Surgical access system and related methods
A surgical access system including a tissue distraction assembly and a tissue refraction assembly, both of which may be equipped with one or more electrodes for use in detecting the existence of (and optionally the distance and/or direction to) neural structures before, during, and after the establishment of an operative corridor to a surgical target site.
1. A system for accessing a lateral aspect of a lumbar spine, comprising:
an initial dilator configured to advance to a targeted spinal disc along a lateral, trans-psoas path to the lumbar spine, a distal tip region of the initial dilator including a stimulation electrode configured to deliver electrical stimulation away from the distal tip region for nerve monitoring when the initial dilator is positioned in the lateral, trans-psoas path;
an elongate guidewire instrument advanceable through an inner lumen of the initial dilator, the elongate guidewire instrument having a distal tip configured to penetrate into a lateral aspect of a targeted spinal disc along the lateral, trans-psoas path to the lumbar spine, the elongate guidewire instrument having a longitudinal length that is greater than a longitudinal length of the initial dilator;
plurality of supplemental dilators of increasing diameters to create a tissue distraction corridor along the lateral, trans-psoas path to the lumbar spine, a first supplemental dilator of the plurality of supplemental dilators having a lumen to slidably receive the initial dilator and having a longitudinal length that is less than the longitudinal length of the initial dilator, and a second supplemental dilator of the plurality of supplemental dilators having a lumen to slidably receive the first supplemental dilator and having a longitudinal length that is less than the longitudinal length of the first supplemental dilator; and
a three-bladed retractor assembly comprising three retractor blades that are simultaneously advanceable over an exterior of an outer dilator of the plurality of supplemental dilators while the three-bladed retractor assembly is advanced toward the spinal disc along the lateral, trans-psoas path, the three retractor blades being configured to enlarge the distraction corridor and maintain a trans-psoas operative corridor along the lateral, trans-psoas path to the lumbar spine, the three-bladed retractor assembly further comprising a respective extension element to mate with each retractor blade of the three retractor blades so that a distal region of the respective extension element is configured to extend distally from a distal end of the retractor blade, the three-bladed retractor assembly further comprising a blade holder assembly configured to adjust the three retractor blades from a first position in which the three retractor blades are advanceable over the exterior of the outer dilator of the plurality of supplemental dilators to a second position in which the three retractor blades are moved away from one another, and wherein the three retractor blades are configured to maintain the trans-psoas operative corridor at a size so dimensioned to pass an implant through the trans-psoas operative corridor along the lateral, trans-psoas path toward the lumbar spine.
2. The system of claim 1 , wherein each retractor blade of the three retractor blades includes a track portion configured to slidably engage the respective extension element so that the distal region of the respective extension element is maintained distally from a distal end of the retractor blade.
3. The system of claim 1 , wherein the respective extension element for at least one retractor blade of the three retractor blades comprises a blade extender configured to prevent ingress to or egress of instruments or biological structures into or out of the operative corridor.
4. The system of claim 1 , wherein the respective extension element for a first retractor blade of the three retractor blades comprises a fixation element including a distal penetration portion configured to penetrate into the lumbar spine.
5. The system of claim 4 , wherein the fixation element includes a proximal portion to engage with the first refractor blade and having a width that is greater than a maximum width of the distal penetration portion of the fixation element that is configured to penetrate into the lumbar spine.
6. The system of claim 1 , wherein the blade holder assembly comprises movable arm portions to adjust the three-bladed retractor assembly from the first position to the second position.
7. The system of claim 6 , wherein the three retractor blades extend generally perpendicularly relative to the movable arm portions.
8. The system of claim 6 , wherein the blade holder assembly is configured to maintain a first retractor blade of the three retractor blades in a generally stationary orientation relative to the lumbar spine while a second blade of the three retractor blades is pivoted relative to the first blade.
9. The system of claim 1 , wherein the blade holder assembly is configured to maintain the three retractor blades in said first position in which the three retractor blades are generally adjacent to one another.
10. The system of claim 8 , the blade holder assembly is configured to adjust the three retractor blades to the second position in which the three retractor blades are spaced apart and generally parallel to one another.
11. The system of claim 1 , wherein the blade holder assembly is configured to adjust the three retractor blades to the second position by simultaneously moving the three retractor blades away from one another.
12. The system of claim 1 , wherein the elongate guidewire instrument is deliverable to the spinal disc together with the initial dilator.
13. The system of claim 1 , wherein the elongate guidewire instrument comprises a K-wire.
14. The system of claim 1 , further comprising a nerve monitoring system configured to deliver an electrical stimulation signal to the stimulation electrode of the initial dilator, monitor electromyographic activity detected by a set of sensor electrodes in muscle myotomes associated with nerves in the vicinity of the spinal disc, and display a numeric stimulation threshold in units of milliAmps indicating an electrical current magnitude required to obtain the electromyographic activity in at least one of said muscle myotomes.
15. The system of claim 14 , wherein the nerve monitoring system comprises a control unit having a video display device, a patient module connected to the control unit via a data cable, and an EMG sensor harness having the set of sensor electrodes connected to the patient module.
16. The system of claim 15 , wherein the control unit receives signals from the patient module and processes EMG response output from the sensor electrodes to extract characteristic information for each of said muscle myotomes.
17. The system of claim 14 , wherein the initial dilator is connected to said nerve monitoring system via a removable connector that establishes electrical communication between the monitoring system and the stimulation electrode at the distal tip region of the initial dilator.
18. The system of claim 1 , wherein the first supplemental dilator includes a stimulation electrode along a distal tip portion of the first supplemental dilator so as deliver electrical stimulation away from the distal tip region for nerve monitoring when the first supplemental dilator is positioned in the lateral, trans-psoas path.
19. The system of claim 18 , wherein the second supplemental dilator includes a stimulation electrode along a distal tip portion of the second supplemental dilator so as deliver electrical stimulation away from the distal tip region for nerve monitoring when the second supplemental dilator is positioned in the lateral, trans-psoas path.
20. The system of claim 1 , wherein the three retractor blades are configured to generally abut one another when the three retractor blades are in the first position.