments by superimposing points and lines on the preoperative image. From this preoperative plan, the intended lateral line and transverse line on the skin and the anterior/posterior (AP) angulation of each instrument is planned. There are three methods contemplated for acquiring the lateral line: (1) use the angle found from the pre/intra operative CT/MRI and position the C-arm to that angle and line up the radiopaque marker over the pedicle; (2) measure the distance from the midline to exit point on the skin; and (3) landmark of the plumb line from exit point of the skin when drawing angles. This crossing of lines identifies true coordinate for entry point. Once the lateral line and the transverse line are established, the Jamclometer tip is placed on the intersection point. Using a two-axis inclinometer the AP angle can be applied in the x plane. While in the lateral plane, the Y angle can be found from the indicator on the C-arm or it can be found by lining up the marker on top of the Jamclometer with the laser and using the angle off of the Jamclometer. Further, the top midline of the Jamclometer can be aligned with the light line and the y angle can be read off the inclinometer. The preoperative planning step may be performed manually on a printed image or electronically using commercially available software and a digital image. Additional lines are constructed on the preoperative image by projecting the position of the intended entry points on the skin in the orthogonal planes to be used for intraoperative imaging at the time of surgery. The intersection of the orthogonal projection lines with anatomical landmarks indicates which anatomical landmark to use in intraoperative imaging to align the system. intraoperative planning may also be performed in the same manner using intraoperative images. 
     Prior to the procedure, the light source is mounted to a commercially available radiographic imaging system, such as a fluoroscope or portable x-ray. The light beams are projected as a line onto the skin at the surgical site. The radiopaque bar markers and light sources are located in known positions with respect to the imaging system. The radiopaque bar markers are imaged with the anatomical location of interest, and the light sources are projected onto the skin in the plane of the intended entry point determined in pre- or intraoperative planning. The intersection of two linear light beams in orthogonal planes, typically but not necessarily the anterior/posterior (AP) and medial/lateral (ML) planes, clearly mark the entry point of the surgical instruments on the skin of the patient. The orientation of the surgical instruments at the entry point is set using the target guide holder, an angularly adjustable, bi-planar, mechanical guide to set the angle of the instruments in both orthogonal planes per the pre- or intraoperative plan. The system thereby provides accurate both the positioning coordinates and the orientation of the surgical instrument to the surgeon, such that if the resulting trajectory is followed, the instrument will reach the intended internal surgical site without direct visualization by dissection or repeated radiographic exposures. 
     An example of the method using the present invention and a preoperative plan includes an axial preoperative image, also known as a “slice”, of the intended surgical site is taken using computed tomography (CT) or magnetic resonance imaging (MRI). On this image, the anatomy of the intended surgical site is seen in cross-sectional axial view (a view not commonly available intraoperatively) and used to preoperatively plan the angles, trajectories and landmark positioning of the surgical instruments. From this preoperative plan, the intended skin entry point is defined for the AP plane. An example of the method using the present invention and an intraoperative plan includes a lateral intraoperative image using fluoroscopy or portable x-ray. On this image, the anatomy of the intended surgical site is seen in side elevation and used to plan the angles, trajectories and positioning of the surgical instruments. From this intraoperative plan, the intended skin entry and bone entry point is defined in the ML plane. When the two exemplary methods are used together, for example in spinal surgery, the intersection of the AP and ML planes using the light beam mark the surgical skin entry point coordinate. The use of the target guide holder insures no human initiated deviation from plotted trajectory is introduced during insertion. This method and device are ideal for minimally invasive procedures including but not limited to discectomy, pedicle screw placement for fixation, facet fusion, facet joint injection, nerve ablation, vertebral augmentation. 
     Another example of the method is for training surgeons in using the invention for improved performance and accuracy. The intersection of the AP and ML Planes using the light beam mark the surgical skin entry point and the surgeons get use to understanding the various degrees of entry required, such that in the case of the back surgery of the previous paragraph, the angles become familiar to the surgeon through identification training and they become more accurate in the surgical entry point and the angles of that entry point. Clearly, the invention is applicable for use with not only spinal surgery but also orthopedic surgeries involving shoulder, hips, joints, wrist, arms, legs, ankles hands and feet. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       In order to better understand the invention and to see how it may be carried out in practice, some preferred embodiments are next described, by way of non-limiting examples only, with reference to the accompanying drawings, in which like reference characters denote corresponding features consistently throughout similar embodiments in the attached drawings. 
         FIG. 1  is a translucent illustration of the lateral and posterior views of the surgical patient, with the linear light beam externally positioned in the posterior view and the intended trajectory of a surgical instrument through the body in the lateral view. 
         FIG. 2  is an example of the instrument trajectory of  FIG. 1  as projected on a radiographic image. 
         FIG. 3  is an illustration of the determination of the surgical angle and projection of the entry point of the skin on an anatomical landmark on a preoperative CT image. 
         FIG. 4  is an illustration of completing the A/P positioning technique by locating the anatomical landmark. 
         FIG. 5  is radiograph example of the technique of  FIG. 5 . 
         FIG. 6  is an illustration of the guide pin insertion. 
         FIG. 7  is radiograph example of the technique of  FIG. 7   
         FIG. 8  is an illustration of final positioning of the guide pin. 
         FIG. 9  is an illustration of the lateral and posterior views of the cranium, externally positioned in the posterior view and the intended trajectory of a surgical instrument through the skull in the lateral view. Straight vertical and horizontal lines illustrate radiopaque markers and contoured lines illustrate skin incision trajectories. 
         FIG. 10  is an illustration of a Fluoroscopic system in a side view. 
         FIG. 11A  is a perspective view of a Fluoroscopic C-Arm System. 
         FIG. 11B  is a side view of a GE Fluoroscopic C-Arm System. 
         FIG. 12  is a perspective view of the collar for the image intensifier with the light source and the radiopaque marker. 
         FIG. 13  is a perspective view of the light source and radiopaque marker and how the light source and holder have movement laterally. 
         FIG. 14  is a side view of the collar for the image intensifier with the light source and radiopaque marker. 
         FIG. 15  is a front view of the collar for the image intensifier with the light source and radiopaque marker. 
         FIG. 16  is a top view of the collar for the image intensifier with the light source and radiopaque marker. 
         FIG. 17  shows perspective views of an alternative the collar for the image intensifier where the face rotates around the image intensifier. 
         FIG. 18  is illustrative of the pre-surgical preparation. 
         FIG. 19  illustrates the view from the monitor of the fluoroscope of the of the radiopaque marker. 
         FIG. 20  illustrates an alternative collar for the image intensifier. 
         FIG. 21A  illustrates a Jamshidi, a stylet and a target guide holder. 
         FIG. 21B  illustrates an inclinometer for determine the AP angle and the lateral angle. 
         FIG. 22  illustrates a hand and wrist having a plate with screws. 
         FIG. 23  illustrates a Humeral Shaft with a plate and screws. 
         FIG. 24  is an illustration of taking the Jamshidi of  FIGS. 21 and 21A  with further improvements and modifications. 
         FIG. 25  illustrates a perspective view from the top of the Instrument-guiding device. 
         FIG. 26  is a back view of the instrument-guiding device having the Instrument-guiding device body, connector, needle or cannula, flange surfaces and impact surface, which can be impacted using one hands or other instruments, such as a hammer like device. 
         FIG. 27  illustrates the Instrument-guiding device Body ready to receive a needle, cannula, pin or start wrench at connector or any similar such device for use during orthopedic surgery. 
         FIG. 28  illustrates an alternative Instrument-guiding device. 
         FIG. 29  shows a side view of the Instrument-guiding device. 
         FIG. 30  illustrates a bottom view of both Instrument-guiding device. 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     First, the light source  1  in  FIG. 1  must be positioned. A collar system  2  will fit the image intensifier  10  incorporating the light source  1  and the radiopaque marker  25 . As shown in  FIG. 1 , using the radiopaque marker  25  on the face of the laterally positioned image intensifier  10  fluoroscopically the light source trajectory  20  is determined through the spine segment. By superimposing the marker over the anatomy, the system automatically places the laser marker over the skin as shown at  30 . This determines both the angle and latitude position on the skin to start the procedure. 
     Next, the A/P position must be determined by looking at the preoperative axial view of the target in question. In  FIG. 2 , the target in question is a vertebral body  35 . The midline  38  is determined, an azimuth through the pedicle or structures desired is positioned, and an angle is determined that would effectively produce the correct trajectory  40  through the anatomy. For example,  FIG. 3  illustrates an angle of 15 degrees at the feature of interest, the end of transverse process. The A/P landmark is determined by using the axial view ( FIG. 4 ) by looking down through the anatomy from the point in which the azimuth exits the body posteriorly  40 .  FIG. 4  illustrates the example of the trajectory overlying the end of the transverse process  50 . The intersection of  50  and  40  is shown at  51 . Finally, using the radiopaque marker on the face of the A/P intensifier, the marker is fluoroscopically superimposed over the landmark previously identified. In the example shown in  FIG. 4 ,  FIG. 5 , and  FIG. 6  this is the end of the transverse process. 
     The inclinometer guide pin  90  can now be deployed. Using both laser beam  60  and laser beam  70  as reference lines on the skin, the skin port or entry point  80  is established as illustrated in  FIG. 7 . Next, the inclinometer guide pin is positioned into the target holder and with the aid of the positioning arm positioned at pre-established angle in AP and target guide holder ML centerline brought into alignment with lateral laser light beam. In the example of  FIG. 8 , the angles are shown as 30 degrees lateral, 15 degrees A/P. Then the inclinometer guide pin is replaced with the procedural guide pin then advanced to its fully inserted position as shown in  FIG. 8 . Once the guide pin is successfully inserted, the procedure can begin. 
       FIG. 9  is an illustration of the lateral and posterior views of the cranium, externally positioned in the posterior view and the intended trajectory of a surgical instrument through the skull in the lateral view. Straight vertical  95  and horizontal 96 lines illustrate radiopaque markers and contoured lines  97  and  98  illustrate skin incision trajectories. 
       FIG. 10  shows a representation of the side of view of a fluoroscope system  100  having an image intensifier  101 , a CCD camera  102 , a monitor  103 , a C-Arm  104 , a collimator  105  and an X-ray tube  106 . The fluoroscope system  100  is known as a C-Arm system. The directed x-ray radiation generated by the X-ray tube  106  passes through the body part at position between the collimator  105  and the image intensifier  101  that is transmitted via the CCD camera  102  to the monitor  103 . The X-rays are either continuous or pulsing so that the surgeon can view the surgery via the monitor  103  in real time. 
       FIG. 11A  is a more detailed prospective view of a self-contained C-Arm Fluoroscopic system  200 . The system  200  having an image intensifier  201 , a grid  201 , optics  203 , a CCD camera  2014 , monitors  205 A and  205 B, collimators  206 , filters  207 , X-ray tube  208 , a generator  209  and automatic brightness control  210 . The collar system  2  of  FIG. 1  would fit around the circumference of the image intensifier  201  at  221  or around the Collimators  206  at  221 .  FIG. 11  B is a side view of a version 250 of the Smart Laser Aimer from GE OEC (GE Healthcare, Salt Lake City, Utah) noted earlier is one of the systems to be used with the invention where is shows the position of the collar system  2  in  FIG. 1  can be placed at positions  251  and  252 , depending on the position of the physician and the need entry point for surgery. 
     The collar system  2  discussed in  FIG. 1  would fit around the circumference image intensifier  101  in  FIG. 10  or the Collimator  110 .  FIG. 12  shows in a perspective cut away the collar system  300  with light source  301 , which in this instance is a laser light source, a radiopaque marker  302  that is held in housing  303  and secured in the housing by fitting  305 . The housing  303  is part of an assembly  320 , shown more clearly in  FIG. 13 .  FIG. 13  illustrates that the housing  303  has pivoting movement  304  in an arc of no more than plus or minus 5 degrees. Limiting the radiopaque bar/visible light marker to pivot on its axis to −+5° ensures projected lines under fluoroscopy stay within the limits of beam divergence parameters for accuracy of visible light on patient&#39;s skin. The radiopaque markers are always facing the center of the collar to minimize beam divergence. The entire assembly  320  fits into the circumferential channel  310  in  FIG. 12 . The entire assembly rotates around the circumference of the image intensifier of  FIGS. 10 and 11  in the channel  310 . The assembly has three wheels  333  and  334  in  FIGS. 13 and 335  in  FIG. 12  that permit circumferential movement around channel  310 . When the proper location is found by viewing the radiopaque marker  302  as it appears on monitor  103  in  FIG. 10  or Monitor  205  A. 
     The assembly  320  has a locking lever  321  that locks the assembly  320  in the desired circumferential position in channel  310  around the circumference of the image intensifier  101  in  FIG. 10 . The collar system  300  also fits around the circumference of the grid  202  and the assembly  320  would move around the circumference of the image intensifier  201  and the grid  201 . 
       FIG. 14  a partial side view of the collar system with assembly  320  in channel  310  with the assembly having light source  310  and radiopaque  302  held in housing  303 .  FIG. 15  shows a partial front view of the collar system  300  showing channel  310 , lock lever  321 , housing  303  light source  301 , and radiopaque marker  302 .  FIG. 16  shows a partial top view of collar system  300  and the assembly  320  with housing  303 , fitting  305  and locking lever  321 . 
       FIG. 17  illustrates a perspective view of collar system  400  having collar  401  that fits around the circumference of the image intensifier  101  or the Collimator  110  in  FIG. 10  and around the circumference  202  at  220  or the Collimators  206  at  221  of  FIG. 11 . There is outer rim  402  where the assemblies  440 ,  450 , and  460  rotate circumferentially around the grid  202  or the image intensifier  101  or the Collimator  110 . There are also assemblies  450 ,  460 , and  470  that have radiopaque markers  405 ,  406 , and  407 , as well as lights sources  411 ,  412 , and  413 , which illustrates that there can be alternative collar systems with multiple light sources and multiple radiopaque markers. Limiting the radiopaque bar/visible light marker to pivot on its axis to −+5° ensures projected lines under fluoroscopy stay within the limits of beam divergence parameters for accuracy of visible light on patient&#39;s skin. Also, the radiopaque markers are always facing the center of the collar to minimize beam divergence. With the introduction of square faces for the image intensifier or the collimator, the collar here can be easily constructed so that it was square to match up and have a circular channel and face to permitted the assemblies including the radiopaque markers and the light sources to travel around the circumference as shown. Further, with two assemblies on the collar system, the light sources can be arranged to create a target “x” by the intersection of the two light sources to create an entry point for medical instruments. Also, the two radiopaque markers may also be positioned to permit a target “x” on that can be followed by the surgeon. 
       FIG. 18  illustrates the use of preoperative preparation where starting with a CT or MRI axial slice of the affected area, you can plot your angles such as the 15-degree angle  501  and identify landmarks such as  502  and  503  and where the skin port  504  for entry of the guide pin that will mimic the radiopaque position  505 . This will normally be accomplished preoperatively, but can also be accomplished intraoperatively as needed. 
       FIG. 19  shows a lateral image  600  having a radiopaque marker  601 . The added accuracy is to have the guide pin insertion (not shown) to mimic or be position the same as the radiopaque marker  601  to provide a more accurate and quicker insertion by also using the AP angle or azimuth angle of 15 degrees. The radiopaque marker provides the surgeon with an insertion to replicate here for use in spine surgery or in any other type of surgery where precision and accuracy are required and the desire is to accomplish the same as minimally invasive. 
       FIG. 20  illustrates another version of a collar system for the fluoroscopic system  700 , where the position of the radiopaque marker  702  is projected on image  600  which would be found on monitor  103  of Fluoroscopic system  100  in  FIG. 10  or on monitor  205  A on fluoroscopic system in  FIG. 11 . The surgeon now has the image that she can precisely follow in inserting a guide pin. 
       FIG. 21  A illustrates a Jamshidi  750  with stylet  752  and cannula  751  where the stylet slides into to complete the Jamshidi. Also, illustrated in  FIG. 21  A is target guide holder  755  with an opening that goes completely through the center of  755 . The target guide holder is made of a plastic that cannot be picked up by the X-rays of the fluoroscopic systems. The target guide  755  is held by a standard mechanical arm used in surgery so that it can be properly positioned by the position of the radiopaque marker and the angle in the AP Plane and the Angles in the ML plane for proper insertion of the surgical instruments.  FIG. 21  B illustrates a series of bubble inclinometers  800  in various positions for inclinometers  801 ,  802 ,  803 , and  804 . These inclinometers will slide into the Jamshidi cannula  805  through opening  806  or the inclinometers can slide into the target guide holder  855  through opening  856  that goes through the entire length of the target guide holder  855  in order to determine the angel for the lateral plane and the AP plane for use correct angle and placement of the instruments such as a Jamshidi to make the initial incision. 
       FIG. 21  A illustrates a Jamshidi  750  that can be placed in a target guide holder  755 . The holder would be held by a standard mechanical arm used in surgery (not shown) that would not be picked up on the x-ray of the fluoroscope system, whether they be system illustrated in  FIG. 10, 11  A or  11  B or any other commercial fluoroscopic system.  FIG. 21  B illustrates bubble inclinometers  800  that would be used to provide the correct angle of the Jamshidi. The stylet of Jamshidi  751  would be withdrawn and an inclinometer such as  801  can be used by placing in the cannula of the Jamshidi  751  or  806  of  805  in  FIG. 21B  and the angle positioning can be determined for the AP Plane and the ML plane. Finally, the position of the Jamshidi  750  in target guide holder  755  would be aligned to mimic the position of the radiopaque marker  601  in  FIG. 19 . Then the surgeon can position the mechanical arm over the point of intersection of the entry point  51  of  FIG. 4 , which is where the two light sources intersect. Once there is the final position at point  51 , the surgeon can then make the incision using the Jamshidi  750 . The surgeon can also use a trocar, cannula, a drill bit or any surgical device used to make an incision at point  51  in  FIG. 4 . The instant invention and its many uses should not be limited to spine surgery, but can be used in surgery where there are two planes or even where there is a single plane of interest. 
       FIG. 22  is an illustration of a wrist  950  having a plate  951  and screws  952  with hand  955  that can benefit from the precision of the instant invention. Horizontal and vertical laser lines can be projected on the plane of the screw holes in the x and y plane and a radiopaque marker can be used to establish the correct position for inserting the screws  952 . 
       FIG. 23  is an illustration of a Humeral Shaft  1000  that can benefit from the instant invention as the screw lines  1001  and  1002  can be projected on the skin from the laser light sources, as well as the radiopaque marker, not shown, can illustrate further an exact duplication of the insert points for the screws. 
       FIG. 24  is an illustration of a device which combines features of the Jamshidi of  FIGS. 21A and 21B  with further improvements and modifications. The instrument of  FIG. 24 , will be referred to as an instrument-guiding device  1100 . Instrument-guiding device  1100  has a body  1101  first inclinometer  1102  for measuring an angle in one plane and a second inclinometer  1103  for measuring an angle in another plane. The planes can be, for example, the lateral plane and the anterior-posterior (AP) plane at 90 degrees from the lateral plane. The body  1101  has a flange at each side thereof, which can be referred to as first flange  1104  and second flange  1107 . First inclinometer  1102  has angle indicia  1105  and second inclinometer  1103  has angle indicia  1106  each for establishing an angle relative to a position of the instrument-guiding device in different planes in order to assist in determining the skin-entry point for the entry incision and placement of a surgical instrument such as a pedicle screw, a cannula, a Steinman pin, a Moore&#39;s Pin, a Knowel&#39;s Pin, a Denham Pin. K Wire, or any such similar surgical instrument. 
     Also illustrated in  FIG. 24 , there is a cannula  1108  connected to the body  1101  at fitting  1110 . The fitting  1110  can be a screw, snap in device or any component that connects a cannula  1108  to the body  1101 . The cannula  1108  can in the alternative be a needle, a Steinman pin, a Moore&#39;s Pin, a Knowel&#39;s Pin, a Denham Pin, K Wire, a Star Wrench or any surgical instrument that would assist in any orthopedic surgery with the use of the instrument-guiding device.  FIG. 24  also illustrates angle indicator  1112  that can travel around the edge of the indicia  1106 . 
       FIG. 25  illustrates a perspective view from the top of the instrument-guiding device  1100 . It illustrates that first inclinometer  1102  rotated 90 degrees from second inclinometer  1103 . This is to enable the use of the instrument-guiding device  1100  to find the correct incision angle in each of two planes. The instrument-guiding device  1100  has impact surface  1115  that can be used to push the cannula or needle  1108  into appropriate position during orthopedic surgery to create an incision. 
       FIG. 26  is a rear view of the instrument-guiding device  1100  having the body  1101 , connector  1110 , needle or cannula  1108 , first and second flange surfaces  1104  and  1107  and impact surface  1115 , which can be impacted using one hands or other instruments, such as a hammer like device, which is not shown. 
       FIG. 27  illustrates the body  1101  ready to receive a needle, cannula, pin or start wrench at connector  1110  or any similar such device for use during orthopedic surgery. 
       FIG. 28  illustrates an alternative instrument-guiding device  1200 , which has a body  1201 , first inclinometer  1202 , second inclinometer  1203  with angle indicia  1205  and  1206 , impact surface  1215 , first flange  1204  and second flange  1207  and graduated marked needle or cannula  1208  connected at connector  1210 , which can be a screw, snap-on or any easy manner to connect the cannula  1208 . Again  1208 , can be a cannula, a needle, a Steinman pin, a Moore&#39;s Pin, a Knowel&#39;s Pin, a Denham Pin, K Wire, a Star Wrench or any surgical instrument that would assist in any orthopedic surgery with the use of the instrument-guiding device  1200 . There is also the angle marker  1212  that can ride along the curved surface of the indicia  1206  indicating the angle of second inclinometer  1203 . The impact surface  1215  is more substantial in this  1200  version of the instrument-guiding device than the  1100  version of the instrument-guiding device above and can be seen in the side view of the instrument-guiding device  1200  in  FIG. 29 . 
       FIG. 30  illustrates a bottom view of both instrument-guiding device  1100  and  1200  illustrating the body  1201 , the connector  1210 , the angle indicator  1212  and indicia surface  1206 . 
     The use of the instrument-guiding devices detailed herein provide a great advance over the use of K Wire for screw insertion because K Wire can break, bend, pull out or advance during the orthopedic procedure. 
     The method and system here can be used not just for surgery but also for training of surgeons on cadavers or simulated bodies to improve technique and understanding. The training aspect of the instant invention is a key use of the method and system disclosed herein because it will provide a much more precise and accurate surgical technique being developed by surgeons. 
     Now, therefore, in accordance with the described features and examples, a system for guiding a surgical instrument during a medical procedure is described, the system may comprise: a collar device comprising: a radiographic marker configurable about the collar device to be aligned with an anatomical feature associated with the medical procedure, and a laser light source coupled to the collar device and configured to emit laser light for replicating a surgical reference plane extending through each of the radiographic marker and the anatomical feature; and an instrument-guiding device configured for use in conjunction with the collar device, the instrument-guiding device comprising: a body configured to be coupled to the surgical instrument, and a gravimetric inclinometer coupled to the body and configured to measure an instrument angle relative to the surgical reference plane for translating the surgical instrument along a surgical axis; wherein the system is configured to guide the surgical instrument with at least one of the surgical instrument and the instrument-guiding device being maintained in alignment with the laser light, and the gravimetric inclinometer being maintained at the instrument angle. 
     In an embodiment, the system may further include: a second gravimetric inclinometer being coupled with the body and configured to measure a second instrument angle indicating alignment of the surgical instrument. 
     In an embodiment, the gravimetric inclinometer is integrated with the body of the instrument-guiding device. 
     In an embodiment, the collar may further comprise a circumferential channel, wherein the radiopaque marker and the laser light source are each coupled therewith and independently configured for rotation about said circumferential channel. 
     In an embodiment, the collar device may further comprise a housing coupled to the radiographic marker and the laser light source, wherein the housing is adapted for pivotal movement. In some embodiments, the housing may be adapted for up to 10 degrees of pivotal movement with respect to a housing axis. 
     In an embodiment, the radiographic marker may comprise a linear radiographic marker. In some embodiments, the radiographic marker may be configured to intersect a center of the collar device. 
     In an embodiment, the collar device may further comprise a plurality of laser light sources and a plurality of radiopaque markers. 
     Of course, the foregoing description is that of certain features, aspects and advantages of the present invention, to which various changes and modifications can be made without departing from the spirit and scope of the present invention. 
     Moreover, the surgical targeting systems and methods need not feature all of the objects, advantages, features and aspects discussed above. Thus, for example, those skilled in the art will recognize that the invention can be embodied or carried out in a manner that achieves or optimizes one advantage or a group of advantages as taught herein without necessarily achieving other objects or advantages as may be taught or suggested herein. In addition, while a number of variations of the invention have been shown and described in detail, other modifications and methods of use, which are within the scope of this invention, will be readily apparent to those of skill in the art based upon this disclosure. It is contemplated that various combinations or subcombinations of these specific features and aspects of embodiments may be made and still fall within the scope of the invention. Accordingly, it should be understood that various features and aspects of the disclosed embodiments can be combined with or substituted for one another in order to form varying modes of the discussed surgical marking systems and methods.