US007198598B2
`
`(12) United States Patent
`Smith et al.
`
`(10) Patent N0.:
`(45) Date of Patent:
`
`US 7,198,598 B2
`*Apr. 3, 2007
`
`(54) DEVICES AND METHODS FOR
`PERCUTANEOUS SURGERY
`
`(75) Inventors: Maurice M- Smith, Cordova, TN (Us);
`Kevin T- F°leys Gennamown, TN (Us);
`Th‘mlas E- ROehm, HI, Bradejns TN
`(US); William Barry Null, Olive
`Branch’ MS (Us)
`
`(73) Assignee: Warsaw Orthopedic, Inc., Warsaw, IN
`US
`(
`)
`Subject to any disclaimer, the term of this
`patent is extended or adjusted under 35
`U.S.C. 154(b) by 417 days.
`
`( * ) Notice:
`
`This patent is subject to a terminal dis
`claimen
`
`(51) Int. Cl.
`(2006.01)
`A61B 1/00
`(2006.01)
`A61B 1/313
`(52) us. Cl. ..................................... .. 600/114; 600/102
`(58) Field of Classi?cation Search .............. .. 600/102,
`600/114, 101, 125, 136; 604/164.01, 164.07,
`604/264
`See application ?le for complete search history.
`
`(56)
`
`References Cited
`U.S. PATENT DOCUMENTS
`2,235,979 A
`3/194 1 Brown
`
`(Continued)
`FOREIGN PATENT DOCUMENTS
`
`(21) Appl. N0.: 10/760,817
`
`DE
`
`1 566 “6
`
`M970
`
`(22) Filed:
`
`Jan. 20, 2004
`
`(Continued)
`
`(65)
`
`Prior Publication Data
`
`OTHER PUBLICATIONS
`
`Us 2004/0186346 A1
`
`8313- 23, 2004
`
`Related US. Application Data
`_
`_
`_
`_
`
`_
`
`(60) Contmuation-m-pait of appl1cat1on No. 09/815,693,
`?led on Mar. 23, 2001, noW Pat. No. 6,679,833,
`Which is a continuation-in-part of application No.
`PCT/US99/21866, ?led on Sep. 21, 1999, Which is a
`continuation-in-part of application No. 09/233,879,
`?led on Jan. 20, 1999, noW Pat. No. 6,217,509, Which
`is a division of application No. 08/736,626, ?led on
`Oct. 24, 1996, noW Pat. No. 5,902,231, Which is a
`continuation-in-part of application No. 08/620,933,
`?led on Mar. 22, 1996, noW Pat. No. 5,792,044,
`Which is a continuation-in-part of application No.
`10/359,996, ?led on Feb. 6, 2003, Which is a con
`tinuation of application No. 09/449,647, ?led on Nov.
`30, 1999, noW Pat. No. 6,520,907, Which is a division
`ofapplication No. 08/920,991, ?led onAug. 29, 1997,
`noW Pat. No. 6,007,487, Which is a division of
`application No. 08/620,933, ?led on Mar. 22, 1996.
`
`Met/"x SystemTM MicroEndoscopic Discectomy Surgical Technique,
`Medtronic Sofamor Danek, 1999.
`
`Primary Examinerilohn P. Leubecker
`
`(74) Attorney] Agent] or FirmiKrieg Devault LLP
`
`(57)
`
`ABSTRACT
`
`Methods and devices for performing surgery in a patient are
`provided. A cannula provides a Working channel for access
`to a location in the patient. A clamp assembly is removably
`engaged to the cannula. The clamp assembly alloWs use of
`an endoscopic vieWing system or can be removed to alloW
`use of a microscopic vieWing system in order to vieW the
`surgical site in the patient through the Working channel. The
`clamp assembly includes a vieWing element mounting por
`tion having a length along Which an endoscopic vieWing
`element can be selectively positioned.
`
`26 Claims, 29 Drawing Sheets
`
` 1
`
`NUVASIVE 1038
`NuVasive, Inc. v. Warsaw Orthopedic, Inc.
`IPR2013-00206
`IPR2013-00208
`
`

`

`US. PATENT DOCUMENTS
`.
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`Page 2
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`
`DE
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`EP
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`FR
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`W0
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`
`
`
` 2
`
`

`

`U.S. Patent
`U.S. Patent
`
`Apr. 3, 2007
`Apr. 3, 2007
`
`Sheet 1 0f 29
`Sheet 1 of 29
`
`US 7,198,598 B2
`US 7,198,598 B2
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`Apr. 3, 2007
`Apr. 3, 2007
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`US 7,198,598 B2
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`Apr. 3, 2007
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`U.S. Patent
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`Apr. 3, 2007
`Apr. 3, 2007
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`Apr. 3, 2007
`Apr. 3, 2007
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`U.S. Patent
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`Apr. 3, 2007
`
`Sheet 6 0f 29
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`US 7,198,598 B2
`
`2
`
`1
`DEVICES AND METHODS FOR
`PERCUTANEOUS SURGERY
`
`CROSS-REFERENCE TO RELATED
`APPLICATIONS
`
`The present application is a continuation-in-part of US.
`patent application Ser. No. 09/815,693 filed on Mar. 23,
`2001, and issuing as US. Pat. No. 6,679,833; which is a
`continuation-in-part of International Patent Application
`Number PCT/US99/21866,
`filed on Sep. 21, 1999, and
`having a priority date of Sep. 25, 1998, which is hereby
`incorporated by reference. Also, the present application is a
`continuation-in-part of US. patent application Ser. No.
`09/815,693 filed on Mar. 23, 2001 and issuing as US. Pat.
`No. 6,679,833; which is a continuation-in-part of US. patent
`application Ser. No. 09/233,879 filed on Jan. 20, 1999 and
`now issued as US. Pat. No. 6,217,509; which is a divisional
`of US. patent application Ser. No. 08/736,626, filed on Oct.
`24, 1996, now issued as US. Pat. No. 5,902,231; which is
`a continuation-in-part of US. patent application Ser. No.
`08/620,933, file Mar. 22, 1996, and now issued as US. Pat.
`No. 5,792,044. Also, this application is a continuation-in-
`part of US. patent application Ser. No. 10/359,996 filed on
`Feb. 6, 2003; which is a continuation of US. patent appli-
`cation Ser. No. 09/449,647 filed Nov. 30, 1999, now issued
`as US. Pat. No. 6,520,907; which is a divisional application
`of US. patent application Ser. No. 08/920,991, filed Aug.
`29, 1997, and now issued as US. Pat. No. 6,007,487; which
`is a divisional of US. application Ser. No. 08/620,933, filed
`on Mar. 22, 1996, now issued as US. Pat. No. 5,792,044.
`
`BACKGROUND
`
`The present invention relates to devices, instruments and
`methods for performing percutaneous surgeries, particularly
`at locations deep within the body. One specific application
`of the invention concern devices,
`instruments and tech-
`niques for percutaneous, minimally invasive spinal surgery.
`In another aspect of the invention, the percutaneous surgery
`is performed under direct vision at any location in the body.
`Traditional surgical procedures for pathologies located
`deep within the body can cause significant trauma to the
`intervening tissues. These open procedures often require a
`long incision, extensive muscle stripping, prolonged retrac-
`tion of tissues, denervation and devascularization of tissue.
`Most of these surgeries require recovery room time of
`several hours and several weeks of post-operative recovery
`time due to the use of general anesthesia and the destruction
`of tissue during the surgical procedure. In some cases, these
`invasive procedures lead to permanent scarring and pain that
`can be more severe than the pain leading to the surgical
`intervention.
`
`Minimally invasive alternatives such as arthroscopic tech-
`niques reduce pain, post-operative recovery time and the
`destruction of healthy tissue. Orthopedic surgical patients
`have particularly benefited from minimally invasive surgical
`techniques. The site of pathology is accessed through portals
`rather than through a significant incision thus preserving the
`integrity of the intervening tissues. These minimally inva-
`sive techniques also often require only local anesthesia. The
`avoidance of general anesthesia reduces post-operative
`recovery time and the risk of complications.
`Minimally invasive surgical techniques are particularly
`desirable for spinal and neurosurgical applications because
`of the need for access to locations deep within the body and
`the danger of damage to vital
`intervening tissues. For
`
`10
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`example, a common open procedure for disc herniation,
`laminectomy followed by discectomy requires stripping or
`dissection of the major muscles of the back to expose the
`spine. In a posterior approach, tissue including spinal nerves
`and blood vessels around the dural sac,
`ligaments and
`muscle must be retracted to clear a channel from the skin to
`
`the disc. These procedures normally take at least one-two
`hours to perform under general anesthesia and require
`post-operative recovery periods of at least several weeks. In
`addition to the long recovery time, the destruction of tissue
`is a major disadvantage of open spinal procedures. This
`aspect of open procedures is even more invasive when the
`discectomy is accompanied by fusion of the adjacent ver-
`tebrae. Many patients are reluctant to seek surgery as a
`solution to pain caused by herniated discs and other spinal
`conditions because of the severe pain sometimes associated
`with the muscle dissection.
`
`In order to reduce the post-operative recovery time and
`pain associated with spinal and other procedures, micro-
`surgical techniques have been developed. For example, in
`micro-surgical discectomies, the disc is accessed by cutting
`a channel from the surface of the patient’s back to the disc
`through a small incision. An operating microscope or loupe
`is used to visualize the surgical field. Small diameter micro-
`surgical instruments are passed through the small incision
`and between two laminae and into the disc. The intervening
`tissues are disrupted less because the incision is smaller.
`Although these micro-surgical procedures are less invasive,
`they still involve some of the same complications associated
`with open procedures, such as injury to the nerve root and
`dural sac, perineural scar formation, rehemiation at
`the
`surgical site and instability due to excess bone removal.
`Other attempts have been made for minimally invasive
`procedures to correct symptomatic spinal conditions. One
`example is chemonucleolysis which involved the injection
`of an enzyme into the disc to partially dissolve the nucleus
`to alleviate disc herniation. Unfortunately,
`the enzyme,
`chymopapain, has been plagued by concerns about both its
`effectiveness and complications such as severe spasms,
`post-operative pain and sensitivity reactions including ana-
`phylactic shock.
`The development of percutaneous spinal procedures has
`yielded a major improvement in reducing recovery time and
`post-operative pain because they require minimal, if any,
`muscle dissection and they can be performed under local
`anesthesia. For example, US. Pat. No. 4,545,374 to Jacob-
`son discloses a percutaneous lumbar discectomy using a
`lateral approach, preferably under fluoroscopic X-ray. This
`procedure is limited because it does not provide direct
`visualization of the discectomy site.
`Other procedures have been developed which include
`arthroscopic visualization of the spine and intervening struc-
`ture. US. Pat. Nos. 4,573,448 and 5,395,317 to Kambin
`disclose percutaneous decompression of herniated discs
`with a posterolateral approach. Fragments of the herniated
`disc are evacuated through a cannula positioning against the
`annulus. The ’317 Kambin patent discloses a biportal pro-
`cedure which involves percutaneously placing both a work-
`ing cannula and a visualization cannula for an endoscope.
`This procedure allows simultaneous visualization and suc-
`tion, irrigation and resection in disc procedures.
`Unfortunately, disadvantages remain with these proce-
`dures and accompanying tools because they are limited to a
`specific application or approach. For example, Jacobson,
`Kambin, and other references require a lateral or a postero-
`lateral
`approach for percutaneous discectomy. These
`approaches seek to avoid damage to soft tissue structures
`
`
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`US 7,198,598 B2
`
`3
`and the need for bone removal because it was thought to be
`impractical
`to cut and remove bone through a channel.
`However,
`these approaches do not address other spinal
`conditions which may require a mid-line approach, removal
`of bone, or insertion of implants or other technique.
`US. Pat. No. 5,439,464 to Shapiro discloses a method and
`instruments for performing arthroscopic spinal surgeries
`such as laminectomies and fusions with a mid-line or medial
`
`posterior approach using three cannulae. Each of the can-
`nulae requires a separate incision. While Shapiro discloses
`an improvement over prior procedures which were limited to
`a postero-lateral or lateral approach for disc work, Shapiro’s
`procedure still suffers from many of the disadvantages of
`known prior percutaneous spinal surgery techniques and
`tools. One disadvantage of the Shapiro procedure is its
`requirement of a fluid work space. Another significant
`detriment is that the procedure requires multiple portals into
`the patient.
`Fluid is required in these prior procedures to maintain the
`working space for proper function of optics fixed within a
`prior art cannula and inserted percutaneously. Irrigation, or
`the introduction of fluid into the working space, can often be
`logistically disadvantageous and even dangerous to the
`patient for several reasons. The introduction of fluid into the
`working space makes hemostasis more diflicult and may
`damage surrounding tissue. Excess fluid may dangerously
`dilute the sodium concentration of the patient’s blood supply
`which can cause seizures or worse. The fluid environment
`
`can also make drilling difficult due to cavitation. The
`requirement for a fluid environment generally increases
`expenses associated with the surgery and adds to the com-
`plexity of the surgery, due in part to the relatively high
`volume of fluid required.
`Aneed has remained for devices and methods that provide
`for percutaneous minimally invasive surgery for all appli-
`cations and approaches. A need has also remained for
`percutaneous methods and devices which do not require a
`fluid-filled working space, but that can be adapted to a fluid
`environment if necessary.
`A significant need is also present in this field for tech-
`niques and instruments that permit surgical procedures in the
`working space under direct vision while employing micro-
`scopic and endoscopic viewing systems. Procedures that
`reduce the number of entries into the patient are also highly
`desirable. The fields of spinal and neuro surgery particularly
`require devices and techniques that minimize the invasion
`into the patient and that are streamlined and concise in their
`application.
`
`SUMMARY
`
`The present invention is directed to methods and devices
`for performing surgery in a patient. In one preferred form,
`the present invention contemplates a cannula that includes a
`working channel to provide access to a location in the patient
`along with the selective employment of an endoscopic
`viewing system or a microscopic viewing system to view the
`location through the working channel. In another preferred
`form,
`the present
`invention contemplates mounting of a
`clamp assembly on the proximal end of a cannula. The
`clamp assembly includes a viewing element mounting por-
`tion having a length along which a viewing element can be
`selectively positioned.
`The present invention further contemplates an elongated
`cannula sized for introduction into a patient. The cannula
`defines a length and a working channel between a distal
`working end and an opposite proximal end. A clamp assem-
`
`4
`
`bly having a viewing element mounting portion can be
`engaged to the cannula with the viewing element mounting
`portion extending proximally from the cannula. A viewing
`element can be selectively engaged at various positions
`along the length of the viewing element mounting portion.
`In a further form, the present invention contemplates a
`device for supporting a viewing element during surgery in a
`patient. The device includes a cannula having a working
`channel defined by an inner surface that extends between a
`proximal end and a distal end of the cannula. A clamp
`assembly is engageable to the cannula by applying a clamp-
`ing force to the inner surface and the outer surface of the
`cannula. The clamp assembly includes a viewing element
`mounting portion that extends proximally from the cannula.
`In one embodiment, the clamp assembly includes a foot that
`extends from the viewing element mounting portion. The
`foot has a channel positionable over the proximal end of the
`cannula. A lever arm is pivotably attached to the foot. The
`lever arm includes a cam member with a cam surface
`
`frictionally engageable to the outer surface of the cannula.
`In yet another form, a device for performing surgery in a
`patient is provided that includes a cannula with a distal
`working end and a proximal end and a working channel
`extending therethrough. The cannula has a length between
`the proximal end and the distal end such that the proximal
`end is positioned at the skin level of the patient when said
`distal end is positioned at a desired location in the patient.
`A clamp assembly that supports a viewing element
`is
`engageable to the proximal end of the cannula. In a preferred
`form the viewing element includes an optics cannula that
`extends into the working channel.
`According to another aspect of the invention, a kit for use
`in percutaneous surgery is provided. The kit includes an
`elongated cannula having a working channel extending
`between a distal working end and an opposite proximal end.
`The kit
`further includes a clamp assembly reinovably
`engageable to the cannula and a viewing element support-
`able by the clamp assembly with an optics cannula of the
`viewing element
`in the working channel. The kit also
`includes a microscope positionable over the proximal end of
`the cannula.
`
`The present invention also contemplates surgical methods
`and techniques employing the instruments and devices
`described herein.
`
`These and other aspects, forms, features, objects, and
`advantages are further described in the following description
`of the illustrated embodiments.
`
`DESCRIPTION OF THE FIGURES
`
`FIG. 1 is a side elevational view of a device according to
`this invention.
`
`FIG. 2 is a top elevational view of a fixture for supporting
`a viewing device within a cannula according to this inven-
`tion.
`FIG. 3 is a side cross-sectional view of the fixture shown
`in FIG. 2.
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`FIG. 4 is a side elevational view of a retractor according
`to one embodiment of this invention.
`FIG. 4A is an end cross-sectional view of the retractor of
`
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`
`FIG. 4 taken along lines AiA.
`FIG. 5 is a top elevational view of the retractor shown in
`FIG. 4.
`FIG. 6 is an end elevational view of the retractor shown
`in FIGS. 4 and 5.
`
`65
`
`FIG. 7 is a side elevational view of a retractor according
`to another embodiment of this invention.
`
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`US 7,198,598 B2
`
`5
`FIG. 7A is an end cross-sectional view of the retractor of
`
`FIG. 7 taken along lines AiA.
`FIG. 7B is an end cross-sectional view of the retractor of
`
`6
`FIG. 33 is a perspective view of one embodiment of a
`lever arm forming part of the barrel clamp mechanism
`shown in FIG. 32.
`
`FIG. 7 taken along lines B7B.
`FIG. 8 is a top elevational view of the retractor shown in
`FIG. 7.
`
`5
`
`FIG. 34 is a perspective view of another embodiment of
`a lever arm forming part of the barrel clamp mechanism of
`FIG. 32.
`
`FIG. 9 is a side elevational view of a dilator according to
`this invention.
`
`FIGS. 10(a)7(i) depicts the steps of a method according to
`this invention.
`FIG. 11 is a side cross-sectional view of a device accord-
`
`ing to one embodiment of this invention.
`FIG. 12 is a side cross-sectional view of an aspiration cap
`as shown in FIG. 11.
`
`FIG. 13 is a top perspective view of a device according to
`another embodiment of the present invention.
`FIG. 14 is a side perspective view of a fixture for
`supporting a viewing device forming part of the device
`shown in FIG. 13.
`
`FIG. 15 is a side elevational view of the device depicted
`in FIG. 13 with the device shown connected to optical
`equipment depicted in phantom lines.
`FIG. 16 is a side elevational view of a scope body forming
`part of the fixture depicted in FIGS. 13 and 14.
`FIG. 17 is a bottom elevational view of the scope body
`shown in FIG. 16.
`
`FIG. 18 is a top elevational view of a lever arm forming
`part of a barrel clamp mechanism used with the fixture
`depicted in FIG. 14.
`FIG. 19 is an end cross-sectional view of the lever arm
`
`shown in FIG. 18 taken along line 19719 as viewed in the
`direction of the arrows.
`
`FIG. 20 is a top elevational view of a barrel cam forming
`part of a barrel clamp mechanism incorporated into the
`fixture depicted in FIG. 14.
`FIG. 21 is a side elevational view of the barrel cam shown
`in FIG. 20.
`
`FIG. 22 is a bottom assembly view showing the assembly
`of the lever arm of FIGS. 18719, the barrel cam of FIGS.
`20721 with the scope body shown in FIG. 14.
`FIG. 23 is a side elevational view of a scope body as
`depicted in FIG. 14 connected to an aspiration circuit.
`FIG. 24 is a cross-sectional view of a human patient at a
`lumbar vertebral
`level with a device according to one
`embodiment of the invention situated within the patient to
`define a working channel above the laminae of the vertebra.
`FIG. 25 is a side elevational view of a tissue retractor
`
`incorporating an optical viewing device.
`FIG. 26 is a top elevational view of the tissue retractor
`incorporating an optical viewing device as shown in FIG.
`25.
`
`FIG. 27 is a side perspective view of a device according
`to another embodiment of the present invention.
`FIG. 27a is a section view along line 271172711 of FIG.
`27.
`
`FIG. 28 is a side perspective view of a modular clamp and
`endoscope assembly forming part of the device of FIG. 27.
`FIG. 29 is a side perspective view of one embodiment of
`a modular clamp for use with the assembly of FIG. 28.
`FIG. 30 is a side perspective view of one embodiment of
`an endoscope for use with the assembly of FIG. 29.
`FIG. 31 is a side elevational view of a coupling mecha-
`nism forming a part of the assembly of FIG. 28.
`FIG. 32 is a partially fragmented cross-sectional view of
`the device taken along line 32732 of FIG. 27.
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`FIG. 35 is a partially fragmented cross-sectional view of
`an alternate embodiment of the device illustrated in FIG. 32.
`FIG. 36 is a sectional view of an alternate embodiment
`
`cross-section of a cannula for use with the present invention.
`FIG. 37 is a sectional view of another alternate embodi-
`
`ment cross-section of a cannula for use with the present
`invention.
`
`FIG. 38 is a perspective view of a device according to a
`further embodiment of the present invention.
`FIG. 39 is a perspective view of a cannula comprising a
`portion of the device of FIG. 38.
`FIG. 40 is a perspective view looking up at a clamp
`assembly comprising a portion of the device of FIG. 38
`detached from the cannula of FIG. 39.
`
`FIG. 41 is another perspective view looking down at the
`clamp assembly rotated about 90 degrees around its central
`vertical axis from its position of FIG. 40.
`FIG. 42 is a perspective view looking down at the clamp
`assembly with the clamp assembly having generally the
`same orientation about its central vertical axis as in FIG. 40.
`
`FIG. 43 is another perspective view looking down at the
`clamp assembly rotated about 180 degrees around its central
`vertical axis from its position of FIG. 40.
`FIG. 44 is side elevational view of a lever arm comprising
`a portion the clamp assembly of FIG. 40.
`FIG. 45 is a bottom plan view ofthe lever arm of FIG. 44.
`FIG. 46 is an elevational view of a fastener for securing
`the lever arm of FIG. 44 to the clamp assembly of FIG. 40.
`FIG. 47 is an elevational view of a roller pin for moving
`a viewing element along a portion of the clamp assembly of
`FIG. 40.
`
`40
`
`FIG. 48 is a section view taken through line 48748 of
`FIG. 47.
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`FIG. 49 is a perspective of the device of FIG. 38 accord-
`ing to another embodiment of the present invention.
`FIG. 50 is a perspective view of a clamp assembly
`comprising a portion of the device of FIG. 49.
`
`DESCRIPTION OF THE ILLUSTRATED
`EMBODIMENTS
`
`For the purposes of promoting an understanding of the
`principles of the invention, reference will now be made to
`the embodiments illustrated in the drawings and specific
`language will be used to describe the same. It will never-
`theless be understood that no limitation of the scope of the
`invention is thereby intended, such alterations and further
`modifications in the illustrated devices and described meth-
`
`ods, and such further applications of the principles of the
`invention as illustrated therein being contemplated as would
`normally occur to one skilled in the art
`to which the
`invention relates.
`
`The present invention provides instruments and methods
`for performing percutaneous surgery, including spinal appli-
`cations such as laminotomy, laminectomy, foramenotomy,
`facetectomy or discectomy, with a single working channel
`endoscope. The present inventors have discovered that many
`percutaneous surgeries may be performed without a fluid
`workspace through the use of optics which move indepen-
`
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`

`US 7,198,598 B2
`
`7
`dently of the cannula. The present invention contemplates
`techniques and instruments that can be implemented with or
`without a fluid environment.
`
`8
`preferably supports the viewing element 50 for movement
`within the optics bore 60 along the longitudinal axis 1 of the
`bore 60 to extend or retract the lens 55 relative to the distal
`
`This invention also brings the advantages of percutaneous
`procedures to applications that previously required open
`surgery. One advantage is based upon the further discovery
`that bone work can be performed percutaneously through a
`large working channel. Another advantage is realized in the
`use of a single portal within the patient to perform a wide
`range of simultaneous procedures.
`According to one embodiment of the present invention, as
`depicted in FIG. 1, a device 10 is provided for use in
`percutaneous surgery which includes an elongated cannula
`20 having a first inner diameter D 1 and an outer diameter DO
`sized for percutaneous introduction into a patient. The
`cannula 20 also includes a distal working end 21 and an
`opposite proximal end 22. The cannula defines a working
`channel 25 between the ends 21, 22 having a second
`diameter d2 equal to the first inner diameter Dl sized for
`receiving a tool therethrough. The cannula has a length
`along its longitudinal axis L that is sized to pass through the
`patient from the skin to an operative site or working space.
`In some cases, the working space may be adjacent a vertebra
`or disc, or in the spinal canal.
`An elongated viewing element 50 is mountable inside
`cannula 20 adjacent the working channel 25. The viewing
`element 50 has a first end 51 connectable to a viewing
`apparatus, such as an eyepiece or camera, and an opposite
`second end 52 disposed or positionable adjacent the distal
`working end 21 of the cannula 20. The particular elongated
`viewing element 50 is not critical to the invention. Any
`suitable viewing element is contemplated that creates an
`optical or image transmission channel. In one embodiment,
`the elongated viewing element 50 includes a fiber optic
`scope 54 and a lens 55 at the second end 52. Preferably, the
`fiber optic scope includes illumination fibers and image
`transmission fibers (not shown). Alternatively, the viewing
`element may be a rigid endoscope or an endoscope having
`a steerable or bendable tip.
`One advantage of this invention is that it provides optics
`which are movable relative to the can