Methods and devices for surgical access

Abstract

Devices, systems and surgical methods for achieving surgical access to a site within the body, particularly the spine. Systems include one or more of a modular retractor with a body and hood that are independently operable at their proximal ends to manipulate soft tissue at their distal ends and may be adjustably and releasably coupled to form an open channel to a target tissue, and instruments for manipulating tissue.

I claim: 
     
         1 . A tissue preparation device comprising:
 a. an insertion assembly having a proximal end that is adapted to extend outside of a surgical field and a distal end that is adapted to extend into the surgical field,   b. a tissue engagement component comprising at least one tissue manipulator;   c. a drive component having proximal and distal portions and connectable at its proximal portion to the insertion assembly and at its distal portion to the tissue engagement component;   d. an actuator having proximal and distal ends and connectable to the insertion assembly and adapted to engage at its distal end with the drive component to actuate the tissue manipulator,
 wherein the drive component directs force along a path between proximal and distal ends of the tissue engagement component to selectively advance the at least one tissue manipulator in a distal direction and withdraw the at least one tissue manipulator in a proximal direction. 
   
     
     
         2 . A tissue preparation device according to  claim 1 , further comprising a housing that at least partially encloses all or a portion of each of the drive components and tissue engagement components, the housing selected from an open frame, a closed frame, and at least one pair of opposing slates, and the housing having a shape that is rectilinear or curvilinear along at least a portion of a length between proximal to distal ends. 
     
     
         3 . A tissue preparation device according to  claim 1 , wherein at least the tissue engagement component is curvilinear and has a radius of curvature from between 5 cm and 25 cm. 
     
     
         4 . A tissue preparation device according to  claim 1 , wherein at least the tissue engagement component is rectilinear. 
     
     
         5 . A tissue preparation device according to  claim 1  wherein the tissue engagement component comprises a tissue manipulator selected from cutting instruments selected from a single blade, a plurality of blades, and a box shaped blade that has a central void and is rectangular in shape; a pair of opposing elongated blades that are one of rectilinear and curvilinear, each of the blades having a distal end and a proximal end, wherein the distal ends of the blades are translatable from a collapsed orientation wherein the blades touch at least at their distal ends, to a spread orientation wherein the blades are spread apart and not in contact; a distractor paddle; an implant trial; an endplate scraper; an implant; and a length adjuster frame that is adapted for actuation between a plurality of preset lengths to adjust the distance of a tissue manipulator for extension into the disc space. 
     
     
         6 . A spinal tissue preparation device according to  claim 5 , the tissue engagement component comprising a pair of opposing curvilinear elongated blades, wherein each of the blades has a radius of curvature from between 5 cm and 60 cm or more. 
     
     
         7 . A spinal tissue preparation device according to  claim 1 , wherein the actuator is selected from a strike plate for directing either distal or proximally oriented concussive force to advance or withdraw the insertion assembly, a handle, a trigger, and an axial rotatable knob. 
     
     
         8 . A spinal tissue preparation device according to  claim 1 , wherein the drive component is selected from a ratchet, a gear system comprising one or more rack and pinion components, a walking beam and plates drive system, and a threaded rod with a shift for providing rotational force to alternately drive distal to proximal movement of the tissue engagement component. 
     
     
         9 . A spinal tissue preparation device according to  claim 1 , further comprising one or more of an adjustable and releasable stabilization handle for positioning and stabilizing the tissue preparation device, the handle being adjustable and releasable to avoid interference with other surgical instruments. 
     
     
         10 . A spinal tissue preparation device according to  claim 1 , further comprising a vertical shift component for dorsal to ventral vertical adjustment and positional locking of the actuator to avoid interference between components of the insertion assembly and with other surgical instruments. 
     
     
         11 . A tissue preparation device according to  claim 1 , wherein the actuator comprises a strike plate, the drive component of the insertion assembly comprises a curvilinear housing that at least partially encloses the tissue manipulator and at least a portion of the distal end of the actuator, the housing comprising at its distal end a tissue engagement seat comprising at least a pair of engagement teeth for penetrating target tissue and a guide for directing the tissue manipulator into engagement with target tissue between the teeth, and comprising an elongate curvilinear push rod having proximal and distal ends and engageable at its distal end to the tissue manipulator and at its proximal end to the actuator, and wherein the tissue manipulator comprises a cutting instrument releasably attachable to the drive component, the cutting instrument selected from a single blade, a plurality of blades, and a box shaped blade that has a central void and is rectangular in shape. 
     
     
         12 . A tissue preparation device comprising:
 a. an insertion assembly having a proximal end that is adapted to extend outside of a surgical field and a distal end that is adapted to extend into the surgical field,   b. a tissue engagement component comprising at least one tissue manipulator;   c. a drive component having proximal and distal portions and connectable at its proximal portion to the insertion assembly and at its distal portion to the tissue engagement component;   d. an actuator having proximal and distal ends and connectable to the insertion assembly and adapted to engage at its distal end with the drive component to actuate the tissue manipulator   wherein the tissue engagement component comprises a first tissue manipulator that comprises a pair of opposing curvilinear elongated blades, each of the curvilinear blades having a distal end and a proximal end, wherein each of the blades has a radius of curvature from between 5 cm and 40 cm, and wherein the distal ends of the curvilinear blades are translatable from a collapsed orientation wherein the blades touch at least at their most distal ends, to a spread orientation wherein the blades are spread apart and not in contact.   
     
     
         13 . A spinal tissue preparation device according to  claim 12 , wherein the drive component is selected from a ratchet or gear system comprising one or more rack and pinion components, a walking beam and plates drive system, and, a threaded rod with a shift for providing rotational force to alternately drive distal and proximal movement of the insertion assembly. 
     
     
         14 . A spinal tissue preparation device according to  claim 12 , further comprising a tissue manipulator attachment element comprising a universal joint attachable to the distal end of the drive system actuator, a frame having distal and proximal attachment ends and blade receiving sidewalls into which each of the respective blades are inserted, the frame attachable at its proximal end to the universal joint, and movable from the proximal to the distal ends of the blades to a terminal position defined by a positive stop on one or both blades. 
     
     
         15 . A spinal tissue preparation device according to  claim 12 , further comprising a releasable tissue manipulator fastener for engagement of a second tissue manipulator. 
     
     
         16 . A spinal tissue preparation device according to  claim 15 , further comprising a second tissue manipulator selected from a distractor paddle, an implant trial, a cutting instrument, an endplate scraper, and an implant; a length adjuster that is adapted for actuation between a plurality of preset lengths to adjust the distance of the second tissue manipulator from the frame. 
     
     
         17 . A tissue preparation device according to  claim 12 , comprising:
 a. an actuator selected from a ratchet or gear system comprising one or more rack and pinion components, a walking beam and plates drive system, and, a threaded rod with a shift for providing rotational force to alternately drive distal and proximal movement of the insertion assembly;   b. an optional drive release button to release the drive to manual proximal to distal insertion and removal;   c. one or more of an adjustable and releasable stabilization handle for positioning and stabilizing the tissue preparation device, the handle being adjustable and releasable to avoid interference with other surgical instruments, and a vertical shift component for dorsal to ventral vertical adjustment and positional locking of the drive actuator to avoid interference between components of the insertion assembly and with other surgical instruments;   d. a tissue manipulator attachment element comprising
 i. a universal joint attachable to the distal end of the actuator, 
 ii. an extender frame having distal and proximal attachment ends and blade receiving sidewalls into which each of the respective blades are inserted, the frame attachable at its proximal end to the universal joint, and movable from the proximal to the distal ends of the blades to a terminal position defined by a positive stop on one or both blades, 
 iii. a releasable tissue manipulator fastener for engagement of a second tissue manipulator selected from a distractor paddle, an implant trial, a cutting instrument, an endplate scraper, and an implant; 
 iv. a length adjuster that is adapted for actuation between a plurality of preset lengths to adjust the distance of the second tissue manipulator from the extender frame; 
   wherein, in operation, the blades are insertable into the target tissue in their collapsed orientation with the frame at the proximal end of the blades, and positive actuation of the drive component directs the extender frame towards the tissue and expands the blades, driving the second tissue manipulator into contact with the target tissue, and upon further positive actuation, withdrawing the blades from the tissue leaving the extended second tissue manipulator within the target tissue; and   wherein negative actuation of the drive component withdraws the frame away from the tissue, drawing the frame toward the proximal end of the instrument and allowing the blades to collapse for easy withdrawal from the surgical field, and   wherein, in operation, the blades are insertable into the target tissue in their collapsed orientation with the frame at the proximal end of the blades, and positive actuation of the drive component directs the frame towards the tissue and expands the blades, driving the second tissue manipulator into contact with the target tissue, and upon further positive actuation, withdrawing the blades from the tissue leaving the extended second tissue manipulator within the target tissue. And According to such embodiments, negative actuation of the drive component withdraws the frame away from the tissue, drawing the frame toward the proximal end of the instrument and allowing the blades to collapse for easy withdrawal from the surgical field.   
     
     
         18 . A method for performing a surgical procedure on the spine of a patient, the method comprising:
 selecting a tissue preparation device according to  claim 1 , and proceeding with one or more of the following steps in the provided or any other order, including:   inserting the tissue preparation device into the channel and into contact with the target vertebral space, the tissue preparation device fitted with a cutting instrument for penetrating a annulus of a disc within the target vertebral space, and actuating the drive component to direct the cutting instrument into contact with the target vertebral space to penetrate the annulus;   actuating the drive component to withdraw and replace the cutting instrument with another cutting instrument for penetrating a contralateral annulus of the disc within the target vertebral space, actuating the drive component to insert the tissue manipulator into contact with the target vertebral space to penetrate the contralateral annulus;   actuating the drive component to withdraw and replace the cutting instrument with a distraction paddle, actuating the drive component to insert the tissue manipulator into contact with the target vertebral space to deliver the paddle distractor which is actuated to enhance distraction of the adjacent vertebrae;   actuating the drive component to withdraw and replace the distraction paddle with an endplate scraper, and actuating the drive component to insert the tissue manipulator into contact with the target vertebral space to deliver the scraper which is actuated to withdraw disc material from the disc space;   actuating the drive component to withdraw and replace the endplate scraper with an implant trial, and actuating the drive component to insert the tissue manipulator into contact with the target vertebral space to deliver the implant trial to determine implant size;   actuating the drive component to withdraw and replace the implant trial;   fitting the tissue preparation device with first and second tissue manipulators including a first tissue manipulator comprising a pair of opposing elongated blades that are one of rectilinear and curvilinear, each of the blades having a distal end and a proximal end, wherein the distal ends of the blades are translatable from a collapsed orientation wherein the blades touch at least at their distal ends, to a spread orientation wherein the blades are spread apart and not in contact, and actuating the drive component to direct the pair of blades into the target vertebral space, and including a second tissue manipulator comprising an implant;   actuating the drive component to expands the blades,   actuating the drive component to insert the second tissue manipulator into contact with the target vertebral space to deliver the implant between the expanded blades into the disc space,   actuating the drive component to collapse and withdraw the blades,   actuating the drive component to release and deposit the implant in the vertebral space;   withdrawing the tissue preparation device from the channel.   
     
     
         19 . A method for performing a surgical procedure on the spine of a patient according to  claim 18 , the method comprising:
 at least one of the steps selected from:   inserting the tissue preparation device into the channel and into contact with the target vertebral space, the tissue preparation device fitted with a cutting instrument for penetrating a annulus of a disc within the target vertebral space, and actuating the drive component to direct the cutting instrument into contact with the target vertebral space to penetrate the annulus;   inserting the tissue preparation device into the channel and into contact with the target vertebral space, the tissue preparation device fitted with a cutting instrument for penetrating a contralateral annulus of the disc within the target vertebral space, actuating the drive component to insert the tissue manipulator into contact with the target vertebral space to penetrate the contralateral annulus;   inserting the tissue preparation device into the channel and into contact with the target vertebral space, the tissue preparation device fitted with an endplate scraper, and actuating the drive component to insert the tissue manipulator into contact with the target vertebral space to deliver the scraper which is actuated to withdraw disc material from the disc space.   
     
     
         20 . A method for performing a surgical procedure on the spine of a patient according to  claim 18 , the method comprising:
 inserting the tissue preparation device into the channel and into contact with the target vertebral space, the tissue preparation device fitted with first and second tissue manipulators including a first tissue manipulator comprising a pair of opposing elongated blades that are one of rectilinear and curvilinear, each of the blades having a distal end and a proximal end, wherein the distal ends of the blades are translatable from a collapsed orientation wherein the blades touch at least at their distal ends, to a spread orientation wherein the blades are spread apart and not in contact, and actuating the drive component to direct the pair of blades into the target vertebral space, and including a second tissue manipulator comprising an implant;   actuating the drive component to expands the blades,   actuating the drive component to insert the second tissue manipulator into contact with the target vertebral space to deliver the implant between the expanded blades into the disc space,   actuating the drive component to collapse and withdraw the blades,   actuating the drive component to release and deposit the implant in the vertebral space;   withdrawing the tissue preparation device from the channel.