Systems and methods for pedicle screw stabilization of spinal vertebrae - Patents.com

Abstract

Disclosed herein are embodiments of systems and methods for stabilizing a spinal vertebra through a skin incision. In some embodiments, the system or method may include a first screw having a first screw head, a second screw having a second screw head, a third screw having a third screw head, a first tower having a distal portion, a proximal portion, and a bend between the distal portion and the proximal portion, a second tower having a distal portion and a proximal portion, the second tower configured to be removably coupled to the second screw at a distal end of the second tower, and a third tower having a distal portion, a proximal portion, and a bend between the distal portion and the proximal portion.

Description

[Technical Field]

[0001] Priority Claims and Incorporation by Reference This application claims priority to U.S. Patent Application No. 62 / 187,859, entitled "SYSTEMS AND METHODS FOR PEDICLE SCREW STABILIZATION OF SPINAL VERTEBRAE," filed May 12, 2021, the contents of which are incorporated herein by reference in their entirety as if fully set forth herein. The benefit of priority is claimed under appropriate statutory standards, including, but not limited to, under 35 U.S.C. § 119(e). Any and all applications for which a foreign or domestic priority claim is identified in the Application Data Sheet filed with this application are hereby incorporated by reference in their entirety and made a part hereof. This application also incorporates by reference International Patent Application No. PCT / US2020 / 059547, entitled "SYSTEMS AND METHODS FOR PEDICLE SCREW STABILIZATION OF SPINAL VERTEBRAE," filed November 6, 2020, which claims priority to U.S. Patent Application No. 62 / 933,321, entitled "SYSTEMS AND METHODS FOR PEDICLE SCREW STABILIZATION OF SPINAL VERTEBRAE," filed November 8, 2019, the contents of each of which are incorporated herein by reference in their entirety as if fully set forth herein.

[0002] Embodiments of the present disclosure relate to devices, systems, and methods for treating the spine, including, but not limited to, devices, systems, and methods for stabilizing adjacent vertebrae in at least the cervical, thoracic, and lumbosacral spine. [Background technology]

[0003] Although some lower back conditions can be improved with non-surgical approaches, spinal fusion is recommended for certain conditions when non-surgical approaches fail. Non-surgical approaches include medication, physical therapy, chiropractic care, traction, epidural steroid injections, facet blocks or nerve root resections, weight loss, smoking cessation, and acupuncture. Conditions that generally serve as indications for spinal fusion or stabilization surgery can be broadly divided into three categories: (i) trauma-induced, (ii) curvature, and (iii) degenerative.

[0004] Trauma-induced conditions include fractures and ligament injuries. Fractures typically result from unfortunate accidents involving external forces or falls, but can also result from pathological conditions such as cancer or osteoporosis. Fractures are often compressive in nature and typically lead to pathological curvature of the spine, resulting in loss of the natural lordotic curve in the lumbar and cervical spine, known as kyphosis. Spinal fractures can also be caused by translational or rotational forces perpendicular to the axis of the spine. These forces result in fractures of facets or pars interarticularis (pars). If the external force is large enough, the vertebrae can collapse, leading to a burst fracture that can damage all three vertebral columns (anterior, middle, and posterior columns). While many traumatic injuries can heal without surgery, unstable injuries that pose a risk of neurological injury and / or pain require stabilization through procedures such as immobilization.

[0005] Spondylolisthesis, a condition characterized by the slippage of bones or vertebrae of the spine relative to one another, can result from a fracture of the interarticular segment (partial fracture), known as spondylolysis. Spondylolisthesis can also result from pathological conditions, such as malformation of the facet joints due to degenerative arthritis, as well as congenital malformations and tumors. When bilateral segments are fractured, the spinous processes and lamina are essentially completely separated from the pedicle and vertebral body. This large fragment is called the gill body. Partial fractures are common in people of virtually all ages (often occurring in the teenage years). Many of these patients experience mild symptoms and do not require surgery, but those with progressive symptoms may require surgical decompression, with or without fusion. Spondylolisthesis leads to spinal misalignment and increases the risk of nerve entrapment. Nerves travel within the spinal canal, bounded by the vertebrae, and their roots emerge through curved openings on the sides of the vertebrae, called foramina (singular foramen). These spinal nerves are suspected of causing back and radicular pain when they become entrapped or when the nerve endings are irritated by irregular or abrasive motion around the disc, bone, or joint. Spondylolisthesis may also exacerbate or be accompanied by degeneration of the disc or facet joints, which can lead to axial back pain.

[0006] The normal curvature of the lumbar and cervical spine is lordosis, with the posterior aspect of these spinal levels forming a concave curve. The thoracic spine usually has a kyphosis or convex curve. Curve conditions include correction of natural curvatures as well as abnormal lordosis, abnormal kyphosis, or lateral / rotational bending referred to as scoliosis. Curve conditions can occur idiopathically during adolescence (e.g., adolescent idiopathic scoliosis) or can develop as a secondary problem in situations where spinal muscle activation is abnormal (e.g., cerebral palsy, spina bifida, or tethered cord syndrome). Abnormal spinal curvatures are common in spinal degeneration, when asymmetric degeneration of intervertebral discs and joints occurs as the spine's biomechanical integrity is disrupted, resulting in progressive curvature (scoliosis, kyphosis, or lordosis). Curvatures also occur after trauma involving compression or burst fractures or ligamentous injury. Additionally, curvatures can arise iatrogenically after previous spinal surgery, which alters the spinal anatomy and biomechanical integrity. Examples include removal of the posterior tension band after laminectomy and altered physiologic displacement after spinal fusion, leading to adjacent level compensation and degeneration. Curvatures result in abnormal biomechanical stresses on the intervertebral discs and facet joints, with compensatory measures such as intervertebral or ligamentous hypertrophy. Patients may experience both axial back pain and radicular pain. Surgery may be effective in patients who have failed conservative treatment and bracing. Surgery in these conditions includes decompression of nerve or spinal cord compression, as well as fusion or stabilization. The curve can be corrected by surgery, and fusion prevents further curves from developing.

[0007] Degenerative conditions include spondyloarthritis and recurrent disc herniation. Spondyloarthritis is the most common indication for fusion surgery and can exist in the form of severe disc degeneration (also known as degenerative disc disease, or DDD) or facet disease. Degenerative arthritis can also be the cause of spondylolisthesis in addition to the traumatic fractures mentioned above. Degenerative conditions generally involve nerve compression in the distribution of the nerve's receptive field, causing radicular pain, which usually correlates with and manifests as pain in the arms or legs. Pure nerve compression syndromes, such as nucleus pulposus herniation (disc herniation) or foraminal stenosis (narrowing of the lateral foraminal canal through which the nerve passes), can often be treated with decompression without fusion. Pure disc degenerative syndromes can also be treated with fusion without nerve decompression. However, most commonly, disc degeneration occurs in combination with nerve compression, causing both axial back pain and radicular limb pain. In these situations, fusion surgery is combined with nerve decompression surgery.

[0008] Fusion functions to eliminate movement of the disc space and facet joints between adjacent vertebrae. The vertebrae provide the rigid structural framework of the spine, while the fibrocartilaginous disc space acts as a cushion or shock absorber. Deterioration of the disc space can distort alignment and alter the biomechanical cushioning the disc provides to the adjacent vertebrae. This deterioration alters the force of impact on the vertebrae, resulting in axial back pain. Fusion is designed to eliminate movement between adjacent vertebrae by either forming a solid bridge of bone across the disc space and / or generating new bone formation within the posterolateral space to provide stabilization, rigidity, and strength. Fusion sometimes involves the use of bone grafts harvested from another location within the body (e.g., autografts from the iliac crest in the pelvis) or from external sources, such as allografts. Physicians generally indicate the level of fusion. A single-level fusion involves stabilizing two vertebrae adjacent to the affected disc. Bilevel fusion involves stabilizing three adjacent vertebrae spanning two problematic disc spaces. Each vertebra contacts (articulates) its neighbor at three points, with paired facet joints located posteriorly and discs located anteriorly. Thus, lumbar fusion can target either the posterior facet joints or the anterior interbody / disc space, or both. When anterior interbody fusion is performed in combination with posterior fusion, the procedure is called a 360° fusion. One commonly used posterolateral fusion technique is pedicle screw fusion, in which screws are directed into the pedicles and bodies of the adjacent vertebrae, and then rods are connected to the screws across the disc space. The screws and rods hold the adjacent vertebrae immobile relative to one another and allow bone grafts placed in either the interbody (disc) space or the posterolateral space to grow into solid bone. Traditional pedicle screws and rods are made from metals, typically titanium (Ti) alloys, but also stainless steel, cobalt chromium, and molybdenum rhenium. Recently, rods have been made from a minimally flexible polymer called polyetheretherketone (PEEK). Other metals have also been used and can be employed. These can include, for example, cobalt, molybdenum, and other metals as well as non-metallic polymers.

[0009] Newer lumbar pedicle screw techniques involve placing screws through a midline incision and placing them superiorly and laterally instead of the typical trajectory, which starts and aims laterally through the pedicle into the vertebral body in a medically appropriate manner. This technique is called cortical bone trajectory (CBT) because the screw trajectory traverses more cortical bone as opposed to cancellous bone. Cortical bone is typically harder and therefore offers greater pullout strength. Therefore, cortical bone trajectory allows for smaller and shorter screws using a single midline incision instead of bilateral Wiltz-type incisions. A problem with CBT screw trajectories is that superior screws in lumbar fusion procedures, such as the L4 trajectory in an L4, L5 TLIF procedure, have a trajectory that is directed more superiorly and laterally than the medically appropriate trajectory. Inferior screws may have a parallel trajectory in the sagittal plane (rather than superiorly) or a more linear trajectory. This configuration creates a natural intersection between the upper and lower screws in that the upper screw is directed upward, and therefore, a minimally invasive spinal (MIS) screw attached to a tower has a tower facing downward because the screw is directed upward. While the lower screw is directed, the trajectory is not as far upward, so the towers attached to these two screws are constrained to interfere. Furthermore, because the incision is midline and the screws are directed in a medial-to-lateral direction, screws from the ipsilateral and contralateral sides are also constrained to intersect. Thus, cortical bone trajectories are a technology that benefits from towers attached to screws that do not interfere with each other due to the fact that they have interference trajectories.

[0010] Interbody fusion involves placing one or more spacers (typically pre-filled with bone graft material) into the interbody (disc) space between bony vertebral bodies after the degenerated disc has been dislodged and removed. The spacers are made from bone graft, titanium, carbon fiber, or polymers such as PEEK. Interbody fusion can be performed through multiple approaches, including an anterior approach (anterior lumbar interbody fusion, ALIF), a posterior approach (posterior lumbar interbody fusion, PLIF, or transforaminal lumbar interbody fusion, TLIF), or a lateral approach (direct lateral interbody fusion, DLIF™—Medtronic, Inc., or translateral lateral interbody fusion, XLIF™—Nuvasive, Inc.). The goal of these approaches is to remove the degenerated disc and replace it with a material that induces bone fusion. Alternatively, the disc can be replaced with a prosthetic disc (described below). Each of these interbody approaches has advantages and disadvantages. Anterior procedures allow for very large spacers with a large degree of lordosis, but require a retroperitoneal incision and risk injury to large vessels anterior to the lumbar spine. Furthermore, damage to the nerve plexus anterior to the vertebrae can result in sexual dysfunction. The lateral approach also allows for very large spacers, but some lordosis is limited to the upper and mid-lumbar levels (rostral to L5 and S1) due to obstruction by the iliac crest. The posterior interbody approach is more time-consuming and typically requires more muscle dissection and retraction. However, the posterior approach allows for interbody graft placement, posterior pedicle screw fixation, and nerve decompression, all to occur through the posterior incision(s).

[0011] Although the anterior and lateral approaches can be performed independently (without posterior instrumentation), many surgeons back up or supplement anterior or lateral interbody fusion by placing posterior pedicle screws after the interbody cage or implant has been placed. This 360° fusion limits migration and increases the velocity of fusion more than simply isolated anterior or posterior fusion. However, in the case of ALIF and lateral interbody fusion (DLIF™, XLIF™), two sets of incisions are required for 360° fusion.

[0012] Posterior approaches (TLIF and PLIF) allow interbody fusion, pedicle screw fixation, and neural decompression, all through the same posterior incision(s). In TLIF, after neural decompression is completed, a single large interbody spacer is inserted ipsilateral to the patient's symptomatic side. If both sides are symptomatic, bilateral decompression is required. PLIF is performed by placing two interbody spacers, one on each side. Posterior procedures may be performed according to (i) an invasive open procedure, in which large and / or multiple incisions are made; (ii) a percutaneous approach, in which small and / or multiple incisions are made; and potentially (iii) an endoscopic approach, in which small incisions are made and all tools and devices are inserted through a portal, with visualization provided on an external monitor.

[0013] As an alternative to fusion surgery, recent advances in interbody stabilization have led to the development of artificial disc technology. Artificial discs replace degenerated discs and allow continued motion at the joint. Artificial discs have been developed for the cervical and lumbar spine. Additionally, dynamic stabilization techniques for the posterior spine have been developed. These posterior techniques utilize pedicle screws and dynamic rods. Typically, the dynamic rods have mechanisms for flexing under certain loads or forces, thereby absorbing some of the stress and strain applied to the spine. The advantage of dynamic stabilization is that motion is preserved within the spine. However, the durability of these systems can be an issue. In fusion surgery, bone grafts (interbody or posterolateral) ultimately stabilize the vertebrae, eliminating the need for spinal instrumentation (screws and rods). However, with dynamic stabilization, no fixation occurs, and therefore the screws and dynamic rods are constantly subjected to the strain and forces of the spine. Over time, the likelihood of pedicle screw loosening or mechanical failure can increase. Sometimes, the use of slightly flexible rods, such as those made from PEEK, can actually increase fusion by reducing stress shielding, which occurs when a rigid fusion construct shields the vertebrae in contact with the bone graft from the stresses necessary to form and remodel bone.

[0014] Posterior lumbar stabilization (immobilization and dynamic stabilization) techniques have evolved toward minimally invasive approaches because such minimal exposure reduces patient morbidity and facilitates functional recovery. Blood loss and hospital stays are shorter. The process for minimally invasive pedicle screw fixation is the same as that for dynamic stabilization and involves two basic parts. First, screws are placed percutaneously through the pedicle into the vertebral body. In minimally invasive systems, cannulated screws are placed percutaneously over a guidance element guided by fluoroscopy (X-rays visible on a video screen). Recent advances also allow for the placement of either cannulated or non-cannulated screws using intraoperative navigation, robotic guidance, or virtual reality guidance. Typically, two screws are used for each vertebral body being fused, one on the right side and one on the left side. Single-level fusion involves connecting the vertebral bodies adjacent to the disc level being fused. For example, an L5, S1 fusion requires screws placed at L5 and S1, usually bilaterally, to stabilize the L5, S1 disc. The second part of the process involves connecting the screws to a rod and locking the rod and screw together. In dynamic stabilization, the rod or rod-like device (flexible connector) is bendable, but the process of inserting this bendable rod is the same as that of fusion. For example, a rod-like device (flexible connector) like a rod fits within the screw head but may also include elements (such as dampers, springs, etc.) that allow some movement. The variability between different minimally invasive systems mainly arises in the method of placing the rod through a minimal incision and locking the rod with a screw.

[0015] Before inserting an intervertebral body spacer, the damaged or degenerated disc within the disc space must be removed. In the TLIF approach, the disc space is accessed through a facetectomy, in which the foramina around the nerve roots are opened using a bone-cutting tool such as an osteotome or high-speed drill. In the PLIF approach, a laminectomy or laminotomy is performed to access the disc space. Both TLIF and PLIF allow for decompression of the spinal thecal sac and nerve roots, but the facetectomy in TLIF allows for maximum decompression of the existing nerve roots on that side. Gentle retraction of the thecal sac facilitates access to the disc space. The instruments used to remove the degenerated disc can then be inserted into the disc space to complete the discectomy.

[0016] Following disc removal, the surgeon must prepare the bone surfaces, known as the endplates, of the vertebral bodies on each side of the removed disc. Using a tool such as a curette to ablate the endplates induces bleeding, which stimulates healing and assimilation of the bone graft that is inserted into the interbody space. The inserted spacer or cage is typically constructed from bone, titanium, carbon fiber, or a polymer such as PEEK. The spacer is usually hollow or at least porous to accommodate the bone graft material therein. An osteoinductive protein, such as bone morphogenetic protein (BMP), is also typically placed within the spacer. After the spacer and bone graft are placed, a rod can be inserted into the pedicle screws, which can be tightened to lock the rod in place.

[0017] Pedicle screw fixation procedures, such as TLIF, can be performed openly through a single large incision or through a minimally invasive (MIS) approach, in which the incision size(s) are smaller and less tissue is damaged or injured. MIS TLIF typically uses percutaneous pedicle screws, with each screw placed through a small incision just lateral to the diameter of a single screw, the screw head, or the largest screw insertion tool. Percutaneous screws are typically easy to place because they are long and thin and are either screwed directly through tissue into bone or over a guidewire placed using fluoroscopic guidance or, sometimes, stereotactic navigation with the aid of a surgical robot. In an open approach, the screws are placed using visually identified anatomical landmarks and fluoroscopic guidance, although navigation and robotic guidance can also be useful in open cases. Because percutaneous pedicle screws are placed through small incisions barely large enough to fit the screw or screw insertion tool, visual landmarks are virtually unavailable. There is a mini-open approach in which visual landmarks for pedicle screw placement can be identified through a small incision using either a microscope or an endoscope, either through a small tubular retractor or an endoscope. Importantly, once the pedicle screw canal is located and a guidewire is placed in the pedicle screw canal, it is relatively easy to place a percutaneous pedicle screw over the guidewire. Stereotactic navigation and robotic guidance also make pedicle screw placement relatively easy.

[0018] In most minimally invasive surgery (MIS) systems used today, a guidance element, such as a wire or guidewire, is placed percutaneously through the pedicle under fluoroscopic guidance. Recent advances have also enabled the placement of either cannulated or non-cannulated screws using intraoperative navigation, robotic guidance, intraoperative CT, or virtual reality guidance. These methods also allow for the accurate placement of pedicle screws directly without a guidewire and without cannulation. When a guidewire system is used, a percutaneous cannulated drill and screw tap are inserted over the guidance element / wire to prepare the tunnel through the pedicle and vertebral body for pedicle screw insertion. Dilation tubes and guide tube or retractor systems are often used to dilate and hold open the pathway around the guidance element through the skin and muscle to reduce muscle and tissue trauma when the pedicle screw and insertion tool are inserted. Pedicle screws are inserted over the guidance element, with or without passing through the guide tube / retractor. Again, due to the development and widespread use of intraoperative navigation to guide pedicle screw placement, some pedicle screws can be placed without the use of pre-drilling holes or the use of a guidewire. These systems use intraoperative navigation to place pedicle screws directly through tissue and into bone without pre-drilling or tapping holes. Furthermore, robotic arms may be used in addition to, and often in combination with, navigation systems to assist in the accurate placement of pedicle screws.

[0019] In MIS pedicle screw fixation, after the pedicle screw is inserted, a critical step remains in connecting the screw heads and locking adjacent screws using a rod and a locking cap. Inserting the rod connecting the screw heads and the locking cap for locking the rod inside the screw head are currently some of the most difficult steps using an MIS approach through a minimal incision. To place the rod and locking assembly within the screw head, each screw head is associated with a blade or tower that extends upward from the screw head through the skin incision. The tower must accommodate the rod and locking assembly and is therefore typically the same size as or larger than the largest diameter of the screw head. Once the tower attached to the screw is in place, the rod is inserted by one of a variety of methods. The leading MIS system is Medtronic's Sextant™. In this system, the rod is placed by forming a pendulum-like mechanism. Two or three towers (for one or two levels of fixation, respectively) are joined together to align the towers, and a rod is swung in a pendulum fashion through a separate incision above or below the tower. Once the rod is swung into place, a locking cap is placed through the tower and tightened. Alternatively, most existing systems insert the rod through one of the towers and then rotate the rod approximately 90 degrees to capture another screw in the other tower. Inserting the rod through the screw head in minimally invasive systems is done blindly, e.g., without direct visualization of the screw head. Therefore, this process can be tedious and frustrating.

[0020] The Sextant™ System and other existing systems that use towers are hampered by both the number of incisions required. Using a separate tower for each screw requires a separate incision for each tower, or a single incision long enough to accommodate two towers. The Sextant™ System also requires additional incisions for the rods, which equates to six incisions (three on each side) for single-level fixation and eight incisions for two-level fixation. Other existing tower systems that use direct rod insertion and rotation mechanisms still require one incision for each screw, and each incision must be larger than the size of the tower into which the screw is inserted. Typically, each incision is at least 15 mm long. When the total length of all incisions on both sides is added together, the overall length of the current leading minimally invasive systems is often longer than the single midline incision of a traditional "open" approach for single- or two-level pedicle screw fixation.

[0021] Furthermore, none of the current MIS pedicle screw systems are designed to take advantage of the lumbar lordosis typically present in most patients. Approximately 80% of lumbar pedicle screw fixations are performed at the lowest two levels, L4-L5 and L5-S1. These lowest lumbar levels also typically exhibit the strongest lumbar lordosis, such that the pedicle screw channels through L4, L5, S1, and even L3 often cross near a single point near the skin, similar to the spokes on a bicycle tire. For most pedicle screw systems, this lordotic curve is an obstacle to the crossing of all pedicle screw towers. The crossing of the towers makes it difficult for these MIS screw systems to allow rods to be placed through the tower channels.

[0022] U.S. Patent No. 7,306,603, entitled "Device and Method for Percutaneous Placement of Lumbar Pedicle Screws and Connecting Rods," by Frank H. Boehm, Jr. et al., assigned to Innovative Spinal Technologies, Inc. (Mansfield, Massachusetts), which is incorporated herein by reference in its entirety, discloses a system for connecting a rod to a pedicle screw using a pin and a recess in the screw head. With this system, the rod can pivot about the longitudinal axis of the pin between a first position in which the rod is parallel to the longitudinal axis of the screw (e.g., oriented perpendicularly) and a second position in which the rod transverses its axis to bridge screws on adjacent vertebrae. The '603 patent teaches various guide systems (see FIGS. 5 and 6), rod holder systems (see FIGS. 8, 9, 10, and 11), and rod guide systems (see FIG. 12), but does not include any smooth, removable systems. Rather, the illustrated system is tower-like, with very bulky dilators (80 and 86 in FIGS. 6 and 8), a sheath (81 in FIG. 6), and / or an outer housing (120 in FIGS. 11 and 12). U.S. Patent Application Publication No. 2008 / 0140075, entitled "Press-On Pedicle Screw Assembly," by Michael D. Ensign and assigned to Alpinespine LLC (American Fork, Utah), which is incorporated herein by reference in its entirety, discloses indirectly attaching a rod to a screw head via a tulip assembly. The tulip assembly has a housing with an inner diameter smaller than the inner diameter of the screw head so that it can be easily pressed into place on the screw head. The rod is then deployed by connecting the tulip assembly to the screw head and then attaching it directly to the tulip assembly.This publication mentions the use of a Kirschner guidance element (or K-guidance element) to insert both the pedicle screw and the tulip member (see

[0030] ,

[0032] ,

[0045] ), but does not disclose how the rod is guided into position.

[0023] Unassigned U.S. Patent Application Publication No. 2008 / 0097457, entitled "Pedicle screw systems and methods of assembling / installing the same," by David R. Warnick (which is incorporated herein by reference in its entirety, as is the '075 publication), also discloses the use of a tulip assembly as an intervening means for connecting a rod to a screw. In this system, rather than a press-to-lock mechanism, the structure is tightened by rotating the inner member and outer housing of the tulip assembly relative to one another.

[0024] U.S. Patent No. 7,179,261, entitled "Percutaneous access devices and bone anchor assemblies," by Christopher W. Sicvol et al. and assigned to Depuy Spine, Inc., which is incorporated herein by reference in its entirety, describes one of several tower systems for percutaneously placing pedicle screws. The patent describes a situation in which the screw angles cross, potentially causing the towers to interfere with each other. This situation is fairly typical in the lordotic lumbar spine, particularly the lumbosacral (L5, S1) joint. To solve this problem, they describe providing notches in the tubes to allow the two tubes to intersect. Given that vertebral angles vary from patient to patient and the depth of the vertebrae below the skin varies greatly, the variations in the notches must be numerous. In addition, as shown in Figure 22B of the '261 patent, when two tubes intersect at a notch, the edge of the notch in one tube interferes with or blocks the lumen of the other tube, and vice versa. This occurs because the muscle and tissue surrounding the tubes push the tubes together at the notch, thereby significantly reducing the lumen through which rods and other elements can be inserted. The only way to avoid this interference or blockage of the lumen is to keep the tubes separated, requiring a larger incision and eliminating the need for a notch in the first place. Additionally, two- or three-level fixation, requiring three or four screws that may intersect, becomes problematic when the towers on the screws intersect. Summary of the Invention

[0025] Some embodiments described herein are directed to systems, devices, and / or methods for bone stabilization, such as for stabilizing the spine. In some embodiments, one or more guide elements may be provided, which may also be referred to herein as guidance elements, guide elements, towers, or extensions, or other terms described below. The guide elements may be connectable, attachable, and / or engageable with bone screws, such as pedicle screws. These guide elements, in some embodiments, can be utilized to deliver connecting members, such as rods, to bone screws implanted within a patient's vertebrae. Additional systems, devices, and methods are described herein, including, but not limited to, guidance tools for rod insertion devices and drills. The systems, methods, and devices of the present disclosure each have multiple innovative aspects, implementations, or aspects, no single aspect of which may be solely responsible for the desirable attributes disclosed herein.

[0026] Some embodiments of the systems for bone stabilization disclosed herein can include a first guide element including an elongate body having a first longitudinal axis, a proximal end, and a distal end, the distal end configured to engage a first bone screw, a second guide element including an elongate body having a second longitudinal axis, a proximal end, and a distal end, the distal end configured to engage a second bone screw, and an opening in an intermediate portion of the first guide element in use. In some embodiments, the opening can be sized and configured to allow passage of the second guide element therethrough such that the second longitudinal axis is at an angle relative to the first longitudinal axis, and the opening is sized and configured to limit movement and / or rotation of the second guide element along the first longitudinal axis relative to the first guide element.

[0027] Disclosed herein are embodiments of a system for stabilizing a spinal vertebra through a skin incision. In some embodiments, the system can include a first screw having a first screw head, a second screw having a second screw head, a third screw having a third screw head, a first tower having a distal portion, a proximal portion, and a bend between the distal and proximal portions, a second tower having a distal portion and a proximal portion, the second tower configured to be removably coupled to the second screw at a distal end of the second tower, and a third tower having a distal portion, a proximal portion, and a bend between the distal and proximal portions.

[0028] Any embodiment of the devices, systems, and methods disclosed herein can include, in additional embodiments, one or more of the following features, components, and / or details in any combination with any of the other features, components, and / or details of any other embodiment of the devices, systems, and methods disclosed herein: the first tower can be configured to be removably coupled to the first screw at a distal end of the first tower; the third tower can be configured to be removably coupled to the third screw at a distal end of the third tower; the first tower is configured to be removably coupled to the first screw such that, when the first tower is coupled to the first screw, an axial centerline of the distal portion of the first tower is generally collinear with an axial centerline of the first screw; and the second tower is configured to be removably coupled to the distal end of the second tower such that, when the second tower is coupled to the second screw, an axial centerline of the distal portion of the second tower is generally collinear with an axial centerline of the first screw. the third tower is configured to removably couple with the third screw such that an axial centerline of the distal portion of the third tower is approximately collinear with the axial centerline of the second screw when the third tower is coupled to the third screw; the proximal portion of the first tower extends at a non-zero acute angle away from the axial centerline of the distal portion of the first tower and the proximal portion of the third tower extends at a non-zero acute angle away from the axial centerline of the distal portion of the third tower; and in an operable state, the first, second, and third towers are configured to intersect one another and / or the proximal portions of one or more of the towers (e.g., without limitation, the first and third towers or extensions) are configured to mate with graspers, coupling mechanisms, and other components of a surgical robotic system.

[0029] Also disclosed herein are embodiments of a system for stabilizing a spinal vertebra through a skin incision. In some embodiments, the system can include a first screw having a first screw head, a second screw having a second screw head, a third screw having a third screw head, a first tower having a distal portion and a proximal portion, a second tower having a distal portion and a proximal portion, the second tower configured to be removably coupled to the second screw at a distal end of the second tower, and a third tower having a distal portion and a proximal portion.

[0030] Any embodiment of the devices, systems, and methods disclosed herein can include, in additional embodiments, one or more of the following features, components, and / or details in any combination with any of the other features, components, and / or details of any other embodiment of the devices, systems, and methods disclosed herein: the first tower can be configured to be removably coupled to the first screw at a distal end of the first tower; the third tower can be configured to be removably coupled to the third screw at a distal end of the third tower; the first tower is configured to be removably coupled to the first screw such that, when the first tower is coupled to the first screw, an axial centerline of the distal portion of the first tower is generally collinear with an axial centerline of the first screw; and the second tower is configured to be removably coupled to the second screw such that, when the first tower is coupled to the first screw, an axial centerline of the distal portion of the first tower is generally collinear with an axial centerline of the first screw. the third tower is configured to removably couple with the third screw such that, when the third tower is coupled to the third screw, an axial centerline of the distal portion of the third tower is approximately collinear with an axial centerline of the third screw; the proximal portion of the first tower extends at a non-zero acute angle away from the axial centerline of the distal portion of the first tower and the proximal portion of the third tower extends at a non-zero acute angle away from the axial centerline of the distal portion of the third tower; and in the operable state, the proximal portion of the first tower extends in a first direction away from the second tower and / or in the operable state, the proximal portion of the third tower also extends in the first direction away from the second tower.

[0031] Also disclosed herein are embodiments of methods for stabilizing spinal vertebrae. In some embodiments, the method may include implanting a first screw coupled to a first tower through an incision into the first vertebra, advancing a second tower coupled to a second screw through an opening formed in the first tower to implant the second screw into the second vertebra, advancing a third tower coupled to a third screw through an opening formed in the first tower to implant the third screw into the third vertebra, and moving a proximal portion of the first tower toward a proximal portion of the third tower to move the first vertebra from a first position relative to the third vertebra to a second position relative to the third vertebra.

[0032] Also disclosed herein are methods for stabilizing spinal vertebrae. In some embodiments, the method includes implanting a first screw coupled to a first extension into a first vertebra through a single incision, the first extension having a proximal portion and a distal portion, and advancing a second extension coupled to a second screw through the single incision and a first opening formed in the first extension such that an axial centerline of at least the distal portion of the second extension is at an acute angle with respect to an axial centerline of at least the distal portion of the first extension. and implanting the second screw into the second vertebra; advancing a third extension coupled to the third screw through the single incision and the first opening formed in the first extension such that an axial centerline of at least a distal portion of the third extension is at an acute angle relative to an axial centerline of at least a distal portion of the first extension and is at an acute angle relative to an axial centerline of at least a distal portion of the second extension; and implanting the third screw into the second vertebra.

[0033] Any embodiment of the devices, systems, and methods disclosed herein may, in additional embodiments, include one or more of the following features, components, and / or details in any combination with any of the other features, components, and / or details of any other embodiment of the devices, systems, and methods disclosed herein, wherein in an operative state, the first, second, and third towers are configured to cross at or adjacent to the patient's skin level, and wherein in an operative state, the first, second, and third towers: The first tower is configured to intersect while implanted at or adjacent to the patient's skin level, wherein a distance from the skin level to a proximal-most end of a distal portion of the first tower is 10% or less of a length of the distal portion of the first tower, and a distance from the skin level to a proximal-most end of a distal portion of the third tower is 10% or less of a length of the distal portion of the third tower, and the first tower is sized and configured to receive the second tower and the third tower therein in an operable state such that an outer wall of a portion of the first tower surrounds outer surfaces of a portion of the second and third towers. The first tower has an opening therein, the opening extending through at least a proximal end of the distal portion of the first tower, the opening extending along the first tower to an edge adjacent the proximal end of the distal portion of the first tower, the proximal portion of the first tower configured to extend at a non-zero acute angle away from an axial centerline of the proximal portion of the second tower such that, in an operable state of the system, the proximal portion of the first tower forms an acute angle with the proximal portion of the second tower, a distal portion of the first tower configured to extend at a non-zero acute angle away from an axial centerline of the distal portion of the second tower such that the distal portion of the first tower forms an acute angle with the distal portion of the second tower, and a proximal portion of the third tower configured to extend at a non-zero acute angle away from an axial centerline of the proximal portion of the second tower such that the proximal portion of the third tower forms an acute angle with the proximal portion of the second tower in an operable state of the system;The distal portion of the third tower is configured to extend at a non-zero acute angle away from the axial centerline of the distal portion of the second tower such that the distal portion of the third tower forms an acute angle with the distal portion of the second tower, and / or the distal portion of the first tower and / or the third tower has a curved cross-sectional profile and the proximal portion of the first tower and / or the third tower has a flat or rectangular cross-sectional profile.

[0034] Any embodiment of the devices, systems, and methods disclosed herein can, in additional embodiments, include one or more of the following features, components, and / or details in any combination with any of the other features, components, and / or details of any other embodiment of the devices, systems, and methods disclosed herein, wherein a first tower is sized and configured such that, in an implanted state, a proximal portion of the first tower extends away from the skin incision in a first direction and a proximal portion of a third tower also extends away from the skin incision in the first direction. and configured such that, in an operable state, a proximal portion of the third tower is positioned between the proximal portion of the first tower and the proximal portion of the second tower, the first tower is sized and configured such that, in an operable state, the proximal portion of the first tower extends in a first direction away from the skin incision and the proximal portion of the third tower also extends in the first direction away from the skin incision, and the distal portion of the first tower extends away from the first screw to a level just below the skin incision or level with the patient's skin when the first screw is fully implanted into the first vertebra. wherein the proximal portion of the first tower is configured to be grasped by a surgeon such that the surgeon can apply a counter torque force to the first tower about at least an axial centerline of the distal portion of the first tower, and in the operable state, the proximal portion of the third tower is configured to be grasped by a surgeon such that the surgeon can apply a rotational force to the third tower about at least an axial centerline of the distal portion of the third tower, and in the operable state, the system is capable of moving the proximal portion of the first tower toward the proximal portion of the third tower. , configured to create a compressive force on at least a first vertebra in which the first screw is implanted relative to a third vertebra in which the third screw is implanted, the first tower and the third tower being sized and configured such that when the first screw is implanted in the first vertebra, only proximal portions of the first tower and the third tower are outside the skin incision, the system being configured such that the first, second, and third screws are implanted through the same skin incision, the proximal portion of the first tower having a length approximately the same as the length of the distal portion of the first tower,a proximal portion of the first tower being removably coupled to the distal portion of the first tower, a proximal portion of the third tower being removably coupled to the distal portion of the third tower, a proximal portion of the first tower being non-removably coupled to the distal portion of the first tower, a proximal portion of the third tower being non-removably coupled to the distal portion of the third tower, the proximal portion of the first tower being integrally formed with a body portion of the first tower, the first tower, the second tower, and at least the distal portions of the third tower having a full or partial tubular shape, the first tower having a pair of hooks configured to receive a pair of wires used during the implantation procedure, the hooks providing a surface about which the third tower can rotate; the first tower has a protrusion that provides a fulcrum for rotation of the third tower relative to the first tower; the third tower may have an opening formed through a wall portion of the third tower that allows the second tower to pass through the opening in the third tower in the operable state; at least a portion of the wall of the third portion may be configured to at least partially surround an outer surface of the second tower; the distal portion of the first tower and / or the third tower is open along one side thereof and is not completely enclosed; and / or in the operable state, the axial centerlines of both the distal portion of the third tower and the proximal portion of the third tower extend away from the axial centerline of the second tower in the same direction at a non-zero angle.

[0035] Any embodiment of the devices, systems, and methods disclosed herein can, in additional embodiments, include one or more of the following features, components, and / or details in any combination with any of the other features, components, and / or details of any other embodiment of the devices, systems, and methods disclosed herein: at least a distal portion of the first tower and a distal portion of the third tower have an adjustable length; and at least a distal portion of the first tower, a distal portion of the second tower, and a distal portion of the third tower are shaped in a generally cylindrical shape. , the proximal portion of the first tower and the proximal portion of the third tower have a cross-sectional profile with a curved shape, the proximal portion of the first tower and the proximal portion of the third tower have a cross-sectional profile with a semicircular tubular shape, the proximal portion of the first tower and the proximal portion of the third tower have a planar shape, and the device, system, or method may include a rigid connecting element, a first receiving element coupled with the first screw head, a second receiving element coupled with the second screw head, and a third receiving element coupled with the third screw head, the first tower has at least one opening extending through a side of its distal portion configured to receive a connecting element configured to extend between the first, second, and third screws in the operative state, and the second tower is configured to receive a connecting element configured to extend between the first, second, and third screws in the operative state. the first tower, the second tower, and / or the third tower having at least one opening extending through a side of the body portion configured to receive a connecting element configured to extend between the first, second, and third screws in an operative state, and the device, system, or method selectively covering the channels or openings of the first tower, the second tower, and / or the third tower to increase the torsional or bending stiffness of the first tower, the second tower, and / or the third tower.and / or one or more covers configured to selectively couple with the third tower, and / or the device, system, or method may include two or more of the first towers and / or two or more of the third towers, wherein each of the two or more of the first towers defines a different angle between a proximal portion and a distal portion of the first tower, and each of the two or more of the third towers defines a different angle between a proximal portion and a distal portion of the third tower.

[0036] Any embodiment of the devices, systems, and methods disclosed herein may, in additional embodiments, include one or more of the following features, components, and / or details in any combination with any of the other features, components, and / or details of any other embodiment of the devices, systems, and methods disclosed herein, wherein in an operative state, the first, second, and third towers are configured to intersect at or adjacent to the patient's skin level, and the device, system, or method includes connecting elements extending forward toward the first screw, the second screw, and the third screw. The method may include advancing the first, second, and third extensions through a single incision in the patient's skin, and securing the connecting element to the first screw, the second screw, and / or the third screw to prevent the first vertebra from returning to the first position relative to the third vertebra, wherein the first extension has a proximal portion, a distal portion, and a bend between the proximal and distal portions, and the third extension is sized and configured such that the proximal portions of the first and third extensions are positioned below an outer surface of the patient's skin, and / or the device, system, or method may include advancing the first, second, and third extensions through a single incision in the patient's skin.

[0037] Any embodiment of the devices, systems, and methods disclosed herein can, in additional embodiments, include one or more of the following features, components, and / or details in any combination with any of the other features, components, and / or details of any other embodiment of the devices, systems, and methods disclosed herein, wherein the first extension has an axial centerline between the proximal portion of the first extension and the distal portion of the first extension such that the axial centerline of the proximal portion of the first extension is at an acute angle with respect to the axial centerline of the distal portion of the first extension. the third extension has a bend between the proximal portion of the third extension and the distal portion of the third extension such that an axial centerline of the proximal portion of the third extension is at an acute angle with respect to an axial centerline of the distal portion of the third extension; and / or the device, system, or method may include moving the proximal portion of the first extension toward the proximal portion of the third extension, rotating the first extension relative to the third extension, and moving the first screw toward the third screw, thereby moving the first vertebra toward the third vertebra.

[0038] Some embodiments disclosed herein can be described as follows. 1. A system for bone stabilization, comprising: a first guide element comprising an elongate body having a first longitudinal axis, a proximal end, and a distal end, the distal end configured to engage the first bone screw; a second guide element comprising an elongate body having a second longitudinal axis, a proximal end, and a distal end, the distal end configured to engage the second bone screw; an opening in an intermediate portion of the first guide element in use, the opening being sized and configured to allow the second guide element to pass therethrough such that the second longitudinal axis is at an angle to the first longitudinal axis, the opening being sized and configured to restrict movement of the second guide element along the first longitudinal axis; A system comprising: 2. The system of embodiment 1, wherein the first and second inductive elements each comprise a pair of blades. 3. The system of embodiment 2, wherein each pair of blades has one or more bends or curvatures to increase the separation distance between the opposing blades when the pair of blades is engaged with a bone screw. 4. The system of embodiment 1, wherein the first and second guide elements comprise partial tubes. 5. The system of any one of the preceding embodiments, wherein the opening is provided in an intermediate portion of the first inductive element. 6. A system according to any one of embodiments 1 to 4, wherein the opening is provided by an external restraint configured to surround at least the first guiding element. 7. A system for bone stabilization, comprising: a first guide element comprising an elongate body having a first longitudinal axis, a proximal end, and a distal end, the distal end configured to engage the first bone screw; a second guide element comprising an elongate body having a second longitudinal axis, a proximal end, and a distal end, the distal end configured to engage the second bone screw; a second guide element configured to pass through a portion of the first guide element when the first and second guide elements are engaged with the first and second bone screws, respectively, and when the first and second bone screws are implanted within the patient; means for limiting relative movement and creating a fulcrum between the first and second guide elements when the second guide element passes through a portion of the first guide element, the first and second guide elements engage the first and second bone screws, respectively, and the first and second bone screws are implanted within the patient; A system comprising:

[0039] Some embodiments are directed to screws including one or more features of the preceding description. Some embodiments are directed to devices, systems, and / or methods as shown and / or described. Some embodiments are directed to methods of operating any of the devices or systems of the preceding description. Additional embodiments are described throughout the following description, including, but not limited to, systems for stabilizing spinal vertebrae, methods for stabilizing spinal vertebrae, guide assemblies, screws, rod inserters, methods of operating any of the foregoing, and other devices, systems, and methods.

[0040] The accompanying drawings, which are incorporated in and constitute a part of this specification, illustrate embodiments of the present disclosure and, together with the general description given above and the detailed description of the embodiments given below, serve to explain the principles of embodiments of the present disclosure. [Brief explanation of the drawings]

[0041] [Figure 1A] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1B] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1C] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1D] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1E] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1F] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1G]1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1H] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1I] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1J] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1K] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1L] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1M] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1N] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1O] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1P] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1Q] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1R] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1S] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1T] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1U] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1V] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1W] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1X] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1Y] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 1Z] 1 illustrates one embodiment of a method and system for stabilizing spinal vertebrae comprising a pedicle screw with a hybrid guidance element. [Figure 2A] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2B] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2C] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2D] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2E] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2F] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2G] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2H] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2I] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2J] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2K] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2L] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2M] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2N] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2O] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2P] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2Q] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2R] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2S] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 2T]10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 3A] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 3B] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 3C] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 3D] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 3E] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 3F] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 3G] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 3H] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 3I] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 3J] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 3K] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 3L] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 3M] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 3N] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 3O] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4A] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4B] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4C] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4D] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4E] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4F] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4G] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4H] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4I] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4J] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4K] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4L] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4M] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4N]10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4O] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4P] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4Q] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4R] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4S] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 4T] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 5A] 1 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including a spinal screw. [Figure 5B] 1 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including a spinal screw. [Figure 5C] 1 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including a spinal screw. [Figure 5D] 1 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including a spinal screw. [Figure 5E] 1 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including a spinal screw. [Figure 5F] 1 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including a spinal screw. [Figure 5G] 1 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including a spinal screw. [Figure 5H] 1 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including a spinal screw. [Figure 5I] 1 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including a spinal screw. [Figure 5J] 1 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including a spinal screw. [Figure 5K] 1 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including a spinal screw. [Figure 6A] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6B] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6C] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6D] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6E] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6F] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6G] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6H] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6I] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6J] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6K] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6L]10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6M] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6N] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6O] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6P] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6Q] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6R] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6S] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6T] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6U] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 6V] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 7A] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 7B] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 7C] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 7D] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 7E] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 7F] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 7G] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 7H] 10 illustrates another embodiment of a method and system for stabilizing spinal vertebrae, including spinal screws. [Figure 8A] 1 illustrates another embodiment of a method and system for delivering a spinal screw to a spinal location. [Figure 8B] 1 illustrates another embodiment of a method and system for delivering a spinal screw to a spinal location. [Figure 8C] 1 illustrates another embodiment of a method and system for delivering a spinal screw to a spinal location. [Figure 8D] 1 illustrates another embodiment of a method and system for delivering a spinal screw to a spinal location. [Figure 8E] 1 illustrates another embodiment of a method and system for delivering a spinal screw to a spinal location. [Figure 8F] 1 illustrates another embodiment of a method and system for delivering a spinal screw to a spinal location. [Figure 8G] 1 illustrates another embodiment of a method and system for delivering a spinal screw to a spinal location. [Figure 9A] 10 illustrates another embodiment of a method and system of a guidance tool for delivering pedicle screws. [Figure 9B] 10 illustrates another embodiment of a method and system of a guidance tool for delivering pedicle screws. [Figure 9C] 10 illustrates another embodiment of a method and system of a guidance tool for delivering pedicle screws. [Figure 9D] 10 illustrates another embodiment of a method and system of a guidance tool for delivering pedicle screws. [Figure 9E]10 illustrates another embodiment of a method and system of a guidance tool for delivering pedicle screws. [Figure 9F] 10 illustrates another embodiment of a method and system of a guidance tool for delivering pedicle screws. [Figure 9G] 10 illustrates another embodiment of a method and system of a guidance tool for delivering pedicle screws. [Figure 9H] 10 illustrates another embodiment of a method and system of a guidance tool for delivering pedicle screws. [Figure 9I] 10 illustrates another embodiment of a method and system of a guidance tool for delivering pedicle screws. [Figure 9J] 10 illustrates another embodiment of a method and system of a guidance tool for delivering pedicle screws. [Figure 9K] 10 illustrates another embodiment of a method and system of a guidance tool for delivering pedicle screws. [Figure 9L] 10 illustrates another embodiment of a method and system of a guidance tool for delivering pedicle screws. [Figure 9M] 10 illustrates another embodiment of a method and system of a guidance tool for delivering pedicle screws. [Figure 9N] 10 illustrates another embodiment of a method and system of a guidance tool for delivering pedicle screws. [Figure 9O] 10 illustrates another embodiment of a method and system of a guidance tool for delivering pedicle screws. [Figure 9P] 10 illustrates another embodiment of a method and system of a guidance tool for delivering pedicle screws. [Figure 10A] 1 illustrates another embodiment of a system for stabilizing spinal vertebrae, including spinal screws. [Figure 10B] 1 illustrates another embodiment of a system for stabilizing spinal vertebrae, including spinal screws. [Figure 10C] 1 illustrates another embodiment of a system for stabilizing spinal vertebrae, including spinal screws. [Figure 10D]1 illustrates another embodiment of a system for stabilizing spinal vertebrae, including spinal screws. [Figure 10E] 1 illustrates another embodiment of a system for stabilizing spinal vertebrae, including spinal screws. [Figure 10F] 1 illustrates another embodiment of a system for stabilizing spinal vertebrae, including spinal screws. [Figure 10G] 1 illustrates another embodiment of a system for stabilizing spinal vertebrae, including spinal screws. [Figure 11A] 1 illustrates another embodiment of a system for stabilizing spinal vertebrae, including spinal screws. [Figure 11B] 1 illustrates another embodiment of a system for stabilizing spinal vertebrae, including spinal screws. [Figure 11C] 1 illustrates another embodiment of a system for stabilizing spinal vertebrae, including spinal screws. [Figure 11D] 1 illustrates another embodiment of a system for stabilizing spinal vertebrae, including spinal screws. [Figure 11E] 1 illustrates another embodiment of a system for stabilizing spinal vertebrae, including spinal screws. [Figure 11F] 1 illustrates another embodiment of a system for stabilizing spinal vertebrae, including spinal screws. [Figure 11G] 1 illustrates another embodiment of a system for stabilizing spinal vertebrae, including spinal screws. [Figure 12A] 1 illustrates another embodiment of a system for stabilizing spinal vertebrae, including spinal screws. [Figure 12B] 1 illustrates another embodiment of a system for stabilizing spinal vertebrae, including spinal screws. [Figure 12C] 1 illustrates another embodiment of a system for stabilizing spinal vertebrae, including spinal screws. [Figure 12D] 1 illustrates another embodiment of a system for stabilizing spinal vertebrae, including spinal screws. DETAILED DESCRIPTION OF THE INVENTION

[0042] Embodiments of the present disclosure relate to medical devices, systems, and methods for bone fixation. Specifically, some embodiments disclosed herein may be configured to stabilize adjacent vertebrae in at least the cervical, thoracic, and lumbosacral spine. Additionally, some embodiments may be configured to fixate and stabilize vertebrae in the lumbar spine to relieve axial back pain and radicular pain. Some embodiments may be configured to improve minimally invasive surgical (MIS) approaches to pedicle screw fixation by reducing the number and size of incisions and the size of medical instruments inserted therein. Furthermore, some embodiments disclosed herein may improve the efficiency of percutaneous lumbar pedicle screw fixation for surgeons while minimizing surgical trauma to patient tissue.

[0043] For example, but not by way of limitation, some embodiments of the systems for stabilizing spinal vertebrae disclosed herein are directed to, but not limited to, improving minimally invasive (optionally adaptable for use with percutaneous or endoscopic approaches) TLIF and PLIF approaches, as well as supporting ALIF, DLIF™, and XLIF™ approaches. The TLIF approach can offer several advantages, including: (i) stabilization of both the anterior and posterior portions of the spine through one or more posterior incisions; (ii) the ability to fill larger volumes and various spaces (anterior disc space with spacers, on the sides, and between the screws and rods in the posterior aspect of the vertebrae) with bone graft material, which increases the chances of successful stabilization through bone development and solidification; (iii) the spacer placed in the anterior disc space maintains natural interbody disc height and reduces pressure on nerve roots (from osteophytes, hypertrophy, ligaments, etc.); and (iv) improved safety because the spinal canal is accessed from only one side, which reduces the risk of pinching, stretching, or otherwise disturbing spinal nerves.

[0044] Embodiments of the present disclosure provide systems, devices, and / or methods for performing minimally invasive posterior and / or transforaminal lumbar pedicle screw fixation or stabilization procedures. Hereinafter, references to "fixation" implicitly include stabilization that provides some degree of motion that falls short of complete fixation of the bone. Similarly, below, references to "stabilization" implicitly include fixation. Primary situations in which a surgeon can use the disclosed system include minimally invasive TLIF procedures involving either (i) micro-lumbar interbody fusion (MLIF™), or (ii) mini-open TLIF on the symptomatic side to decompress neural compression and pedicle screw fixation through a minimally invasive incision on the contralateral side. Similarly, the systems disclosed herein can be used bilaterally in a PLIF approach, with decompression and interbody spacer placement performed bilaterally. Alternatively, the disclosed system is ideal for "backup" (with minimal posterior incision) anterior interbody fusion (ALIF) and lateral interbody fusion (XLIF™ and DLIF™). MLIF™ collectively encompasses (i) transforaminal lumbar interbody fusion and stabilization, (ii) posterior lumbar interbody fusion and stabilization, (iii) anterior lumbar interbody fusion and stabilization, and (iv) lateral lumbar interbody fusion and stabilization via a minimally invasive "micro" approach using the guidance system described herein, and (v) posterolateral instrumented fusion, in which only pedicle screws are placed for posterolateral fusion without the use of an interbody spacer or implant. Because lateral fusions such as XLIF or DLIF are truly minimally invasive, a minimal posterior incision to support a lateral interbody spacer with pedicle screw fixation is highly complementary. Lateral interbody fusion is becoming more common, and more spine-related companies are offering their own lateral interbody fusion systems. While the particular embodiments described herein are directed to minimally invasive procedures through a single skin incision, it will be understood that the systems and methods may also be used in open surgery or mini-open procedures through an opening in the patient's skin, as desired by the practicing surgeon.

[0045] The lumbar spine has a lordotic curvature such that the lowest levels (L4, L5, and S1) have a concave posterior orientation or alignment, while the higher levels (L1-L3) are less lordotic. This curvature creates a unique situation in which the trajectories through the pedicles (trajectories for inserting pedicle screws) from L2 to S1 are not parallel. Rather, the trajectories generally intersect at a point around the level of the skin. This configuration is similar to the spokes of a wheel, with the spokes meeting at a common central point (hub). Given that many patients have such a lordotic configuration of the lumbar spine, it is possible to insert pedicle screws through a single incision centered at the center of the lumbar curve. However, if multiple screws are present simultaneously, each requiring a separate tower (or tube) (as in a conventional tower / tube system), the total cross-sectional area of ​​the tower / tube does not allow for a single, small incision. The towers / tubes interfere with each other and get in each other's way due to their size. Also, if the towers of the pedicle screws are crossed and not aligned, it is difficult to place the rod through the tower channels and into the pedicle screw seats.

[0046] Alternative methods are needed to minimize the number and size of incisions. Reducing the number and size of incisions would minimize the tissue trauma required to place pedicle screws for lumbar stabilization or fixation. An ideal system and procedure would maximize the natural curvature of the lumbar spine to provide this reduction. However, the devices and methods of the present application described and claimed herein are not limited to use in the lumbar spine, but may also find use for fixing, stabilizing, or otherwise treating vertebrae in other regions of the spine, such as the cervical spine, where lordosis is again a typical anatomical alignment.

[0047] The number of osteoporotic spinal patients requiring surgical intervention is increasing. Historically, this complex patient population has experienced complications with bone screw fixation due to the nature of the bone, the type of screw used, and the projection geometry, as well as the method of insertion. These complications include implant failure, screw loosening, and pullout. Recent research suggests that novel cortical screws that project in an anterior-medial-lateral direction have advantages over traditional screws that project in an anteromedial direction. Embodiments of the present disclosure take this research into account and can be used to guide and place novel cortical screws that project in an anterior-medial-lateral direction to overcome many of the problems of traditional screws in osteoporotic patients. Furthermore, embodiments of the present disclosure can be used to place multiple novel cortical screws through a single incision, minimizing trauma to already sensitive osteoporotic patients.

[0048] The final steps of pedicle screw fixation may include rod reduction and final tightening. Rod reduction is typically necessary when there is vertebral misalignment, such as spondylolisthesis. In this case, the misalignment can be realigned by pulling or pushing the pedicle screw secured to that vertebra relative to the other screws in the other vertebrae. By adjusting the relative position of the screw head, a bent rod can be lowered into the screw head, preferably "reducing" the misalignment or spondylolisthesis. In open surgery, the reduction process is usually performed with a rod reduction tool that pushes the rod into the screw head. In MIS systems, extending threads on a tower or extension tab that extends higher than the screw head allow a locking cap to engage the threads at a higher position, thereby capturing the rod higher or further away from the final seat of the screw head, thereby reducing the rod into the screw head.

[0049] After the rod is reduced and the vertebrae are aligned, the rod can be locked into the screw head by a locking cap. The locking cap is typically tightened to a final torque using a counter torque instrument. The counter torque is typically a sleeve that passes over the screw head and blade or tower, if present. The counter torque can have a groove that fits into the screw head, and often the rod as well, to provide a counter force when the locking cap is finally tightened. The counter torque can stabilize the screw head so that rotation of the screw head is minimized during final tightening.

[0050] It is also common to provide compression of the screw heads during the final tightening process. Because any interbody fusion is believed to be more successful under pressure or compression, compression during final locking is believed to aid in the fusion process. Compression also helps to apply pressure to the interbody spacer, reducing the likelihood of the spacer backing out, retrograde, or migrating. Compression is also useful for restoring lumbar lordosis. Many interbody spacers placed anteriorly through ALIF, laterally through XLIF or DLIF, obliquely through OLIF (oblique lateral interbody fusion), or posteriorly through PLIF or TLIF can all have a lordotic profile. Newer expandable cages allow for even more significant lordosis. Compression during final tightening can optimize lordosis through posterior compression during final locking.

[0051] Typical pedicle screw systems use separate tools for screw insertion, screw alignment, rod insertion, cap insertion, rod reduction, counter-torque, and final tightening. All of these separate tools require an extra step for each pedicle screw. Each extra step introduces additional irritation of muscle and tissue as well as time. Therefore, a system that allows pedicle screws pre-attached to a tower system to perform all of these tasks without additional tools would actually save time and be optimal. Some embodiments disclosed herein describe a system of towers that are removably attached to the pedicle screws. In some embodiments, The tower can cross the path without interference (in situations with lordosis), The tower can be used to align screw heads without the need for a separate tool to straighten the screw heads. The tower can be used to measure the length and curvature of the rod. The tower allows for easy rod placement and visualization, even in MIS approaches and in large patients where visualization is difficult. The tower can enable and / or facilitate rod reduction and spondylolisthesis reduction; The tower can allow final tightening under compression or distraction without a separate compression or distraction tool; The tower can provide counter torque during final tightening without a counter torque tool, and / or The screw-attached towers can be placed by a robot, and the rod placement, rod reduction, compression, and final tightening by counter-torque can all be performed by the robot through mechanical connections between the tower system components and the robot arm. The robot, navigation system, and software can be configured to know the position of all towers, screws, rods, and caps at all times.

[0052] The crossing tower system of some embodiments disclosed herein can enable or provide an optimal MIS system in which incision size and tissue trauma are minimized, surgical steps are optimized, the number of tools is minimized, and surgical time is reduced. Previous MIS tower systems have been placed in an awkward configuration with the towers angled parallel to one another and the screw trajectories crossed due to lumbar lordosis. In other cases, MIS towers are placed through a single incision, with the towers crossed adjacent to one another, making rod insertion and final tightening very difficult and frustrating. Some embodiments of the present disclosure can avoid these difficulties and provide an optimized MIS pedicle screw system.

[0053] Some embodiments disclosed herein provide a simple method and associated device for placing two or more pedicle screws through a single small hole, providing better cosmetic and functional results using only a single skin incision of small size (approximately 0.5 cm to 4 cm long, approximately 0.5 cm to 3 cm long, or approximately 1 cm to 2 cm long), regardless of the number of screws used. In one embodiment, the single incision is smaller than the sum of the maximum widths of the two largest elements of each screw inserted through the single incision, including the screw, screw head, rod, locking assembly, and associated tools.

[0054] Some embodiments disclosed herein are configured to allow a surgeon or other user to insert, position, and manipulate spinal implants, such as rods and locking assemblies, through the same small incision to lock the rods into the screws. Certain embodiments provide a novel method for inserting a rod into the head of a pedicle screw and a method for locking the rod into the screw through a single small incision. The present systems and methods, in certain embodiments, involve the attachment of guide elements, consisting of one or more flexible wires, flexible yet rigid extension blades, extension tabs, or towers, attached to the head of each pedicle screw, which are used to guide the rod down to the screw. The guide elements are configured and interlocked to be able to overlap or cross at or under the skin incision, thereby enabling the use of a single small skin incision. The screws, rods, and locking assemblies can all be placed through the single small incision and still be properly interconnected within it due to the natural lordotic curvature of the lumbar spine. By attaching at least one guidance element to each side of the screw head, the guidance elements help align the screw head. The guidance elements also capture or limit the displacement of the rod, fitting the rod between them and directly into the screw head.

[0055] In comparison to the aforementioned Sicvol U.S. Patent No. 7,179,261, embodiments of the present disclosure eliminate the need for "notches" through which guide elements intersect. For example, in embodiments utilizing extension tabs or extension blades, these extension tabs or extension blades do not have proximal, distal, or any lumens, and the configuration of the guidance elements (extension tabs or extension blades) for screws at adjacent levels allows the tabs to completely intersect and overlap for any patient with any relative geometry. Therefore, interference between adjacent guidance elements on adjacent vertebrae is not an issue. Also, with the notched tubes taught by the '261 patent, a rod or other element must still be inserted through the tube at some point. The notched tube requires that the rod (or other inserted element) be oriented longitudinally parallel to the long axis of the tube as it is directed into the body until it reaches a section with a sidewall opening or slot distal to the notched section, at which point the rod may optionally be redirected perpendicular to the long axis and directed to exit the sidewall through the opening or slot. In embodiments of the present disclosure, by using guidance elements such as extension blades or extension tabs (from the screw head), the element (e.g., rod, locking assembly, etc.) guided and inserted along them does not need to be inserted through any lumen. When the rod is inserted using a blade, the blade can simply be fed through the outer edge of the rod body, through a retaining element or fastener attached to the rod body, or between the outer edge of the rod body and the retaining element (retaining thread). Thus, the inserted rod or other element can be oriented perpendicular to the long axis or in any other manner or at any angle throughout the entire entry path. This provides greater flexibility to avoid interference between adjacent stabilization system components and eliminates the need for the surgeon to identify the notched section before vertically rotating and / or reorienting the screw / rod.Furthermore, because there are no proximal or distal lumens with extension tabs, blades from adjacent levels can overlap and cross without the need for notches, thus allowing all blades to exit through a single small minimal incision.

[0056] The guidance element may also be used to guide the locking assembly down onto the screw head in embodiments where the locking assembly is not part of (and is already down onto) the screw head itself.

[0057] Another embodiment is a hybrid system in which each screw is placed through a short tower or tube that does not reach the skin surface. Wires, blades, or tab extensions are attached to the top of the towers or tubes, so that the screws, rods, locking assemblies, and tools used for insertion, adjustment, locking, compression, distraction, and removal are guided through the individual towers or tubes by the extensions close to the skin but close to the bone and pedicle screws. This hybrid system offers both the advantages of a wire / extension blade / tab, in that many guidance elements can overlap in a single incision at skin level, and the advantages of a tower or tube system, retained at bone level. Some surgeons who find the tower system comfortable but desire the benefits of a blade / tab system may wish to use this hybrid system.

[0058] Making some of the guidance elements telescopic allows more guidance elements to fit smoothly through a single incision, thereby advantageously reducing the need for larger and / or multiple incisions. After insertion, the various guidance elements may be telescopically deployed as needed. By using a telescopic component as part of the upwardly directed extension guidance element, a rod for stabilizing the vertebrae can be inserted into the body through the telescopic component and through the same single incision, minimizing the invasiveness of the procedure.

[0059] All combinations and arrangements of towers, tubes, blades, arms, tabs, wires, and other upwardly extending guidance elements, either as described herein or hybrid systems combining traditional towers / guidance elements as described in the prior art (as described in the references incorporated by reference throughout this specification), are contemplated as being within the spirit and scope of the present disclosure. As used herein, the term guide element or guidance element is intended to include one or more components that extend between the screw and the skin incision and are preferably coupled or removably connected, directly or indirectly, to the screw head, and includes both traditional towers or tubes, such as those made from rigid or semi-rigid materials, as described in the patents and publications incorporated by reference throughout this specification, as well as additional embodiments of guide or guidance elements as described herein. The most appropriate selection and arrangement is up to the surgeon to decide in each particular case. For example, in one embodiment, a telescoping tube may be on one level, a wire on the next level, and a blade on the next level on one side (of the slot for the rod) with the blade attached to the wire on the other side (of the slot for the rod). Different variations can be selected for each side (medial, lateral) to introduce more components through the same incision. The goal is to minimize the number of incisions and prevent overcrowding while providing enough guidance elements to properly guide stabilization rods, locking assemblies, tools, etc. into the pedicle. Eliminating overcrowding allows for proper visualization, allowing the surgeon to work comfortably and efficiently.

[0060] In some embodiments, a system for performing spinal stabilization through an opening in a patient's skin is provided. In some embodiments, the opening can be a single minimally invasive skin incision. The system includes a first screw having a screw head and a first guide element (also referred to herein as a first extension) having a height component removably connected to the first screw, the first screw configured for implantation into a first vertebra. The system also includes a second screw having a screw head and a second guide element removably connected to the second screw, the second screw configured for implantation into a second vertebra. The first screw with the first guide element and the second screw with the second guide element can be delivered into the first and second vertebrae.

[0061] Other objects and advantages of embodiments of the present disclosure will be set forth in the following description. Suggested modifications of the present disclosure, based on the explicit description, will be, at least in part, obvious from the description or may be learned by practice of the present disclosure. Such subtle and foreseeable modifications and adaptations are deemed to be within the scope of the present disclosure. Further advantages of the present disclosure may be realized and obtained by means of the instrumentalities and combinations particularly pointed out hereinafter.

[0062] The embodiments disclosed herein include improved systems, apparatus, and methods for guiding one or more screws, rods, and locking assemblies down into vertebrae and securing rods or other spinal implants to stabilize the vertebrae. As shown in FIGS. 1A-1Z, an embodiment of a device or system for stabilizing spinal vertebrae is disclosed herein, although the features of this system may be utilized with all of the other embodiments described throughout this specification. In some embodiments, a system for stabilizing spinal vertebrae may include a pedicle screw. In some embodiments, a screw 110 (shown as 110A in some figures) may include a bone-engaging shaft 112 and a screw head 114. In some instances, the bone-engaging shaft 112 is threaded. The bone-engaging shaft 112 may be movable relative to the screw head 114 at different angles. In some embodiments, the screw head 114 has a generally U-shape defining an upwardly extending arm that forms a channel for receiving a rod 120. The rod 120 may seat on the head of the bone engaging shaft 112 or may seat on an insert 116 placed within the screw head 114 to receive the rod 120 .

[0063] The locking assembly may be integrated into or attached to the screw head, or may be a separate element. Locking assemblies that are separate elements include (but are not limited to) those that rely on a cap and set screw. Locking assemblies integrated with the screw head may include (but are not limited to) a rotatable mechanism where rotation of the screw head captures the rod. The locking assembly may be guided downward onto the screw before or after insertion of the rod, depending on the details of the locking mechanism used to secure the rod. In some embodiments, the locking assembly is already present on the screw head before the rod is received. In some examples, the rod is inserted into the screw head 114 first, followed by the locking assembly. In some embodiments, the upwardly extending arm of the screw head 114 may be internally threaded to receive an externally threaded cap screw that is rotated into the screw head 114 to apply a downward force to the rod 120 seated in the channel of the screw head 114. This downward force may then also lock the position of the screw head 114 relative to the rod 120 .

[0064] The guidance elements for directing the rod 120, various locking assembly components (e.g., screw head caps), surgical insertion and manipulation tools, and other components into position may be any type of upwardly oriented, elongated guidance element. These guidance elements are preferably removably connected to the screw head or screw so that they can be easily removed once the procedure is complete. Suitable guidance elements include tubes, towers, blades, arms, extension tabs, wires, strings, etc. In some embodiments, the extension tabs or blades of the guidance element extend upward from adjacent the screw head through the incision. In some cases, the guidance elements may be curved (along one or more axes) or bent (along one or more axes) to accommodate caps and other components. The guidance elements may also be curved or bent to be offset from adjacent elements so as not to interfere when they intersect. The curves may be permanently rounded, or they may be flexibly bendable or comprise foldable panels. The curvature and bend may be permanent, preformed, or adjustable in situ. The extension guidance element may also be tapered, threaded, and / or notched to help stabilize the cap or other components as they are lowered onto the screw head.

[0065] In some embodiments, the guidance element comprises two or more blades that may be offset from one another. In some cases, the offset configuration of the two or more blades allows the two or more blades to intersect without interfering with one another. In some embodiments, the blades 132 of each guidance element 130 of the screw 110 may be configured to intersect and / or overlap as described above. In some cases, the guidance elements may be offset in any functional manner, such as at different locations around the screw head (e.g., for staggered intersections), at different locations with curvatures (e.g., straight to bent), with curvatures that do not intersect with adjacent elements (blades from adjacent screw heads), etc.

[0066] The extension tabs / blades or other guidance elements on adjacent screws may be offset so that they do not interfere with each other when they cross. Rather, the extension tabs / blades (or other guidance elements) can be configured to smoothly pass each other as they cross each other. Thus, the extension tabs / blades on adjacent screws can be inserted through the same small incision and manipulated within that incision. This can be achieved with tabs / blades or other guidance elements on the inside of one screw and the outside of the other screw. In some embodiments, the tabs / blades for adjacent screws may simply be staggered or unaligned. In some examples, one screw can have a single tab / blade on the inside and another screw can have a single tab / blade on the outside. In some embodiments, one screw can have an extension tab, while one or more of the other screws can have a flexible wire as a guidance element.

[0067] In some embodiments, some of the extension guidance elements (tabs, blades, etc.) on some screw heads may be straight, while others are bendable or angled, so that the bendable or angled elements traverse the straight elements and exit the body through the same skin-level incision. In other embodiments, a first screw is connected to a first extension guidance element in the form of multiple blades, and a second screw is connected to a second extension guidance element in the form of multiple blades. The multiple blades of the first extension guidance element can overlap and / or intersect with the multiple blades of the second extension guidance element. Advantageously, the first and second extension guidance elements can intersect or overlap at or near the skin-level incision. By intersecting or overlapping at or near the skin-level incision, this allows both guidance elements to extend through a single small incision.

[0068] The extension tabs / blade or other guidance elements are configured to be easily removed from the screw head once the rod, cap, instrument, and other components have been properly oriented onto the screw head. This removal process may be accomplished by any number of means, including breaking along a pre-drilled or notched line, burning or melting at the base of the tab / blade with an instrument, releasing a mechanical clamp, etc. In some embodiments, extension guidance elements (e.g., extension tabs, extension blades, etc.) for adjacent screws may be attached to their respective screw heads at different locations along the screw head to create offset configurations. In some examples, the extension guidance elements may be attached to their respective screw heads at the same location and bent at different angles to form different configurations that are offset relative to each other when crossed. For example, the extension guidance elements may be bent to exit the screw head at different lateral displacements so that they do not interfere with each other. In some embodiments, three offset extension guidance elements (tabs, blades, etc.) attached to three adjacent screws may be used for two-level fixation. In some examples, four offset extension guidance elements attached to four adjacent screws may be used for three-level fixation. In some embodiments, five offset extension guidance elements attached to five adjacent screws can be used for four-level fixation, where potentially all five offset extension guidance elements can be configured to pass through the same skin level incision and intersect at some point at or near the same level skin incision.

[0069] In some embodiments, the extension tabs / extension blades / arms and wire can function together in a “hybrid” concept. For example, a first tab / blade / arm can be attached to the screw head and configured to be easily removable. Additional tabs / blades / arms between the screw head and the distal wire protruding from the skin can be added and / or removed as needed to extend or shorten the distance of the guidance trajectory. In some embodiments, the guidance element can include multiple break-off tabs / blades / arms attached in series to form a long, extended blade. The blade can then be adjusted to the appropriate length, such as at the level of the skin incision, by breaking the tab at the break point closest to the desired length. In some embodiments, one or more of the break-off tabs can be attached to the proximal wire to track and identify the tab's location within the patient.

[0070] In some embodiments, a flexible guidewire can be used to direct other guidance element features (e.g., tabs, blades, arms) during insertion and removal. The guidewire can function as a guide to direct an add-on tab element into a predetermined location within the patient. In some instances, multiple flexible guidewires can act alone as guidance elements to guide a rod, tool, or locking assembly component to a desired location on or near the spine. In some embodiments, the flexible guidewire can be part of a “hybrid” concept, working in conjunction with a tab / blade / arm to guide the element to a desired location. The rod, tool, or locking assembly component can be delivered through the guidance element by hand, or in some embodiments, using a stereotactic guidance mechanism and / or by a robot.

[0071] Additional embodiments of systems and methods for pedicle screw stabilization of spinal vertebrae are also disclosed in U.S. Pat. No. 8,721,691, the entire contents of which are incorporated herein by reference in their entirety.

[0072] As used herein, distal is defined as the space further from a particular location, and proximal is defined as the space closer to a particular location. In some embodiments, the portion of the tab or blade that extends beyond the incision can be considered the proximal portion, while the portion of the tab or blade that is below the incision can be considered the distal portion.

[0073] The systems, devices and methods of Figures 1A-1Z 1A-1Z illustrate one embodiment of a method for implanting multiple screws into multiple vertebrae, as well as the implantation and fixation of rods. The method disclosed in FIGS. 1A-1Z includes screw 110a and screw 110b described above. While the illustrated method includes only two screws, the disclosed method can be used for any number of screws implanted in any number of vertebrae in any order.

[0074] FIG. 1A shows a first guidewire 160a and a second guidewire 160b positioned at target locations on first and second vertebrae. As shown, the first guidewire 160a is directed to a vertebra lower than the vertebra to which the second guidewire 160b is directed. Each of the first and second guidewires 160a, 160b is configured to direct a first screw 110a and a second screw 110b to their respective vertebrae. As shown in FIG. 1B, the first screw 110a is directed below the first guidewire 160a. As described above, the first screw 110a includes a bone-engaging shaft 112a, a screw head 114a, and multiple wires 140a, 140b, with at least one of the multiple wires 140a located on either side of the screw head 114a.

[0075] Once the screw 110a is guided to the target location on the first vertebra, the bone engaging shaft 112a is threaded and held within the first vertebra, as shown in Figure 1D. Once the screw 110a is secured, the guidewire 160a is removed from the body, as shown in Figure 1E.

[0076] 1E shows a perspective view of the implanted first screw 110a. As shown, wires 140a are attached at their distal ends to screw heads 114a such that the proximal ends of the wires 140a extend out of the incision 150. In preparation for implantation of the second screw 110b, the wires 140a are bent away from each other to increase access to the incision (see FIG. 1F).

[0077] Similar to the implantation of the first screw 110a, the second screw 110b can be guided into the second vertebra by a second guide wire 160b. In some embodiments, as shown in FIG. 1G, the second screw 110b can be inserted with the distal end 139 of the tower 130 held around the proximal end of the screw head 114b. As can be seen more clearly in later figures, the tower 130 is disposed around a plurality of wires 140b. In some examples, as shown in FIG. 1H, the proximal ends of the wires 140b extend from the proximal end 138 of the tower 130.

[0078] 11 shows a perspective view of the tower 130 disposed around the implanted first screw 110a, the implanted second screw 110b, and the wire 140b and screw head 114b of the second screw head 114b. As shown, the second guide wire 160b has been removed, and the multiple wires 140a remain bent away from each other to allow access to the window 131 of the tower 130.

[0079] 1J-1L illustrate the insertion and placement of the rod 120 into the first insert 116a of the first screw 110a and the second insert 116b of the second screw 110b. In some embodiments, the rod 120 (or other implant) can be inserted through the incision 150 between the bending wire 140a and the window 131 of the tower 130. In some examples, the first end 121 of the rod 120 passes through the window 131 of the tower 130. The first end 121 can be guided down the window 131 of the tower 130 and the distal end of the wire 140a until it enters the insert 116a of the first screw head 114a in the first vertebra. In some examples, the second end 122 of the rod 120 is guided down the window 131 until it enters the insert 116b of the second screw head 114a in the second vertebra.

[0080] In some embodiments, a locking assembly can be inserted onto the rod 120 to secure the rod 120 within the first screw 110a and the second screw 110b. As described in more detail above, the locking assembly can be integrated into or attached to the screw head, or can be a separate element. Locking assemblies that are separate elements include (but are not limited to) those that rely on a cap and set screw. The locking assembly can be guided down onto the screw before or after insertion of the rod, depending on the details of the locking mechanism used to secure the rod. In some embodiments, the locking assembly is already present on the screw head before the rod is received. In some examples, the rod is inserted into the screw head 114 first, followed by the locking assembly. In some embodiments, as shown in FIGS. 1M and 1N, the locking assembly is a screw cap 170 that can be placed over the rod 120. As shown in FIG. 1M, the screw cap 170 can be placed within the opening 133 in the proximal end 138 of the tower 130. The tower 130 is configured to guide the tower 130 into the screw head 114b of the screw 110b (see FIG. 1N). In some embodiments, the upwardly extending arm of the screw head 114b can be female-threaded, and the screw cap 170 can be male-threaded. To secure the screw cap 170, the male-threaded screw cap 170 can be rotated into the screw head 114b, applying a downward force to the rod 120, which is seated in the insert 116b of the screw head 114b. This downward force can then also lock the second end 122 of the rod 120, such that the screw head 114b is secured to the rod 120.

[0081] In some examples, the tower 130 can be moved from accessing one screw to another. FIGS. 1O-1V show the tower 130 moved from accessing the second screw 110b to accessing the first screw 110a. As shown in FIG. 1O, the tower 130 can be removed proximally so that the distal end 139 of the tower 130 disengages from the proximal end of the second screw head 114b. As the tower 130 is removed, it is pulled along the length of the wire 140b attached to the proximal end of the screw head 114b (see FIG. 1P). FIGS. 1Q-1S show perspective views of the implanted first screw 110a and second screw 110b. In some embodiments, to allow the tower 130 to be disposed around the multiple wires 140a of the first screw 110a, the wires 140a can be bent so that pairs of wires 140a are closer to each other (see FIG. 1R). In some instances, multiple wires 140b can be bent away from each other to provide additional room and access to incision 150 (see FIG. 1S).

[0082] FIG. 1T shows a side view of implanted first screw 110a and second screw 110b. In some embodiments, tower 130 can be disposed around wire 140a of screw 110a when wire 140a and wire 140b are bent to accommodate tower 130. As shown in FIGS. 1U and 1V, tower 130 can be inserted distally such that distal end 139 of tower 130 is disposed around the proximal end of screw head 114a.

[0083] As described with respect to inserting the screw cap 170 onto the screw head 114a of the screw 110a, the second screw cap 170 can be inserted through the opening 133 in the proximal end 138 of the tower 130. As shown in FIGS. 1W and 1X, the second screw cap 170 can be guided onto the screw head 114a of the screw 110a. As described above with respect to the first screw cap 170, in some embodiments, the upwardly extending arm of the screw head 114a can be female-threaded, and the second screw cap 170 can be male-threaded. To secure the second screw cap 170, the male-threaded screw cap 170 can be rotated into the screw head 114a, applying a downward force to the rod 120 seated within the screw head 114a. This downward force can then lock the first end 121 of the rod 120 such that the screw head 114a is secured to the rod 120.

[0084] Once the first screw 110a and the second screw 110b are implanted and the rod 120 is secured by the first screw cap 170 and the second screw cap 170, the tower 130 can be removed from the incision 150. In some embodiments, as shown in FIG. 1Z, the first pair of wires 140a and the second pair of wires 140b can be removed from the implanted first screw 110a and the second screw 110b. In some examples, the wires 140a, 140b are broken off along with the proximal ends of the screw heads 114a, 114b. As shown in FIG. 1Z, in some embodiments, the first screw cap 170 and the second screw cap 170 are adjacent the proximal ends of the screw heads 114a, 114b.

[0085] The systems, devices, and methods of Figures 2A-2T 2A-2T illustrate another embodiment of a method and system 200 for stabilizing spinal vertebrae. Any of the one or more system embodiments disclosed herein can have any of the screws, extensions (also referred to as towers, extension towers, or guide elements), or other components, features, and / or other details of any of the other embodiments of implanted systems disclosed herein or disclosed in U.S. Pat. No. 8,721,691 or components thereof, which are incorporated by reference as if fully set forth herein, in place of, or in any combination with, any of the components, features, and / or other details disclosed herein with respect to one or more system embodiments disclosed below, including without limitation any of the embodiments of system 200. Additionally, any of the steps, sequences of steps, or actions described above with respect to any other system embodiment or disclosed in U.S. Pat. No. 8,721,691 may be used in place of, or in any combination with, any of the steps, sequences of steps, or actions described below with respect to any of the system embodiments disclosed below (including, but not limited to, embodiments of system 200) to form new steps, sequences of steps, and actions for the system embodiments disclosed below (including, but not limited to, embodiments of system 200).

[0086] FIG. 2A shows a first guidewire 202 and a second guidewire 204 (which may be K wires) of a spinal stabilization system 200 advanced through an incision 206 into a target location within a patient's vertebrae. In any embodiment, as shown, the first and second guidewires may be advanced through a single incision. In other embodiments, three or more guidewires for three or more devices or implants may be advanced through a single incision. FIG. 2B shows a first extension 208 having a proximal end portion 208a and a distal end portion 208b, which may be coupled with a first screw 210 advanced over the first guidewire 202 through the incision 206. The screw 210 may be selectively removable from the extension member 208 at the distal end portion 208b of the extension member 208.

[0087] The following is a description of some embodiments of a system 200 for stabilizing spinal vertebrae that can be performed through a single skin incision, such as incision 206. As shown in Figures 2A-2T, any embodiment of system 200 can include a first screw 210 having a first screw head 210a, a second screw 230 having a second screw head 230a, a first extension 208 having a body portion 209, and a second extension 228 having a body portion 229. The first extension 208 can be configured to be removably coupled to the first screw 210 at a first end of the body portion 209 of the first extension 208 using any of the techniques or components known in the art or as disclosed herein, and the second extension can be configured to be removably coupled to the second screw at a first end of the body portion 229 of the second extension 228 using any of the techniques or components known in the art or as disclosed herein. The first extension 208 can further include a handle portion 214 (also referred to herein as a handle member) that can be coupled to a proximal end of the body portion of the first extension. The handle portion 214 can extend at an angle away from the proximal end of the body portion of the first extension 208. It should be noted that the terms guide element or extension element can be used to describe the extension components described herein.

[0088] First extension: In any embodiment, the first extension 208 may be shorter than the second extension 208. For example, without limitation, the first extension 208 may be sized such that the proximal end of the body portion 209 of the first extension 208 extends to a level just below the patient's skin when the first screw 210 is implanted in the first vertebra 211, or such that the proximal end 208a of the first extension 208 extends to a level just below or even with the patient's skin when the first screw 210 is implanted in the vertebra. Alternatively, the first extension 208 may be sized such that only a proximal end portion 208 a of the first extension 208 (for example, but not limited to, 10% or about 10% or less of the total length of the first extension 208, or 5% or about 5% to 10% or about 10% of the total length of the first extension 208) extends through the skin incision 206 when the first screw 210 is implanted in a vertebra, or such that no portion of the first extension 208 extends through the skin incision when the first screw 210 is implanted in a vertebra. Furthermore, in any embodiment, the first extension 208 may be sized such that the entire body portion 209 of the first extension 208 is positionable below the patient's skin surface with only the handle portion 214 extending through the skin incision when the first screw 210 is implanted in a vertebra.

[0089] For example, without limitation, a surgeon can measure the distance from the vertebrae to the skin surface and select a first extension 208 having an appropriate length that matches or nearly matches the distance from the vertebrae to the skin surface. In some embodiments, the first extension 208 can have an adjustable length, such as a telescoping body, that can be adjusted by the surgeon before and / or after the first screw 210 is implanted. In this configuration, the length of the first extension 208 can be, but need not be, adjusted so that the entire length of the first extension is at or below the patient's skin surface, or substantially (as described above) at or below the patient's skin surface.

[0090] Second extension: In any embodiment, the second extension 228 can be sized to extend completely through the skin incision 206 when the second screw 230 is implanted into the vertebra. In some embodiments, the body portion 209 of the first extension 208 can have an adjustable length. In some embodiments, the first extension 208 and the second extension 228 can each have a fixed length. In some embodiments, the first and second body portions can be molded into a generally cylindrical shape.

[0091] Handle: 4 illustrates a handle portion 214 (also referred to herein as a handle) that may be coupled to or integrally formed with the first extension 208. The handle portion 214 may have a proximal portion 214a and a distal portion 214b. In any embodiment, the handle portion 214 may be coupled to the first extension 208 at the proximal end portion 208a of the first extension 208. The handle portion 214 and the first extension 208 may be configured such that a surgeon or other user can rotate, move, torque, bend, or otherwise manipulate the first extension 208 when the first extension is inside an incision using the handle portion 214 and when the handle portion is positioned outside the body.

[0092] In any embodiment, the handle portion 214 can extend away from the first extension 208 at any desired angle. For example, without limitation, in some embodiments, the handle portion 214 can extend away from the axial centerline of the first extension 208 at an angle A (as shown in FIG. 2C ) that is at or about 45° from the axial centerline of the first extension 208, or at or about 30° to 50° from or about 50° from the axial centerline of the first extension 208, or at or about 40° to 45° from or about 45°. Further, in some embodiments, the angle of the handle portion 214 relative to the first extension 208 may be variable through a joint attachment or an adjustable angle connection between the handle portion 214 and the first extension 208. Additionally, the handle portion 214 can have any desired length. In some embodiments, the length of the handle portion can vary, allowing a user to select a desired length of handle portion from a kit of handle portions of various sizes, or the length of the handle portion can be adjustable. In some embodiments, the length of the handle portion 214 can be the same as or approximately the same as the length of the first extension 208, or within 25% of the length of the first extension. The handle portion 214, or any other handle portion of any embodiment disclosed herein, can have any desired cross-sectional shape, including flat, curved, rounded, oval, etc. The handle portion 214, or any other handle portion of any embodiment disclosed herein, can also have any desired longitudinal shape or curvature, including a curve that is curved away from the skin, a wavy curve to accommodate the grip of a surgeon's hand, or a curve that mates with the handle portion of a second screw to provide a fulcrum and thereby allow compression of the screw head when the two handles are squeezed.

[0093] The device 200 can be configured to be grasped by a surgeon such that a handle portion 214 attached to the proximal end of the first extension 208 can enable the surgeon to manipulate the first extension 208, and thus the first screw 210, and the first vertebra to which the first screw 210 is anchored or coupled, during a surgical procedure. In this configuration, the surgeon can, for example, but not limited to, apply a compressive force to an adjacent vertebra, apply a decompressive force to an adjacent vertebra, or rotate, torque (including a counter torque force applied to a set screw when a set screw is installed to secure a rod between adjacent spinal screws), bend, or otherwise manipulate the first extension, first screw 210, and / or the first vertebra. In some embodiments, the handle portion 214 can be used to apply a rotational force to the first extension 208 about at least a centerline axis of the first extension. For example, but not by way of limitation, the handle portion 214 may be configured to be grasped by a surgeon to enable the surgeon to manipulate the first extension portion, or to enable the surgeon to apply a rotational force to the first extension portion 208 about the centerline axis of the first extension portion.

[0094] The handle portion 214 can be a separate component configured to be removably coupled to the body portion of the first extension. In some embodiments, the handle portion 214 can be removably coupled to the body portion of the first extension, with the handle portion 214 having an end portion that can be receivable within a notch, groove, or other receptacle formed on the side of the body portion of the first extension. For example, the handle portion 214 can be separated from the extension and inserted into a notch, groove, or receptacle formed on one side of the first extension. In this configuration, a screw can be inserted with the first extension 208 using an inserter. During insertion, the inserter is placed through the first extension 208 and can be inserted like a regular tower or extension configuration. However, there can be a groove or slot along the side of the inserter that connects to a groove or slot along the wall of the first extension. Thus, after the screw is inserted, but with the inserter still attached to the screw and first extension, the handle portion 214 can slide along the side of the inserter with a corresponding groove or formation that receives the handle portion 214 and allows it to slide downward into the groove and slot in the wall of the first extension. The system can have a locking mechanism or feature for selectively securing or locking the handle portion 214 in place within the wall of the first extension. In some embodiments, the handle portion 214 can be permanently coupled to or integrally formed with the body portion of the first extension.

[0095] In any embodiment disclosed herein, first extension 208 can have a recess or notch 215 formed therein at an intermediate portion and / or proximal end of body portion 209 of first extension 208, which can be configured to operatively receive a portion of the outer surface of body portion 229 of second extension 228 therein. Recess 215 can have a shape that generally complements the shape of the outer surface of body portion 229 of second extension 228. For example, in some embodiments in which body portion 229 of second extension 228 has a round or circular cross-section, recess 215 can have a curved profile or cross-section that accommodates the round or circular cross-section of second extension 228. In some embodiments, the first extension 208 can have a recess 215 formed in at least an intermediate portion and the proximal end 208a of the first extension 208, the recess being configured to receive a portion of the outer surface of the body portion 229 of the second extension 228 therein in the operable state. The handle portion 214 can extend generally in a direction away from the recess, away from the body portion 209 of the first extension 208. In this configuration, the second extension 228 can be positioned closer to the first extension 208 and can be advanced through a smaller incision in the patient's skin. The recess 215 can result in a more compact system during a surgical procedure, which can reduce the size of the incision, among other benefits.

[0096] In some embodiments, the first extension 208 can have a recess formed therein at the proximal end of the first extension body portion, the recess configured to receive a portion of the outer surface of the body portion 229 of the second extension 228 therein in the operable state. The handle portion 214 can be coupled to a first side of the body portion 209 of the first extension 208, and the recess can be formed on a second side of the body portion 209 of the first extension 208, which can be opposite the first side of the body portion of the first extension. In some embodiments, the handle portion 214 can be attached to the body portion 209 of the first extension 208 adjacent to the recess formed in the first extension body portion. In some embodiments, the details of a portion of the recess can be similar to the recess in the embodiment shown in Figures 39-45 of Patent No. 8,721,691, and the details of such embodiment shown in and described in such figures are incorporated by reference as if fully set forth herein.

[0097] In some embodiments, the system may further include at least one handle portion (similar to the embodiments of handle portion 214 disclosed herein) coupled to body portion 229 of second extension portion 228, or two handle portions coupled to body portion 229 of second extension portion 228 that may be used together with handle portion 214 coupled to first extension portion 208.

[0098] Connecting member: Any embodiment disclosed herein may further include a connecting member 216 (also referred to herein as a restraint, retention member, ring, or ring member), which may be configured to couple the first extension 208 and the second extension 228 together, as shown in FIG. 2I, among other things. The connecting member 216 may be rigid and may be formed integrally or separately from the first extension 208 and may be welded, brazed, or otherwise coupled to the first extension. In this configuration, the connecting member 216 may provide a selectable or reversible coupling or connection between the first extension 208 and the second extension 228. Any embodiment of the connecting member 216 may be configured to improve control and manipulation of the second extension 228 relative to the first extension 208 and / or the first extension 208 relative to the second extension 228. For example, and without limitation, using the connecting member 216 and the handle portion 214, the surgeon can apply a force to the first elongated member 208 relative to the second elongated member 228 to move the distal end 208b of the first elongated member 208 toward the distal end 228b of the second elongated member 228, thereby applying a contraction force to the first and second vertebrae, or apply a force to the first elongated member 208 relative to the second elongated member 228 to spread the distal end 208b of the first elongated member 208 away from the distal end 228b of the second elongated member 228, thereby applying a traction force to the first and second vertebrae.

[0099] In some embodiments, connecting member 216, in the operative state, can be coupled to and surround all or a portion of the outer surface of proximal end 208 a of first extension 208 and body portion 229 of second extension 228. In other embodiments, connecting member 216 can be coupled to and extend away from the outer surface of first extension 208. Referring to FIG. 2I , in some embodiments, connecting member 216 can have an opening 217 therethrough that is aligned with a recess 215 formed in first extension 208 that is sized and configured to receive second extension 228 therethrough such that second extension 208 can be advanced through opening 217 and through recess 215 as the second extension is advanced toward the patient's second vertebra.

[0100] Additionally, any embodiment can also include a connecting member 216. In some embodiments, the connecting member 216 can be coupled to or integrally formed with the first extension 208. In any embodiment, the connecting member 216 can be coupled to the first extension 208 at the proximal end portion 208a of the first extension 208. In some embodiments, the connecting member 216 can surround a portion of the first extension 208 and / or a portion of the handle portion 214 adjacent the proximal end 208a of the first extension 208 and / or the distal portion 214b of the handle portion 214. In other embodiments, the connecting member 216 can extend away from a side of the first extension 208 without surrounding any portion of the first extension 208. In some embodiments, the connecting member 216 can be configured to provide a loose connection between the first extension 208 and the second extension 228.

[0101] Additionally, in any embodiment, connecting member 216 may be selectively releasable such that a surgeon or other user can open connecting member 216 to facilitate advancing second extension 228 therethrough. For example, without limitation, connecting member 216 may have a catch that is selectively releasable so that second extension 228 or another extension may be advanced through an opening in connecting member 216 or otherwise coupled with connecting member 216. In some embodiments, connecting member 216 may have deflectable arms and / or a catch, for example, without limitation, similar to that of a carabiner. In other embodiments, connecting member 216 may comprise a post, such as a T-shaped post, that may be received in a slot in second extension 228 (e.g., a longitudinal slot extending along all or a portion of the length of the second extension), which may provide a selectively detachable rigid connection between the first extension and the second extension.

[0102] Windows in extending members: The first extension 208, second extension 228, or any other extension of any embodiment of treatment system 200 or other treatment systems disclosed herein can have at least one window or slot 240 extending through a side thereof. With reference to FIG. 2L , the at least one slot 240 can be configured to receive a connecting element 244 that can be advanced through the slots 240 of the first and second extensions 208, 228 (and / or any other extensions) toward the first and second screws 210, 230 and can extend and be used to operably connect the first screw 210 to the second screw 230.

[0103] Connection elements: As mentioned above, any of the systems disclosed herein can further include a rigid connecting element 244 that can be coupled to the head 210 a of the first screw 210 and the head 230 a of the second screw 230. The first extension 208 and the second extension 228 can be configured to operably receive the connecting element 244 within the slots or windows 240 of the first and second extensions 208, such that the connecting element 244 can be directed and advanced along the length of the first and second extensions 208, 228 toward the head 210 a of the first screw 210 and the head 230 a of the second screw 230. In an operative state, the connecting element 244 can extend between the first screw 210 and the second screw 230 when the first and second screws 210, 230 are implanted into the first and second vertebrae 211, 213, respectively. Other details regarding the coupling of connecting element 244 and first and / or second screws 210, 230 are described in Patent No. 8,721,691, which details are incorporated herein by reference as if fully set forth herein, such that any of the features, components, methods, or other details of any of the embodiments disclosed in Patent No. 8,721,691 may be combined with any of the features, components, methods, or other details of any of the embodiments disclosed herein to form additional embodiments, all of which are part of this disclosure. Any of the embodiments disclosed herein may be configured to include any of the details, components, methods disclosed in Patent No. 8,721,691, or otherwise disclosed, in combination with any of the details, components, or methods disclosed herein, as if fully set forth herein.

[0104] An alternative embodiment of the coupling of any embodiment of the connecting element and the first, second, and / or third secondary screw disclosed herein can be configured as a pendulum mechanism for swinging the connecting element from outside the skin through separate skin incisions. The pendulum mechanism can then be configured to direct the connecting element from the separate skin incisions in a sequential manner through the head of the first screw, then the head of the second screw, or vice versa. This pendulum method of inserting the connecting element was popularized by Medtronic's Sextant system for MIS fixation, as described above. Any of the embodiments of the system and / or method of using the system can be configured for use with the pendulum mechanism and can have any of the features of Medtronic's Sextant system for MIS fixation, or similar systems or improved versions thereof.

[0105] In some embodiments, the head 210a of the first screw 210 can have a channel, recess, or other feature formed therein configured to receive the connecting element 244, and the head 230a of the second screw 230 can have a channel, recess, or other feature formed therein similarly configured to receive the connecting element 244. The first and second screw heads 210a, 230a can be configured to selectively secure or lock the connecting element 244 to the first and second screw heads 210a, 230a such that the connecting element 244 remains in a fixed position after implantation. In this configuration, the connecting element 244 can secure the first and second vertebrae in a desired relative position.

[0106] Third elongated member: Any embodiment may further include a third screw (not shown) having a screw head and a third extension configured to be removably coupled to the third screw. The embodiments disclosed herein may further include a third screw having a screw head, a third extension configured to be removably coupled to the third screw, and a handle portion 214 coupled to the proximal end of the body portion of the third extension, the handle portion 214 extending at an angle away from the proximal end of the body portion of the third extension. The third extension may have a length approximately the same as the length of the first extension. The third extension may have a recess formed in the proximal end of the body portion of the third extension, which may be configured to receive a portion of the outer surface of the body portion 229 of the second extension 228 in an operative state. Furthermore, any embodiment of the third extension may also have an additional connecting element coupled to the third extension, the connecting element being configured to enable a detachable connection between the third extension and the first extension 208 and / or the second extension 228.

[0107] Implantation procedure: Any of the embodiments disclosed herein may be implanted using any suitable procedure or process, including, but not limited to, any of the procedures or processes described with respect to any other embodiment disclosed herein, including, but not limited to, any of the embodiments disclosed in Patent No. 8,721,691, which procedures or processes are incorporated herein by reference as if fully set forth herein. For example, but not limited to, any of the embodiments disclosed herein may be placed or implanted through a skin incision, the method including any combination of the following steps or acts: implanting a first screw 210 having a first extension 208 (also referred to as a first guide element) associated therewith through the incision and into a first vertebra, the first extension 208 comprising a body portion that extends only to the level of the skin incision or below the level of the skin incision when the first screw 210 is implanted into the first vertebra. The first extension 208 can have a handle portion 214 coupled to and extending away from a proximal end portion of the first extension 208. The method can further include implanting a second screw 230 having a second extension 228 coupled thereto through the incision and into the second vertebra, the second extension 228 having a body portion 229 extending through the skin incision when the second screw 230 is implanted in the second vertebra. The method can further include grasping the handle portion 214 coupled to the first extension 208 to manipulate the first extension 208, and coupling a rigid connector (such as connecting element 244) to the first screw 210 and the second screw 230 to generally fix the position of the first screw 210 relative to the second screw 230. The first and second extensions 208, 228 may then be removed from the first and second screws 210, 230 and from the patient's body.

[0108] Some embodiments of the method may further include advancing second extension 228 through a rigid connecting member that may be positioned adjacent the skin incision, advancing second extension 228 through a rigid connecting member (such as connecting member 216) that may be coupled to a portion of first extension 208, and / or positioning a rigid connecting member around first extension 208 adjacent a distal end portion of handle portion 214 where the distal end portion of handle portion 214 couples with first extension 208. In this configuration, implanting second screw 230 having second extension 228 coupled thereto through the incision and into the second vertebra may include advancing second screw 230 and second extension 228 through an opening (such as opening 217) in connecting member 216.

[0109] In some embodiments of the methods disclosed herein, the body portion of the first extension 208 may include a recess formed in a proximal end portion thereof configured to receive a portion of the outer surface of the second extension 228 therein. Additionally, the first extension 208 and the second extension 228 may each have at least one window extending through a side thereof. Any of the methods disclosed herein may further include coupling a stabilizing element to the screw head 210 a of the first screw 210 and the screw head 230 a of the second screw 230.

[0110] 2E shows the first screw 210 implanted within the first vertebra 211. As shown in FIG. 2E and described above, the device 200 can be sized and configured such that when the first screw is fully implanted within the first vertebra 211, the first extension 208 is positioned fully within the incision 206, and therefore fully within the patient's skin, such that substantially no portion of the first extension 208 extends out of the incision 206 away from the patient's body. As shown, the handle portion 214 can extend away from the incision 206 such that all, or in some embodiments, substantially all, of the handle portion 214 is outside the body during the procedure. The first guidewire 202 can then be removed or can remain in its previous position for subsequent steps.

[0111] 2F-1 and 2F-2, and as described above, the handle portion 214 can be used to apply a force to the first extension portion 208 to move or otherwise manipulate the first extension portion 208, thereby moving or otherwise manipulating the first vertebra 211 relative to other vertebrae, etc. For example, as shown in FIG. 2F-2, the proximal portion 214a of the handle portion 214 can be pushed and / or moved in any direction, including a first direction (represented by A1 in FIG. 2F-2), which can be a direction away from the second vertebra 213, and in some embodiments, when all components of the system 200 are implanted, to apply a compressive force to the first vertebra 211 against the second vertebra 213, moving the first vertebra 211 closer to the second vertebra 213. In another method or procedure, the proximal end portion 214a of the handle portion 214, in some embodiments, once all components of the system 200 are implanted, can be pushed and / or moved in a direction toward the second vertebra 213 to apply a tension or traction force to the first vertebra 211 relative to the second vertebra 213, moving the first vertebra 211 further away from the second vertebra 213. As shown in FIGS. 2F-1 and 2F-2 , the proximal end portion 214a of the handle portion 214 has been moved in a first direction A1 away from the second vertebra 213 such that the proximal end portion 210a of the first extension portion 210 is moved in the first direction A1 away from the second vertebra 213.

[0112] 2G-1 and 2G-2, second extension 228, which may be removably coupled to second screw 230, may then be advanced over second guidewire 204 through incision 206. Importantly, connecting member 216 may be implanted and positioned relative to second guidewire 204 such that second guidewire 204 extends through opening or passageway 217 in connecting member 216. In this arrangement, as second extension 228 is advanced along second guidewire 204 through incision 206, second extension 228 advances through opening or passageway 217 in connecting member 216. Second spinal screw 230 may be implanted in this manner into second vertebra 213, as shown in FIGS. 2H-1 and 2H-2, and the second guidewire may then be removed as shown in FIG. 2I or left in place for a subsequent procedure. The extension, screw, and / or vertebrae can then be manipulated for compression, decompression, or otherwise using the handle portion 214 and second extension portion 228.

[0113] Incision: In any embodiment disclosed herein, the incision can be approximately the diameter of a dime, or approximately ½ to approximately 1 inch, or approximately ½ to approximately ¾ inch. The system can be configured such that the first screw 210, the second screw, and the third screw are implanted through the skin incision.

[0114] Alternative shapes of extensions: In some embodiments, the first extension 208 can have a first planar body and a second planar body (such as in some of the embodiments disclosed in Patent No. 8,721,691), and the first planar body can be spaced apart from the second planar body to create a space between the first and second planar bodies.

[0115] 2L-2T, a rigid connecting element (also referred to as a connecting member or rod) can be advanced through the extension (e.g., without limitation, through a window in such a screw) and the incision and secured to the first and second screws using any known or suitable technique and / or components, such as by using a set screw as shown in Figures 2P-2T. The extension can then be removed, as shown in Figure 2T.

[0116] In addition to the hybrid systems described above, additional systems combining any of the above-described guide elements are possible. For example, a system for rod delivery may include a mixture of one blade and one or more wires on a single screw. Another system for rod delivery may include a combination of one tube or tower on one screw and one or more wires or blades on a second screw. Various combinations of guide elements that can be used through a single incision are possible.

[0117] Certain aspects of the systems, devices, components, and / or methods described above or illustrated with respect to Figures 2A-2T are also encompassed by the following numbered embodiments, which are believed to be directed to systems, devices, components, and / or methods including, but not limited to, the embodiments of Figures 2A-2T, and thus may encompass other embodiments as described throughout this specification. 1. A system for stabilizing spinal vertebrae through a skin incision, comprising: a first screw having a first screw head; a second screw having a second screw head; a first extension having a body portion configured to be removably coupled with a first screw at a distal end of the body portion of the first extension; a second extension having a body portion configured to be removably coupled with a second screw at a distal end of the body portion of the second extension; a handle portion coupled, or configured to be coupled, to a proximal end of the body portion of the first extension, the handle portion extending at an angle away from the proximal end of the body portion of the first extension; Equipped with The handle portion is configured to be grasped by a surgeon such that the surgeon can apply a rotational force to the first extension about at least a centerline axis of the first extension. 2. The system of embodiment 1, wherein the first extension portion is sized so that when the first screw is implanted in the first vertebra, the proximal end of the body portion of the first extension portion extends to a level just below the patient's skin. 3. The system of embodiment 1, wherein the first extension portion is sized so that when the first screw is implanted into the first vertebra, the proximal end of the body portion of the first extension portion extends to a height just below the patient's skin or to the same height level as the patient's skin. 4. The system of embodiment 1, wherein the first extension portion is sized so that when the first screw is implanted into the first vertebra, only the proximal end portion of the body portion of the first extension portion extends through the skin incision. 5. The system of embodiment 1, wherein the first extension portion is sized such that when the first screw is implanted into the first vertebra, no portion of the body portion of the first extension portion extends through the skin incision. 6. The system of embodiment 1, wherein the first extension portion is sized so that when the first screw is implanted into the first vertebra, the entire body portion of the first extension portion is positionable below the patient's skin surface, with only the handle portion extending through the skin incision. 7. The system of any one of the preceding embodiments, wherein the second extension portion is sized to extend completely through the skin incision when the second screw is implanted into the second vertebra. 8. The system of any one of the preceding embodiments, wherein the system is configured so that the first and second screws are implanted through the same skin incision. 9. The system of any one of the preceding embodiments, wherein the system is configured so that the first screw, the second screw, and the third screw are implanted through the same skin incision. 10. A system according to any one of the preceding embodiments, wherein the handle portion is configured to be grasped by a surgeon so that the surgeon can manipulate the first extension portion. 11. A system according to any one of the preceding embodiments, wherein the handle portion is configured to be grasped by a surgeon so that the surgeon can apply a rotational force to the first extension about a centerline axis of the first extension. 12. The system of any one of the preceding embodiments, wherein the handle portion is removably coupled to the body portion of the first extension. 13. A system according to any one of the preceding embodiments, wherein the handle portion is removably coupled to the body portion of the first extension, and the handle portion has an end portion that is receivable within a notch, groove, or other receptacle formed on a side of the body portion of the first extension. 14. The system of any one of the preceding embodiments, wherein the handle portion is permanently coupled to the body portion of the first extension. 15. A system according to any one of the preceding embodiments, wherein the handle portion is integrally formed with the body portion of the first extension. 16. A system according to any one of the preceding embodiments, wherein the first extension has a recess formed therein at a proximal end of the body portion of the first extension, the recess being configured to receive a portion of the outer surface of the body portion of the second extension therein in an operable state. 17. The system of embodiment 16, wherein the recess has a shape that generally complements the shape of the outer surface of the body portion of the second extension. 18. The first extension has a recess formed therein at a proximal end of the body portion of the first extension, the recess being configured to receive a portion of an outer surface of the body portion of the second extension therein in an operable state; The handle portion extends away from the body portion of the first extension, generally in a direction away from the recess; 10. The system of any one of the preceding embodiments. 19. The first extension has a recess formed therein at a proximal end of the body portion of the first extension, the recess being configured to receive a portion of an outer surface of the body portion of the second extension therein in the operable state; the handle portion is coupled to the first side of the body portion of the first extension; The recess is formed on a second side surface of the body portion of the first extension portion opposite to the first side surface of the body portion of the first extension portion. 10. The system of any one of the preceding embodiments. 20. A system according to any one of the previous embodiments, wherein the handle portion is attached to the body portion of the first extension adjacent to a recess formed in the body portion of the first extension. 21. The system of any one of the previous embodiments, wherein the body portion of the first extension has an adjustable length. 22. The system of any one of the preceding embodiments, wherein each of the first and second extensions has a fixed length. 23. The system of any one of the previous embodiments, wherein the first and second body portions are cylindrically shaped. 24. A system according to any one of the preceding embodiments, wherein the first extension includes a first flat body and a second flat body, the first flat body being spaced apart from the second flat body so as to create a space between the first and second flat bodies. 25. The system of any one of the preceding embodiments, further comprising a rigid connecting member having an opening therein, the connecting member configured to operably surround the proximal ends of the body portions of the first extension and the second extension and couple the first and second extensions together. 26. The system of any one of the preceding embodiments, further comprising a rigid connecting member having an opening therein configured to surround the proximal ends of the body portion of the first extension and the body portion of the second extension in an operable state, the connecting member configured to provide a loose connection between the first extension and the second extension. 27. The system of embodiment 25 or 26, wherein the connecting member is selectively releasable. 28. Rigid connecting elements; a first receiving element coupled to the first screw head; a second receiving element coupled to the second screw head; the first and second receiving elements are configured to operably receive a connecting element, the connecting element extending between the first and second receiving elements in the operable state when the first and second screws are implanted into the first and second vertebrae, respectively; 10. The system of any one of the preceding embodiments. 29. The system of any one of the preceding embodiments, wherein the first screw is configured to be implanted into a first vertebra and the second screw is configured to be implanted into a second vertebra. 30. The system of any one of the preceding embodiments, wherein the first screw with the first extension and the second screw with the second extension are configured to be delivered into the first and second vertebrae, respectively, through a skin incision that is a minimally invasive skin incision. 31. The system of any one of the previous embodiments, comprising at least one handle portion coupled with the body portion of the second extension. 32. The system of any one of the preceding embodiments, comprising at least one handle portion coupled with the body portion of the second extension. 33. A system described in any one of the previous embodiments, further comprising a third screw having a screw head and a third extension configured to be removably coupled to the third screw. 34. A third screw having a screw head; a third extension configured to be removably coupled with the third screw; a handle portion coupled to the proximal end of the body portion of the third extension, the handle portion extending at an angle away from the proximal end of the body portion of the third extension; 10. The system of any one of the preceding embodiments, further comprising: 35. The system of embodiment 34, wherein the third extension has a length approximately the same as the length of the first extension. 36. A system described in embodiment 34 or 35, wherein the third extension has a recess formed at the proximal end of the main body portion of the third extension, and the recess is configured to receive a portion of the outer surface of the main body portion of the second extension therein in an operable state. 37. A system described in any one of the preceding embodiments, wherein the first extension has at least one window extending through a side of its body portion, and the at least one window is configured to receive a connecting element configured to extend between the first screw and the second screw in an operable state. 38. The system of any one of the preceding embodiments, wherein the first extension is shorter than the second extension. 39. A system according to any one of the preceding embodiments, wherein the second extension has at least one window extending through a side of its body portion, and the at least one window of the second extension is configured to receive a connecting element configured to extend between the first screw and the second screw in an operable state. 40. A method of performing spinal stabilization through a skin incision, the method comprising: implanting a first screw having a first guide element coupled thereto through the incision and into the first vertebra, the first guide element having a body portion that extends only to the level of the skin incision or below the level of the skin incision when the first screw is implanted into the first vertebra, and a handle portion that is coupled to and extends away from a proximal end portion of the first guide element either before or after the first screw is implanted into the first vertebra; implanting a second screw having a second guide element associated therewith through the incision and into the second vertebra, the second guide element including a body portion that extends through the skin incision when the second screw is implanted into the second vertebra; grasping a handle portion coupled to the first guide element to manipulate the first guide element; coupling a rigid connector to the first and second screws to generally fix the position of the first screw relative to the second screw; removing the first and second guide elements from the first and second screws, respectively; A method comprising: 41. The method of embodiment 40, further comprising advancing a second guide element through a rigid connecting member positioned adjacent the skin incision. 42. The method of embodiment 40, further comprising advancing a second guide element through a rigid connecting member that also surrounds a portion of the first guide element. 43. The method of embodiment 40, further comprising positioning a rigid connecting member around the first guide element adjacent the distal end of the handle portion, and wherein implanting a second screw having a second guide element coupled thereto through the incision into the second vertebra includes advancing the second screw and second guide element through the opening in the connecting member. 44. The method of any one of embodiments 40 to 43, wherein the connecting member is a selectively releasable connecting member. 45. The method of embodiment 44, wherein the connecting member includes a carabiner or is otherwise configured to be selectively releasable. 46. ​​A method according to any one of embodiments 40 to 45, wherein the distal portion of the handle portion extends through the skin incision and couples with the first guide element when the first screw is implanted in the first vertebra. 47. A method according to any one of embodiments 40 to 46, wherein the body portion of the first guide element has a recess formed in its proximal end portion, the recess being configured to receive a portion of the outer surface of the second guide element therein. 48. The method of any one of embodiments 40 to 47, wherein the first inductive element has at least one window extending through a side of the first inductive element. 49. The method of embodiment 48, wherein the second inductive element has at least one window extending through a side of the second inductive element. 50. The method according to any one of embodiments 40 to 49, further comprising coupling a stabilizing element to the head of each of the first and second screws. 51. A guide assembly for use in spinal surgery, comprising: a guide element comprising an elongated body portion, a distal end of the elongated body portion configured to be removably coupled with the screw, and a proximal end of the body portion configured to be positioned at or below the level of the patient's skin; a handle portion coupled to, or configured to be coupled to, a proximal end of the body portion, the handle portion extending at an angle away from the proximal end of the body portion; Equipped with the guide element has a recess formed therein at the proximal end of the body portion, the recess configured to receive a portion of an outer surface of another guide element; The handle portion extends away from the proximal end of the body portion in a direction away from the recess; Guide assembly.

[0118] The systems, devices and methods of Figures 3A-3O Additional embodiments of systems (e.g., system 300) that can be used to stabilize or treat spinal vertebrae through a skin incision S are disclosed below. In any embodiment disclosed herein, any component, feature, or other detail of system 300 can have any of the components, features, or other details of any other system embodiment disclosed herein, or can be used according to any of the steps of any other method embodiment disclosed herein, including, without limitation, any of the aforementioned system 300 or method of use embodiments, in any combination with any of the system components, features, or details. Similarly, any component, feature, step, or other detail of any of the other system or method embodiments disclosed herein can have any of the components, features, steps, or other details of any of the system embodiments 300 or method of use disclosed herein, in any combination with any of the system components, features, or details.

[0119] Some embodiments of a system 300 for stabilizing a spinal vertebra through a skin incision S may include a first screw 302 having a first screw head, a second screw 304 having a second screw head, a first extension 310 (also referred to herein as a first tower) having a distal portion 310 a and a proximal portion 310 b, the first extension 310 configured to be releasably coupled to the first screw 302 at a distal end of the first extension 310, and a second extension 320 (also referred to herein as a second tower) having at least one proximal portion 320 b, the second extension 320 configured to be releasably coupled to the second screw 304 at a distal end of the second extension 320. In any embodiment disclosed herein, the extension may be referred to using an extension, a guide element, a tower, or other similar terminology.

[0120] In some embodiments, the first extension 310 can have two or more proximal portions 310b extending at various angles away from the distal portion 310a of the first extension 310. In some embodiments, the first extension 310 can be removably coupled to the first screw 302 such that, when the first extension 310 is coupled to the first screw 302, the axial centerline C of the distal portion 310a of the first extension 310 is approximately collinear with the axial centerline C of the first screw 302. Additionally, the second extension 320 can be removably coupled to the second screw 304 such that, when the second extension 320 is coupled to the second screw 304, the axial centerline C of the distal portion 310a of the second extension 320 is approximately collinear with the axial centerline C of the second screw 304. In some embodiments, the first extension 310 may be shorter than the second extension 320, or may be longer than the second extension 320, or may have approximately the same length as the second extension 320.

[0121] In some embodiments, the angle between the proximal portion 310b and the distal portion 310a may be adjustable, or the angle between the proximal portion 320b and the distal portion 320a may be adjustable. Common mechanisms for adjustability are gear or ratchet mechanisms. In this manner, the proximal portion 310b or 320b can be angled away from the centerline of the distal portion of the respective screw. By adjusting the angle, there may be more space for placing the rod and locking cap. Also, by adjusting the angle, it may be easier for the surgeon to grasp both proximal portions of the tower to squeeze the two proximal portions of the two screws to compress the screw heads when locking the cap onto the rod connecting the screw heads. In another embodiment, the proximal portions 310b and 320b may be detachable from the distal portions 310a and 320a. In this manner, proximal portions having different angles relative to the centerline of their respective distal portions can be switched and reconnected to the distal portion of the extension as needed.

[0122] Any embodiment of the system 300 disclosed herein may be configured so that the first screw 302 and the second screw 304 may be implanted through the same skin incision S. Additionally, any embodiment of the system 300 may be configured so that the first screw 302, the second screw 304, and the third screw may be implanted through the same skin incision S.

[0123] In some embodiments, the proximal portion 310b of the first extension 310 can extend at an angle away from the axial centerline C of the distal portion 310a of the first extension 310 such that the proximal portion 310b of the first extension 310 is not generally collinear with the distal portion 310a of the first extension 310. Furthermore, the proximal portion 310b of the first extension 310 can be configured such that, in the operable state, the proximal portion 310b of the first extension 310 can also extend at an angle away from the axial centerline C of the distal portion of the second extension 320 such that the proximal portion 310b of the first extension 310 forms an acute angle A with the distal portion of the second extension 320, as shown in FIG. In some embodiments, angle A may be 50° (or about 50°), or 40° (or about 40°) or less to 70° (or about 70°) or more.

[0124] In some embodiments, the first extension 310 can be sized and configured such that, in an operable state, a proximal portion 310b of the first extension 310 can extend away from the skin incision S toward the surgeon. In some embodiments, a distal portion 310a of the first extension 310 can extend away from the first screw 302 to a level just below the skin incision S or flush with the patient's skin when the first screw 302 is fully implanted into the first vertebra. Additionally, the proximal portion 310b of the first extension 310 can be configured to be grasped by a surgeon such that the surgeon can apply a rotational force and / or a torque force to the first extension 310 about at least the axial centerline C of the distal portion 310a of the first extension 310 to rotate the first extension 310 about an axis that is perpendicular to the axial centerline C of the distal portion 310a of the first extension 310. In some embodiments, the first extension 310 can be sized such that only the proximal portion 310b of the first extension 310 is outside the skin incision S when the first screw 302 is implanted in the first vertebra. In any embodiment, the second extension 320 can be sized to extend completely through the skin incision S when the second screw 304 is implanted in the second vertebra.

[0125] The proximal portion 310b of the first extension 310 can have a length that is approximately the same as the length of the distal portion 310a of the first extension 310, or can have a length that is at least 80% or less of the length of the distal portion 310a of the first extension 310. In some embodiments, the proximal portion 310b of the first extension 310 can be removably coupled to the distal portion 310a of the first extension 310. In other embodiments, the proximal portion 310b of the first extension 310 can be non-removably coupled to the distal portion 310a of the first extension 310. For example, without limitation, the proximal portion 310b of the first extension 310 can be integrally formed with the body portion of the first extension 310. In some embodiments, the proximal portion of the first extension 310b or the second extension 320b can be coupled to the distal portion of the respective first extension 310a or the second extension 320b through an adjustable coupling that allows for an adjustable angle between the proximal or distal portions of the respective extensions. An example of such a coupling is a hinge.

[0126] 3A-3B, at least the distal portion 310a, the proximal portion 310b, and / or the second extension 320 of the first extension 310 can have a tubular or semi-tubular shape. Additionally, the first extension 310 can have a notch 324 formed through a wall portion 326 of the first extension 310, the notch 324 configured to receive a portion of the outer surface 320a of the second extension 320 therein in the operable state, as shown, for example, in FIG. 3A. In some embodiments, the notch 324 can extend through at least the proximal end 310c of the distal portion 310a of the first extension 310. The notch 324 can extend completely through the first extension 310 in an operable state so that the second extension 320 and a screw coupled to the extension 320 can pass completely through the notch 324.

[0127] In some embodiments, the notch 324 can extend completely through the first extension 310 such that, in the operative state, the second extension 320 can pass completely through the notch 324 and such that the wall portion 326 of the first extension 310 completely and continuously surrounds the outer surface 320a of a portion of the second extension 320. Furthermore, some embodiments of the notch 324 can be shaped such that the distal edge 330 of the notch 324 is configured to contact the outer surface 320a of the second extension 320 in the operative state such that the second extension 320 can be rotated about the distal edge 330 of the notch 324 relative to the first extension 310. Some embodiments of the notch 324 can have an oval shape.

[0128] 3B-3D , the cutout 324 can have a notch 334 at a proximal end 324a of the cutout 324, the notch 334 of the cutout 324 configured to allow at least a portion of the connecting element 350 to pass through the notch 334 during deployment of the connecting element 350. In some embodiments, the cutout 324 can have a notch 334 at a proximal end 324a of the cutout 324, the notch 334 configured to allow at least a portion of the connecting element 350 and a portion of the connecting element embedding device 370 to pass through the notch 334. The width of the notch 334 can be less than the width of the outer surface 320a of the second extension portion 320 such that the outer surface 320a of the second extension portion 320 is prevented from extending into the notch 334. The width of the notch 334 can be less than the width of the notch 324, such that the notch 324 defines a proximal edge 332 configured to contact the outer surface 320a of the second extension 320 such that the second extension 320 can be rotated about the proximal edge relative to the first extension 310 when at least the proximal portion 310b of the first extension 310 is moved toward the proximal portion 320b of the second extension 320. In some embodiments, the notch 324 can be adjacent the proximal end of the distal portion 310a of the first extension 310 and the distal end of the proximal portion 310b of the first extension 310. Additionally, some embodiments of the first extension 310 can have a distal notch 334 formed at the distal end of the first extension 310, the distal notch 334 configured to allow at least a portion of the connecting element 350 to pass through the distal notch 354 and into the head of the screw.

[0129] In some embodiments, at least the distal portion 310a of the first extension 310 can have an adjustable length. Furthermore, some embodiments of the first extension 310 and the second extension 320 can be cylindrically shaped. Other embodiments can have any other desired cross-sectional shape, including a generally square shape, a triangular cross-sectional shape, an oval cross-sectional shape, a polygonal cross-sectional shape, or any combination of the foregoing. The proximal portion 310b of the first extension 310 can have a cross-sectional profile that can have a curved shape, as shown. Furthermore, the proximal portion 310b of the first extension 310 can have a cross-sectional profile that can have a semicircular tubular shape. In some embodiments, the proximal portion 310b of the first extension 310 can have a cross-sectional profile that is approximately half the cross-sectional profile of the distal portion 310a of the first extension 310. In some embodiments, the proximal portion 310b of the first extension 310 can have a planar shape.

[0130] As mentioned above, any of the embodiments of system 300 disclosed herein can include a rigid connecting element 350 (which can be implanted using any desired shape and configuration of a connecting element implantation device, such as the embodiments of the connecting element implantation device shown in FIGS. 3E-3F ), ​​a first receiving element coupled to the head of a first screw 302, and a second receiving element coupled to the head of a second screw 304. Referring to FIGS. 3L-3M , the first and second receiving elements can be configured to operably receive the connecting element 350, which, in an operable state, can extend between the first and second receiving elements when the first and second screws 302 and 304 are implanted in the first and second vertebrae, respectively. The first screw 302 can be configured to be implanted in the first vertebra, and the second screw 304 is configured to be implanted in the second vertebra.

[0131] In some embodiments, the first extension 310 can have at least one window or slot 358 extending through a side of its body portion, the at least one slot 358 configured to receive or allow passage of a connecting element 350 therethrough, the connecting element 350 being configured to extend between the first screw 302 and the second screw 304 in the operative state. Additionally, the second extension 320 can have at least one slot or window 360 extending through a side of the body portion of the second extension 320, the at least one slot 360 of the second extension 320 being configured to receive a connecting element 350, the connecting element 350 being configured to extend between the first screw 302 and the second screw 304 in the operative state.

[0132] Some embodiments of a method for treating a spinal defect include implanting a first screw 302 coupled to a first extension 310 through an incision into a first vertebra; advancing a second extension 320 coupled to a second screw 304 through a notch 324 formed in the first extension 310 to embed the second screw 304 into the second vertebra; and moving a proximal end of a proximal portion 310b of the first extension 310 toward a proximal end of the second extension 320 to contact an outer surface 320a of the second extension 320 with at least a proximal edge 332 or a distal edge 351 (shown in FIG. 3A ) of the surface of the notch 324 or other portion of the surface of the notch 324. In some embodiments, further moving the proximal end of the proximal portion 310b of the first extension 310 toward the proximal end of the second extension 320 can rotate the outer surface 320a of the second extension 320 about at least the distal edge 330 of the notch 324 and move the distal end of the first extension 310 toward the distal end of the second extension 320, thereby moving the first vertebra toward the second vertebra. In some embodiments, the method can further include coupling a rigid connector 350 to the first screw 302 and the second screw 304 to generally fix the position of the first screw 302 relative to the second screw 304.

[0133] 3E-3G, one embodiment of a connecting element insertion device 370 is shown. In any embodiment disclosed herein, the connecting element insertion device 370 can have a handle 371, a main stem or arm 372 coupled to the handle 371, and a head portion 374 coupled to the main stem 372. In some embodiments, the main stem can have a flexible joint 378 at its midsection. With reference to FIGS. 3E and 3F, the joint 378 can be configured to bend or flex such that the distal portion of the stem 372 can rotate relative to the proximal portion of the main stem 372. In some embodiments, the joint 378 can allow the connecting element 350 to rotate. The joint 378 can be a separate flexible joint or element (such as a component comprising plastic, rubber, and / or nitinol) added to the shaft 372, or can be formed by other methods, such as a flexible notch in the tube of the shaft 372. The flexibility of fitting 378 can allow the tip of connecting element 350 to enter approximately perpendicularly into the axis of the first extension with a solid wall. The tip of connecting element 150 can then slide down the wall toward passage 354 on its way to the screw head, as shown in Figures 3H-3L.

[0134] In some embodiments, the connecting element insertion device 370 can be shorter than a conventional rod inserter or device for inserting a connecting element. The connecting element insertion device 370 can be shorter so that the main stem 372 of the connecting element insertion device 370 can pass through a standard extension or tower. Conventional rod inserters are too long to pass through a standard extension or tower. To do this, the connecting member 380 at the top of the main shaft 372 that connects the element insertion device 370 can have two, three, or more holes or connection interfaces to which a handle, such as handle 371, can connect. Each of the holes can be configured to allow the handle to extend away from the connecting member 380 in a different orientation.

[0135] In some embodiments, a central hole that can pass down the center of the shaft 372 of the connecting element insertion device 370 can be for a screwdriver that can tighten or loosen a screw that secures the connecting element 350 (also referred to herein as a rod) within the head portion 374 of the connecting element insertion device 370. The other two holes can be threaded holes for handles, such as handle 371, that can be attached to the connecting member 380 from the front and / or rear. The front handle 371 can be inserted first and used to lower the connecting element 350 into the extension or tower as it passes downward from a vertical orientation to the head of the first screw. As the connecting element 350 begins to rotate horizontally into the seats of the heads of both screws, the main shaft 372 of the connecting element insertion device 370 can rotate through the extension or tower and terminate on the other side of the extension or tower. On the other side, a final handle can be inserted into the threaded hole, thereby holding and stabilizing the connection element insertion device 370 on the other side of the extension or tower. Finally, in some embodiments, although not required, the main shaft 372 of the connection element insertion device 370 shaft can be flexible. This flexibility can be either hinged or flexible, as shown here as a cutout in the wall of the shaft 372. Any suitable method or material for making the shaft 372 flexible can be used, including, but not limited to, using a flexible material such as plastic, rubber, or a metal such as Nitinol.

[0136] Referring to FIG. 3J, this figure shows the connecting element 350 being inserted into the seats of the heads of both screws. The connecting element 350 is transitioning from a vertical orientation to a horizontal orientation. The flexible portion 378 of the shaft 372 can be bent as shown in FIG. 3J. One useful method for inserting the connecting element 350 is to keep the tip of the connecting element 350 in contact with the midline wall of the first extension or tower. By keeping the tip of the connecting element 350 in contact with the wall, the surgeon can determine the position of the connecting element 350 until it hits the bottom of the tower and enters the seats of the heads of the screws. The insertion device 370 can then be rotated to the other side of the extension or tower to seat the connecting element 350 within the heads of both screws. The insertion device 370 can then be moved to the other side of the extension or tower so that a cap (such as cap 390) can be placed through the extension or tower to secure the connecting element 350 to the attached threads.

[0137] Some embodiments of the connecting element insertion device 370 can have a second feature. The connecting element insertion device 370 can be short enough to pass under the top of the tower of the second screw, which holds the two "blades" or sides of the tower or extension together. The second handle 371 can be threaded onto the connecting member 380 from the other side of the extension (as shown in FIG. 3K) after the connecting element insertion device 370 has passed between the blades of the extension or through the slot in the extension. At this point, the first handle 371 of the rod holder can be removed. In any embodiment, the handle 371 of the insertion device 370 can be moved from one side of the extension or tower to the other, as described. Alternatively, in some embodiments, the second screw can be open at the top (distal end), like an open blade. The handle 371 can then easily pass through. The blades can then be locked together by a cap or screw cap. After the connecting element 350 is coupled to the screw or screw head, in any embodiment disclosed herein, a fastener such as an insert screw or cap 390 shown in Figures 3L-3M can be advanced through the extension and coupled with the insert or seat that supports the connecting element 350.

[0138] Referring to FIG. 3L, the insertion device 370 is now positioned on the other side of the extension or tower with the second handle 373 inserted and the first handle 371 removed. A cap 390 can be inserted through the tower and secured onto the L5 screw, which can be connected to the extension or tower. The screw can be finally tightened to a final torque. It is during the final tightening process that the cap 390 can be tightened to a final torque. This final torque tightening requires a counter-torque mechanism for the screw head while the cap is being tightened to a final torque, so that the entire structure does not rotate during final tightening. The angled proximal portion of the first extension of the first screw 310b serves as a handle for counter-torque. Thus, extensions 310 and 302 function as towers for aligning the screw heads, for creating a path for insertion of connecting element (rod) 350, for conduits for locking insertion of cap 390, for compression of the screw heads when tightening cap 390 is finally tightened onto connecting element 350, and for counter torque when cap 390 is finally tightened. All of these steps typically require separate tools that are inserted and removed at the appropriate steps of the process. However, in the present invention, all of these steps are incorporated and performed by the same extensions 310 and 320. In this way, the procedure is simplified, shortened, and streamlined. Finally, insertion device 370 can be detached from connecting element 350 by loosening the internal threads that secure connecting element 350 to the head of insertion device 370.

[0139] In any of the embodiments disclosed herein, the system can include generally inflexible structures (e.g., extensions) attached to the screws that pass through and then interact with each other, allowing the extensions to enable compression and reduction without additional tools being inserted into the patient. This saves time and maintains small incisions for faster recovery. Additionally, in any of the embodiments disclosed herein, the system components can be configured for use in robotic surgery. Because the extensions are generally rigid, they can be affixed, held, or attached to a robotic arm that can know the exact location and orientation of each screw head. Knowing this information allows for robotic insertion of a connecting element into the seat of the screw head.

[0140] In any embodiment disclosed herein, one or more screws may be implanted using other means, and the extensions or guide elements may be coupled to the screw head or other components coupled with the screw after the screw is implanted. In any embodiment disclosed herein, the extensions, guide elements, and / or towers may be used in conjunction with any of the devices or components shown and described in connection with FIGS. 1A-1Z , including, but not limited to, wires 140 a, 140 b, screw 110, insert 116 a, and / or screw head 114. For example, but not limited to, in any embodiment, first and second extensions 310, 320 may be passed over any of wires 140 a, 140 b and secured to screw 110 or screw head 114, such that first and second extensions 310, 320 may be coupled with screw 110 for further treatment as disclosed herein or otherwise.

[0141] Certain aspects of the systems, devices, components, and / or methods described above or illustrated with respect to Figures 3A-3O are also encompassed by the following numbered embodiments, which are considered to be directed to systems, devices, components, and / or methods including, but not limited to, the embodiments of Figures 3A-3O, and thus may encompass other embodiments described throughout this specification. 1. A system for stabilizing spinal vertebrae through a skin incision, comprising: a first screw having a first screw head; a second screw having a second screw head; a first extension having a distal portion and a proximal portion, the first extension configured to be removably coupled with the first screw at a distal end of the first extension; a second extension having at least a proximal portion, the second extension configured to be removably coupled with the second screw at a distal end of the second extension; Equipped with the first extension is configured to removably couple with the first screw such that, when the first extension is coupled to the first screw, an axial centerline of the distal portion of the first extension is substantially collinear with an axial centerline of the first screw; the second extension is configured to removably couple with the second screw such that, when the second extension is coupled to the second screw, an axial centerline of the distal portion of the second extension is substantially collinear with an axial centerline of the second screw; the proximal portion of the first extension extends at an angle away from an axial centerline of the distal portion of the first extension such that the proximal portion of the first extension is not generally collinear with the distal portion of the first extension; A system wherein the proximal portion of the first extension is configured, in an operable state, to extend at an angle away from an axial centerline of the proximal portion of the second extension such that the proximal portion of the first extension forms an acute angle with respect to the proximal portion of the second extension. 2. The system of embodiment 1, wherein the first extension is sized and configured such that, in an operable state, a proximal portion of the first extension extends away from the skin incision toward the surgeon. 3. A system as described in embodiment 1 or 2, wherein the distal portion of the first extension extends away from the first screw to a height just below the skin incision or to the same height level as the patient's skin when the first screw is fully implanted within the first vertebra. 4. The system of any one of the preceding embodiments, wherein the proximal portion of the first extension is configured to be grasped by a surgeon so that the surgeon can apply a rotational force and / or a torque force to the first extension about at least an axial centerline of the distal portion of the first extension to rotate the first extension about an axis that is perpendicular to the axial centerline of the distal portion of the first extension. 5. The system of any one of the preceding embodiments, wherein the first extension is sized such that when the first screw is implanted into the first vertebra, only a proximal portion of the first extension is outside the skin incision. 6. The system of any one of the preceding embodiments, wherein the second extension portion is sized to extend completely through the skin incision when the second screw is implanted into the second vertebra. 7. The system of any one of the preceding embodiments, wherein the system is configured so that the first and second screws are implanted through the same skin incision. 8. The system of any one of the preceding embodiments, wherein the system is configured so that the first screw, the second screw, and the third screw are implanted through the same skin incision. 9. A system according to any one of the preceding embodiments, wherein the proximal portion of the first extension has a length that is approximately the same as the length of the distal portion of the first extension. 10. A system according to any one of the preceding embodiments, wherein the proximal portion of the first extension has a length that is at least 80% of the length of the distal portion of the first extension. 11. The system of any one of the preceding embodiments, wherein the proximal portion of the first extension is removably coupled to the distal portion of the first extension. 12. The system of any one of the preceding embodiments, wherein the proximal portion of the first extension is permanently coupled to the distal portion of the first extension. 13. The system of any one of the preceding embodiments, wherein the proximal portion of the first extension is integrally formed with the body portion of the first extension. 14. The system of any one of the preceding embodiments, wherein at least the proximal portions of the first extension and the second extension have a tubular shape. 15. A system according to any one of the preceding embodiments, wherein the first extension has a notch formed through a wall portion of the first extension, the notch being configured to receive a portion of the outer surface of the second extension therein in an operable state. 16. The system of embodiment 15, wherein the notch extends through at least the proximal end of the distal portion of the first extension. 17. The system of embodiment 15, wherein the cutout extends completely through the first extension portion, such that in an operable state, the second extension portion can pass completely through the cutout. 18. The system described in embodiment 15, wherein the cutout extends completely through the first extension, such that in an operable state the second extension can pass completely through the cutout, such that the wall portion of the first extension surrounds a portion of the outer surface of the second extension. 19. A system described in any one of embodiments 15 to 18, wherein the notch is shaped such that the distal edge of the notch is configured to contact the outer surface of the second extension portion in an operable state so that the second extension portion can rotate around the distal edge of the notch relative to the first extension portion. 20. The system of any one of embodiments 15 to 19, wherein the cutout has an oval shape. 21. A system described in any one of embodiments 15 to 20, wherein the cutout has a notch at a proximal end of the cutout, the notch being configured to allow passage of at least a portion of the connecting element through the notch. 22. A system described in any one of embodiments 15 to 21, wherein the cutout has a notch at its proximal end, the notch of the cutout being configured to allow at least a portion of the connection element and a portion of the connection element embedding device to pass through the notch. 23. The system of embodiment 22, wherein the width of the notch is smaller than the width of the outer surface of the second extension, thereby preventing the outer surface of the second extension from extending into the notch. 24. The system of embodiment 22, wherein the width of the notch is smaller than the width of the cutout, such that the cutout defines a proximal edge configured to contact the outer surface of the second extension, such that when at least the proximal end of the first extension moves toward the proximal end of the second extension, the second extension can rotate about the proximal edge relative to the first extension. 25. A system described in any one of embodiments 15 to 24, wherein the notch is adjacent to the proximal end of the distal portion of the first extension and the distal end of the proximal portion of the first extension. 26. A system according to any one of the preceding embodiments, wherein the first extension has a distal notch formed at a distal end of the first extension, the distal notch being configured to allow passage of at least a portion of the connecting element through the distal notch. 27. The system of any one of the preceding embodiments, wherein at least a distal portion of the first extension has an adjustable length. 28. The system of any one of the previous embodiments, wherein the first extension and the second extension are cylindrically shaped. 29. A system according to any one of the preceding embodiments, wherein the proximal portion of the first extension has a cross-sectional profile having a curved shape. 30. A system according to any one of the preceding embodiments, wherein the proximal portion of the first extension has a cross-sectional profile having a semicircular tubular shape. 31. A system according to any one of the preceding embodiments, wherein the proximal portion of the first extension has a cross-sectional profile that is approximately the same as half of the distal portion of the first extension. 32. The system of any one of the preceding embodiments, wherein the proximal portion of the first extension has a planar shape. 33. A rigid connecting element; a first receiving element coupled to the first screw head; a second receiving element coupled to the second screw head; Further provided with the first and second receiving elements are configured to operably receive a connecting element, the connecting element extending between the first and second receiving elements in the operable state when the first and second screws are implanted into the first and second vertebrae, respectively; 10. The system of any one of the preceding embodiments. 34. The system of any one of the preceding embodiments, wherein the first screw is configured to be implanted into the first vertebra and the second screw is configured to be implanted into the second vertebra. 35. The system of any one of the preceding embodiments, comprising two or more separate proximal portions extending away from the distal portion of the first extension. 36. A system according to any one of the preceding embodiments, wherein the first extension has at least one window extending through a side of its body portion, the at least one window being configured to receive a connecting element configured to extend between the first screw and the second screw in an operable state. 37. The system of any one of the preceding embodiments, wherein the first extension is shorter than the second extension. 38. A system described in any one of the preceding embodiments, wherein the second extension has at least one window extending through a side of its body portion, and the at least one window of the second extension is configured to receive a connecting element configured to extend between the first screw and the second screw in an operable state. 39. A method for stabilizing spinal vertebrae, comprising: implanting a first screw coupled to a first extension through the incision and into the first vertebra; advancing a second extension coupled to a second screw through the notch formed in the first extension to embed the second screw into the second vertebra; moving a proximal end of a proximal portion of the first extension toward a proximal end of the second extension so that an outer surface of the second extension contacts at least a distal edge of the notch; further moving the proximal end of the proximal portion of the first extension toward the proximal end of the second extension and rotating an outer surface of the second extension about at least the distal edge of the notch to move the distal end of the first extension toward the distal end of the second extension, thereby moving the first vertebra toward the second vertebra; A method comprising: 40. The method of embodiment 39, further comprising coupling a rigid connector to the first screw and the second screw to generally fix the position of the first screw relative to the second screw.

[0142] The systems, devices, and methods of Figures 4A-4T Additional embodiments of a system 400 for stabilizing spinal vertebrae through a skin incision S are now described. In any embodiment disclosed herein, any component, feature, or other detail of system 400 can have any of the components, features, or other details of any other system embodiment disclosed herein, or can be used according to any of the steps of any other method embodiment disclosed herein, including, without limitation, any of the aforementioned system 200 or 300 or method of use embodiments, in any combination with any of the components, features, or details of system 400 or method of use disclosed below. Similarly, any component, feature, step, or other detail of any of the other system or method embodiments disclosed herein can have any of the components, features, steps, or other details of any of the system components, features, or details of any of the system embodiments disclosed herein, or method of use.

[0143] In some embodiments, the system 400 can include a first screw 402 having a first screw head, a second screw 404 having a second screw head, and a first extension 410 configured to be removably coupled to the first screw 402 at a distal end 410a of the first extension 410, the first extension 410 having a first wall 414 and a first passageway 416 extending through the first extension 410 along an axial centerline C of the first extension 410 such that the first wall 414 of the first extension 410 at least partially surrounds the first passageway 416. In some embodiments, the first screw 402 can be configured to be implanted in a first vertebra 403, and the second screw 404 can be configured to be implanted in a second vertebra 405. The system 400 may further include a second extension 420 configured to be removably coupled to the second screw 404 at a distal end 420a of the second extension 420, the second extension 420 having a second wall 428 (also referred to herein as a wall) and a second passage 426 extending through the second extension 420 along an axial centerline C of the second extension 420 such that the second wall 428 of the second extension 420 at least partially surrounds the second passage 426.

[0144] The first extension may further have an opening 432 (also referred to herein as a first opening) extending through the first wall 414 of the first extension 410. The opening 432 and the first wall 414 of the first extension 410 adjacent the opening 432 may be sized and configured such that the second extension 420 can be operatively advanced through the opening 432 such that the second extension 420, or its axial centerline, is restrained or supported at an acute angle A (as shown in FIG. 4A ) relative to the axial centerline C of the first extension 410.

[0145] In some embodiments, the first extension 410 can be removably coupleable with the first screw 402 such that when the first extension 410 is coupled to the first screw 402, an axial centerline C of the first extension 410 is generally collinear with an axial centerline C of the first screw 402, and the second extension 420 can be removably coupleable with the second screw 404 such that when the second extension 420 is coupled to the second screw 404, an axial centerline C of the second extension 420 is generally collinear with an axial centerline C of the second screw 404. In any embodiment disclosed herein, the first extension 410 and the second extension 420 can be generally cylindrically shaped and / or have a generally tubular shape. Other embodiments can have any other desired cross-sectional shape, including a generally square shape, a triangular cross-sectional shape, an oval cross-sectional shape, a polygonal cross-sectional shape, or any combination of the foregoing. Additionally, some embodiments of first extension 410 and / or second extension 420 can be generally rigid.

[0146] Additionally, in some embodiments, at least the distal portion 410c of the first extension 410 and / or the second extension 420 can have an adjustable length. As with other embodiments, the first extension 410 can be sized and configured such that, in the operable state, the proximal portion 410b of the first extension 410 can extend away from the skin incision S toward the surgeon.

[0147] In some embodiments, the inner size of the first wall 414 of the first extension 410 adjacent the opening 432 in the first extension 410 can be larger than the outer size of at least a portion of the second wall 428 of the second extension 420 such that at least a portion of the second extension 420 can pass through the opening 432 of the first extension 410 at an acute angle A relative to the axial centerline C of the first extension 410 and be at least partially surrounded by the first wall 414 of the first extension 410. Additionally, the proximal portion 410b of the first extension 410 can have an inner cross-sectional size that is larger than the inner cross-sectional size of the distal portion 410c of the first extension 410. Furthermore, in some embodiments, the inner cross-sectional size of the proximal portion 410b of the first extension 410 can also be larger than the outer cross-sectional size of at least the distal portion of the second extension 420 so that at least the distal portion of the second extension 420 can be advanced completely through the opening 432 of the first extension 410.

[0148] In some embodiments, the opening 432 in the first extension 410 can pass through the first wall 414 of the first extension 410 at an angle that is acute with respect to the axial centerline C of the first extension 410. In some embodiments, the opening 432 can include a first notch 434 in a first side surface 436 of the first wall 414 and a second notch 440 in a second side surface 442 of the first wall 414, the second side surface 442 of the first wall 414 being opposite the first side surface 436 of the first wall 414. The second notch 440 can be separated from the first notch 434 such that the first notch 434 and the second notch 440 do not overlap or connect. Furthermore, the second notch 440 can be positioned closer to the distal end 410 a of the first extension 410 than the first notch 434.

[0149] In some embodiments, the first cutout 434 can extend distally from the proximal end 410d of the first extension 410 such that the first wall 414 of the first extension 410 does not form a complete or continuous enclosure around the first passageway 416 at the proximal end 410d of the first extension 410. In some embodiments, the first cutout 434 can remove at least about 40% of the first wall 414 of the first extension 410 at least at the proximal end 410d of the first extension 410. Some embodiments of the first cutout 434 can extend along a length of the first extension 410 that is at least about 30% of the total length of the first extension 410, or that is at least about 40% of the total length of the first extension 410. Additionally, in some embodiments, the distal edge 446 of the first cutout 434 can be planar and angled downward toward the distal end 410 a of the first extension 410 .

[0150] In some embodiments, the proximal portion 440a of the second cutout 440 can axially overlap the distal portion 434a of the first cutout 434. Furthermore, the second cutout 440 can be positioned between the proximal end 410d and the distal end 410a of the first extension 410 such that the proximal portion 440a of the second cutout 440 is spaced apart from the proximal end 410d of the first extension 410 and the distal portion 440b of the second cutout 440 is spaced apart from the distal end 410a of the first extension 410. In some embodiments, the second cutout 440 can remove at least about 40% of the first wall 414 of the first extension 410 in at least a middle portion of the first extension 410. Additionally, the second notch 440 can extend along a length of the first extension 410 that is at least about 30% of the total length of the first extension 410 .

[0151] The second notch 440 can extend along a length of the first extension 410 that is at least about 40% of the overall length of the first extension 410. Further, in some embodiments, the proximal edge 448 of the second notch 440 can be curved or flat. In some embodiments, the distal edge 450 of the second notch 440 can be flat and angled downward toward the distal end 410 a of the first extension 410. Further, in some embodiments, one or more protrusions 454 adjacent the distal edge 450 of the second notch 440 can provide a surface or shoulder that the second extension 420 can contact to limit the range of rotation of the second extension 420 relative to the first extension 410. In some embodiments, protrusion 454 is an angled notch instead of a protrusion, allowing for closer approximation between the two screws and the two extensions, for example, when there is severe lordosis and the angle A between adjacent screws is severe.

[0152] In some embodiments, the first extension 410 and the second extension 420 may be configured such that, in an operable state in which the second extension 420 is advanced through the opening 432 in the first extension 410, the second extension 420 can hinge and / or rotate relative to the first extension 410 such that moving the proximal end of the first extension 410 toward or away from the proximal end of the second extension 420 moves the distal end of the second extension 420 toward or away from the distal end 410a of the first extension 410, respectively. For example, but not by way of limitation, moving the proximal end of the first extension 410 toward or away from the proximal end of the second extension 420 can cause the second extension 420 to hinge and / or rotate about the edge of the opening 432 in the first extension 410, such that the distal end of the second extension 420 moves toward or away from the distal end 410a of the first extension 410, respectively.

[0153] The hinge effect can be created in some embodiments due to a physical barrier that allows extension 410 to pass through opening 434 in the other extension 430. Essentially, extension 410 can be trapped within a topologically defined hole created by an opening or cutout in extension 430. Alternatively, an actual hinge can exist between extensions 430 and 410 by having complementary protrusions near the contact point, creating a ball-and-socket hinge or the like. Some embodiments of system 400 can be configured to create the hinge effect by imposing a constraint on movement between extensions 410 and 430. External rings or restraints, as shown in FIG. 6F and other embodiments disclosed herein, as well as external blockers to movement, such as those shown in FIGS. 6O, 6P, and / or 6R, can all be used to constrain movement to maintain a hinge effect that allows compression and reduction and counter-torque of the screw during final locking using the all-in-one system shown in 400. In contrast to prior art designs where the towers and extensions are parallel and do not interact, the constraint on movement during compression comes from an external tool. In the present invention, because the towers and blades intersect and interact directly, the extensions themselves create a hinge effect by directly limiting and restricting the movement of one extension relative to another. This reduces the need for additional tools, saving time and space during surgery.

[0154] In some embodiments, the first extension 410 and the second extension 420 may be configured such that, in an operable state in which the second extension 420 is advanced through the opening 432 in the first extension 410, contact between an outer surface of the second wall 428 of the second extension 420 and the first wall 414 of the first extension 410 surrounding the opening 432 provides a hinge through which the second extension 420 can rotate relative to the first extension 410. Furthermore, the first extension 410 may be configured such that, in the operable state, when the second extension 420 is advanced through the opening 432 of the first extension 410, the first wall 414 of the first extension 410 surrounding the opening 432 can be configured to prevent or inhibit the second extension 420 from rotating relative to the first extension 410 beyond a predetermined amount.

[0155] Furthermore, in some embodiments, the first extension 410 may be configured such that, in an operable state, when the second extension 420 is advanced through an opening 432 in the first extension 410 and rotated to contact a first wall 414 of the first extension 410 adjacent the opening 432, the first wall 414 of the first extension 410 surrounding the opening 432 can constrain the rotation of the second extension 420 relative to the first extension 410, such that moving the proximal end of the first extension 410 toward or away from the proximal end of the second extension 420 causes the distal end of the second extension 420 to move toward or away from the distal end 410a of the first extension 410, respectively. As with other embodiments, the proximal portion 410b of the first extension 410 can be configured to be grasped by a surgeon so that the surgeon can apply a rotational force and / or a torque force to the first extension 410 about at least the axial centerline C of the distal portion 410c of the first extension 410 to rotate the first extension 410 about an axis that is perpendicular to the axial centerline C of the distal portion 410c of the first extension 410.

[0156] Some embodiments of the second extension 420 can have any of the same features or details of any embodiment of the first extension 410 disclosed herein, including, but not limited to, any of the details related to the openings, notches, and / or slots formed in the first extension 410. In some embodiments, the second extension 420 can include an opening 460 (also referred to as a second opening) extending through the second wall 428 of the second extension 420, and the opening 460 and the second extension 420 adjacent the opening 460 can be sized and configured such that the third extension 464 can be operatively advanced through the opening 460 in the second extension 420 such that the third extension 464 is angled at an acute angle relative to the axial centerline C of the second extension 420. In any embodiment disclosed herein, the third extension 464 may be a standard straight tubular extension configured to facilitate implantation of the third screw 466 into the third vertebra.

[0157] In some embodiments, the first extension 410 and the second extension 420 can be configured such that the third extension 464 can be advanced through the opening 432 in the first extension 410 and through the opening 460 in the second extension 420 in the operative state such that the third extension 464 is angled at an acute angle relative to the axial centerline C of the first extension 410 and the axial centerline C of the second extension 420. In some embodiments, as in the illustrated embodiment, the third extension 464 can be configured to implant the screw generally perpendicularly into the third vertebra. In some embodiments, the distal end 464a of the third extension 464 can be positioned between the distal end 410a of the first extension 410 and the distal end 420a of the second extension 420 in the operative state.

[0158] In any embodiment disclosed herein, the second extension 420 may include at least one slot or window 470 extending through a first side 472 of the second extension 420, wherein the at least one slot 470 of the second extension 420 is configured to receive and / or allow passage of a connecting element 474 (also referred to herein as a rod or connector) configured to extend between the first screw 402 and the second screw 404 in an operative state. Further, in any embodiment disclosed herein, the second extension portion 420 may include a second slot 476 extending through a second side 478 of the second extension portion 420 (opposite the first side 472 of the second extension portion), the second slot 476 also configured to allow a connecting element 474 configured to extend between the first screw 402 and the second screw 404 in an operable state to pass through the second slot 476.

[0159] Any embodiment of the system 400 disclosed herein may further include a rigid connecting element 474, a first receiving element coupled to the head of the first screw 402, and a second receiving element coupled to the head of the second screw 404, wherein the first and second receiving elements may be configured to operably receive the connecting element 474, which may extend between the first and second receiving elements in an operative state when the first screw 402 and the second screw 404 are implanted into the first and second vertebrae 405, respectively. In some embodiments, the first extension 410 may include a first slot 480 extending through its first wall, wherein the first slot 480 of the first extension 410 is configured to allow the connecting element 474, configured to extend between the first screw 402 and the second screw 404 in an operative state, to be advanced through the first slot 480. Referring to FIG. 4C, the first extension portion 410 may also have a second slot 481 configured to receive and / or allow the connecting element 474 to pass through it, the connecting element 474 being configured to extend between the first screw 402 and the second screw 404 in an operable state.

[0160] In some embodiments, the first slot 480 of the first extension 410 can extend proximally from the distal end 410a of the first extension 410 to the second notch 440 of the first extension 410. The first slot 480 of the first extension 410 can have a width that is less than 50% of the width of the outer surface of the first extension 410.

[0161] As mentioned, the second extension 420 can include a first slot 470 extending through the second wall 428 of the second extension 420, the first slot 470 of the second extension 420 configured to allow a connecting element 474, configured to extend between the first screw 402 and the second screw 404 in an operative state, to be advanced through the first slot 470 of the second extension 420. In some embodiments, the first slot 470 of the second extension 420 can extend proximally from the distal end 420a of the second extension 420 to the second notch 440 of the second extension 420. Furthermore, the first slot 470 of the second extension 420 can have a width that is less than 50% of the width of the outer surface of the second extension 420.

[0162] In some embodiments, the first slot 470 of the second extension 420 can be in a first side 472 of a second wall 428 of the second extension 420, and the second extension 420 can further include a second slot 476 extending through a second side 478 of the second wall 428 of the second extension 420, the second side 478 of the second wall 428 being opposite the first side 472 of the second wall 428. The second slot 476 of the second extension 420 can be configured to allow a connecting element 474, configured to extend between the first screw 402 and the second screw 404 in an operative state, to be advanced through the second slot 476 of the second extension 420. In some embodiments, the second slot of the second extension portion 420 can extend proximally from the distal end of the second extension portion 420 and can have a length that is greater than or equal to 40% (or about 40%) of the length of the second extension portion 420, or greater than or equal to 30% (or about 30%) of the length of the second extension portion 420.

[0163] Some embodiments of a method for treating a spinal defect include implanting a first screw 402, which can be coupled with a first extension 410 (as shown in FIGS. 4H-4I ), through an incision into a first vertebra 403. Note that in some embodiments, a tool removably coupled with any of the screws disclosed herein can be advanced through either the guide element or the extension and removably engage the screw head of the screw to implant the screw. Further, with reference to FIGS. 4J-4K , a second extension 420, which can be coupled with a second screw 404, can be advanced through the incision and through an opening 432 formed in the first extension 410 such that an axial centerline C of the second extension 420 can be at an acute angle A with respect to an axial centerline C of the first extension 410, and such that the second screw 404 can be implanted into the second vertebra 405. 4L-4M, if two-level fixation is desired, the third extension 464 can be advanced through the opening 432 in the first extension and the opening 460 in the second extension 420 so that the third screw 466 can be implanted into the third vertebra 467. Referring to FIGS. 4L-4M, the third screw 466 can be implanted into the third vertebra 467 between the first vertebra 403 and the second vertebra 405 by advancing the third extension 464 through the first and second notches 434, 440 in the first extension 410 and through the first and second notches 434, 440 in the second extension 410. If only two-level fixation is desired, the first extension portion 410 and the second extension portion 420 can be joined using screws positioned in adjacent vertebrae, or in other embodiments, not positioned in adjacent vertebrae.

[0164] In any embodiment disclosed herein, the screw may be implanted using other means, and the extension or guide element may be coupled to the screw head or other component coupled to the screw after the screw is implanted. In any embodiment disclosed herein, the extension, guide element, and / or tower may be used in conjunction with any of the devices or components shown and described in connection with FIGS. 1A-1Z , including, but not limited to, wires 140 a, 140 b, screw 110, insert 116 a, and / or screw head 114. For example, but not limited to, in any embodiment, first and second extensions 410, 420 may be passed over any of wires 140 a, 140 b and secured to screw 110 or screw head 114, such that first and second extensions 410, 420 may be coupled to screw 110 for further treatment as disclosed herein or otherwise.

[0165] The third extension 464, in some embodiments, can be supported within the opening 432 of the first extension 410 and the opening 460 of the second extension 420 such that the third extension 464 is constrained to a position at an acute angle relative to the axial centerline C of the second extension 420 and / or the first extension 410. The method or procedure may also include, for example, but not limited to, moving the proximal portion 410b of the first extension 410 toward the proximal portion of the second extension 420 to hinge an outer surface of the second extension 420 relative to the second extension 420 by contacting at least the distal edge 446 of the opening 432 of the first extension 410 or other contacting surface of the first extension 410. In this arrangement, further movement of the proximal portion 410b of the first extension 410 toward the proximal portion of the second extension 420 can rotate the second extension 420 about a hinge point, which may also be the distal edge 446 of the opening 432 or other contact surface of the first extension 410, to move the distal end portion of the first extension 410 toward the distal end portion of the second extension 420. This method or procedure can be used to move the first vertebra 403 in which the first screw 402 is implanted toward the second vertebra 405 in which the second screw 404 is implanted, and / or to move the first vertebra 403 in which the first screw 402 is implanted and the second vertebra 405 in which the second screw 404 is implanted toward the third vertebra 467 in which the third screw 466 is implanted.

[0166] 4N-4T, to secure the first and second vertebrae 405 in a desired position, a surgeon can couple a rigid connecting element 474 to the first screw 402, the second screw 404, and / or the third screw 466 to generally fix the position of the first screw 402 relative to the second screw 404 and / or the third screw 466. A connecting element insertion device 484 can be used to advance the connecting element 464 through openings, channels, and / or slots in the first extension 410, the second extension 420, and / or the third extension 466 and into channels or tulips that are coupled with the first screw 402, the second screw 404, and / or the third screw 466. A second connection element insertion device 485 can also be used in conjunction with the connection element insertion device 484 to advance the connection element 464 through openings, channels, and / or slots in the first extension portion 410, the second extension portion 420, and / or the third extension portion 466 into channels or tulips that are coupled with the first screw 402, the second screw 404, and / or the third screw 466.

[0167] For example, without limitation, the second connecting element insertion device 485 can push the connecting element 464 out of the connecting element insertion device 484 and hold the connecting element 464 in a desired position when the connecting element insertion device 484 is removed. The second connecting element insertion device 485 can then allow a cap to be placed through the third extension 464 to lock the connecting element 464 and also reduce down to the third thread. At this point, in some embodiments, the third thread 466 can be finally tightened (i.e., to final torque tightening).

[0168] In some embodiments, the second connecting element insertion device 485 can have variable length blades so that both blades can contact the connecting element 464 on either side of the third tower 464, even when the connecting element 464 is more vertical in orientation. The variable blade length of some embodiments of the second connecting element insertion device 485 can then be used to press the connecting element 464 down until it is horizontal and seated within all three seats or receiving elements of the first, second, and third screws. Once the connecting element 464 is lowered into the screw seats, the second connecting element insertion device 485 can be used to hold the connecting element 464 down when the connecting element insertion device 484 is removed, a cap can be placed within the third tower to secure the connecting element 464 in place, or even reduce the connecting element 464 within the third tower in the event of spondylolisthesis.

[0169] It is again important to note that in either embodiment, the first, second, and third extensions 410, 420, 464 coupled to the screws extend outside the body through the incision, with their proximal ends providing a "handle" that allows the surgeon to know the position and orientation of the three screw heads at all times. This arrangement also allows the robotic system to "know" the orientation and position of all the screw heads, so that the robotic system can lower the connecting element 464 directly into the screw heads, including rotating the connecting element 464 from vertical to horizontal to enter the screw head seat. Any of the extensions can have additional components added to it or otherwise configured to be integrated into the robotic system. The extensions can then be removed and withdrawn from the body.

[0170] In addition, stereotactic intraoperative navigation and robotic assistance have been implemented in spinal fusion surgery. Both navigation and robotic guidance have been used to guide the trajectory of pedicle screws, either using guidewires or direct placement of screws into the vertebrae. However, to date, neither stereotactic navigation nor robotics have been used to assist in aligning the screw head or to assist in the placement of a rod or connecting element within the screw head seat. Finally, with the natural lordotic curvature of the lumbar spine, particularly at L4, L5, and S1 (where 80% of all fusions occur), conventional towers or extensions connected to pedicle screws typically cross paths and interfere with each other during minimally invasive screw placement. Typically, the towers cross at the incision but end up next to each other. In the embodiments disclosed herein, the towers are designed to cross within each other. Therefore, there is no interference with the crossing trajectory of the screw extension and tower. Additionally, by having an attachment to the proximal end of the extension, a robotic arm can be attached and therefore "know" the specific three-dimensional orientation of each tower or extension relative to one another.

[0171] By computer modeling and "knowing" the 3D spatial composition of each component, the robotic system can implant screw 402 with extension 410 and then screw 404 with extension 440. The robotic system can adjust the two extensions, thereby adjusting the screws attached to them to align the screw heads. The robotic system can then insert a third screw for two-level fixation. Because the screw heads are aligned and the notches and openings create a channel between the towers, a natural space exists for a rod or extension element to be inserted by another robotic arm. In this way, the entire process—from locating the pedicle screw trajectory to screw insertion, screw head alignment, rod insertion, and then locking cap insertion—is accomplished by the same robotic arm. The final locking step involving tower compression can also be performed by squeezing the proximal ends of the extension towers together and using the locking cap to final lock the connecting element or rod. The entire process can be performed in a streamlined manner without the risk of interference between different screw paths due to lumbar lordosis.

[0172] Certain aspects of the systems, devices, components, and / or methods described above or illustrated with respect to Figures 4A-4T are also encompassed by the following numbered embodiments, which are believed to be directed to systems, devices, components, and / or methods including, but not limited to, the embodiments of Figures 4A-4T, and thus may encompass other embodiments as described throughout this specification. 1. A system for stabilizing spinal vertebrae through a skin incision, comprising: a first screw having a first screw head; a second screw having a second screw head; a first extension configured to be removably coupled to the first screw at a distal end of the first extension, the first extension having a wall and a first passageway extending through the first extension along an axial centerline of the first extension, the wall of the first extension at least partially surrounding the first passageway; a second extension configured to be removably coupled to the second screw at a distal end of the second extension, the second extension having a wall and a second passageway extending through the second extension along an axial centerline of the second extension, the wall of the second extension at least partially surrounding the second passageway; a first opening extending through a wall of the first extension; Equipped with The first opening and a wall of the first extension adjacent the first opening are sized and configured such that the second extension can be advanced through the first opening such that the second extension is restrained within the first opening and positionable at an acute angle relative to an axial centerline of the first extension, a system. 2. The system described in embodiment 1, wherein the first extension is removably connectable to the first screw such that, when the first extension is connected to the first screw, the axial centerline of the first extension is approximately collinear with the axial centerline of the first screw, and the second extension is removably connectable to the second screw such that, when the second extension is connected to the second screw, the axial centerline of the second extension is approximately collinear with the axial centerline of the second screw. 3. The system of embodiment 1 or 2, wherein the first extension and the second extension are shaped into a generally cylindrical shape. 4. The system of any one of the preceding embodiments, wherein the first extension and the second extension are substantially rigid. 5. The system of any one of the preceding embodiments, wherein the first extension and the second extension have a tubular shape. 6. The system of any one of the preceding embodiments, wherein at least a distal portion of the first extension has an adjustable length. 7. The system of any one of the preceding embodiments, wherein the first screw is configured to be implanted into a first vertebra and the second screw is configured to be implanted into a second vertebra. 8. The system of any one of the preceding embodiments, wherein the first extension is sized and configured such that, in an operable state, a proximal portion of the first extension extends away from the skin incision toward the surgeon. 9. A system described in any one of the preceding embodiments, wherein the inner size of the wall of the first extension adjacent to the first opening in the first extension is larger than the outer size of at least a portion of the wall of the second extension, so that at least a portion of the second extension can pass through the first opening of the first extension at an acute angle to the axial centerline of the first extension and be at least partially surrounded by the wall of the first extension. 10. The proximal portion of the first extension has an inner cross-sectional size that is larger than the inner cross-sectional size of the distal portion of the first extension; The inner cross-sectional size of the proximal portion of the first extension is also larger than the outer cross-sectional size of at least the distal portion of the second extension such that at least the distal portion of the second extension can be fully advanced through the first opening of the first extension. 10. The system of any one of the preceding embodiments. 11. A system according to any one of the preceding embodiments, wherein the first opening of the first extension passes through the wall of the first extension at an angle that is acute relative to the axial centerline of the first extension. 12. The system of any one of the preceding embodiments, wherein the first opening comprises a first cutout on a first side of the wall and a second cutout on a second side of the wall of the first extension, the second side of the wall facing the first side of the wall, and the second cutout separated from the first cutout, such that the first and second cutouts do not overlap or connect, and the second cutout is positioned closer to the distal end of the first extension than the first cutout. 13. The system of embodiment 12, wherein the first notch extends distally from the proximal end of the first extension such that the wall of the first extension does not form a complete or continuous enclosure around the first passage at the proximal end of the first extension. 14. The system of embodiment 12 or 13, wherein the first cutout removes at least about 40% of the wall of the first extension, at least at the proximal end of the first extension. 15. A system described in any one of embodiments 12 to 14, wherein the first notch extends along a length of the first extension that is at least about 30% of the total length of the first extension. 16. A system described in any one of embodiments 12 to 15, wherein the first notch extends along a length of the first extension that is at least about 40% of the total length of the first extension. 17. A system described in any one of embodiments 12 to 16, wherein the distal edge of the first notch is flat and angled downward toward the distal end of the first extension. 18. A system described in any one of embodiments 12 to 17, wherein the proximal portion of the second notch axially overlaps with the distal portion of the first notch. 19. A system described in any one of embodiments 12 to 18, wherein the second notch is positioned between the proximal end and the distal end of the first extension portion such that the proximal end of the second notch is spaced apart from the proximal end of the first extension portion and the distal end of the second notch is spaced apart from the distal end of the first extension portion. 20. The system of any one of embodiments 12 to 19, wherein the second cutout removes at least about 40% of the wall of the first extension in at least a middle portion of the first extension. 21. A system described in any one of embodiments 12 to 20, wherein the second notch extends along a length of the first extension that is at least about 30% of the total length of the first extension. 22. A system according to any one of embodiments 12 to 21, wherein the second notch extends along a length of the first extension that is at least about 40% of the total length of the first extension. 23. A system described in any one of embodiments 12 to 22, wherein the proximal edge of the second notch is curved. 24. A system described in any one of embodiments 12 to 23, wherein the distal edge of the second notch is flat and angled downward toward the distal end of the first extension. 25. The system of any one of the preceding embodiments, wherein the first extension and the second extension are configured such that, in an operable state in which the second extension is advanced through the first opening in the first extension, moving the proximal end of the first extension toward or away from the proximal end of the second extension causes the second extension to hinge about an edge of the first opening and rotate relative to the first extension about an edge of the first opening in the first extension, such that the distal end of the second extension moves toward or away from the distal end of the first extension, respectively. 26. A system according to any one of the preceding embodiments, wherein the first extension and the second extension are configured such that, in an operable state in which the second extension is advanced through the first opening of the first extension, contact between an outer surface of the wall of the second extension and a wall of the first extension surrounding the first opening provides a hinge along which the second extension can rotate relative to the first extension. 27. A system according to any one of the preceding embodiments, wherein the first extension is configured, in an operable state, such that when the second extension advances through the first opening in the first extension, a wall of the first extension surrounding the first opening prevents the second extension from rotating relative to the first extension more than a predetermined amount. 28. The system of any one of the preceding embodiments, wherein the first extension is configured, in an operable state, such that when the second extension is advanced through the first opening of the first extension and rotated into contact with a wall of the first extension adjacent the first opening, the wall of the first extension surrounding the first opening constrains rotation of the second extension relative to the first extension, thereby moving the proximal end of the first extension toward or away from the proximal end of the second extension, and thereby moving the distal end of the second extension toward or away from the distal end of the first extension, respectively. 29. A system described in any one of the preceding embodiments, wherein the proximal portion of the first extension is configured to be grasped by a surgeon so that the surgeon can apply a rotational force and / or a torque force to the first extension about at least an axial centerline of the distal portion of the first extension to rotate the first extension about an axis that is perpendicular to the axial centerline of the distal portion of the first extension. 30. The system of any one of the preceding embodiments, wherein the second extension comprises a second opening extending through a wall of the second extension, and the second opening and the second extension adjacent the second opening are sized and configured such that the third extension can be operatively advanced through the second opening such that the third extension is angled at an acute angle relative to an axial centerline of the second extension. 31. The system described in embodiment 30, wherein the first extension portion and the second extension portion are configured such that the third extension portion can be advanced through the first opening of the first extension portion and the second opening of the second extension portion in an operable state such that the third extension portion is inclined at an acute angle relative to the axial centerline of the first extension portion and the axial centerline of the second extension portion. 32. A system as described in embodiment 30 or 31, wherein the distal end of the third extension portion is positioned between the distal end of the first extension portion and the distal end of the second extension portion in an operable state. 33. The system of any one of embodiments 30 to 32, wherein the third extension has a tubular shape. 34. The system of any one of the preceding embodiments, wherein the second extension portion comprises at least one slot extending through a wall of the second extension portion, the at least one slot of the second extension portion being configured to receive a connecting element configured to extend between the first screw and the second screw in an operable state. 35. Rigid connecting elements; a first receiving element coupled to the first screw head; a second receiving element coupled to the second screw head; Further provided with the first and second receiving elements are configured to operably receive a connecting element, the connecting element extending between the first and second receiving elements in the operable state when the first and second screws are implanted into the first and second vertebrae, respectively; 10. The system of any one of the preceding embodiments. 36. A system according to any one of the preceding embodiments, wherein the first extension includes a first slot extending through its wall, the first slot of the first extension configured to allow a connecting element, configured to extend between the first screw and the second screw in an operable state, to be advanced through the first slot. 37. The system of embodiment 36, wherein the first slot of the first extension extends proximally from the distal end of the first extension to the second notch of the first extension. 38. The system of embodiment 36, wherein the first slot of the first extension has a width that is less than 50% of the width of the outer surface of the first extension. 39. A system according to any one of the preceding embodiments, wherein the second extension includes a first slot extending through a wall of the second extension, the first slot of the second extension being configured to allow a connecting element, configured to extend between the first screw and the second screw in an operable state, to be advanced through the first slot of the second extension. 40. The system of embodiment 39, wherein the first slot of the second extension portion extends proximally from the distal end of the second extension portion to the second notch of the second extension portion. 41. The system of embodiment 39, wherein the first slot of the second extension has a width that is less than 50% of the width of the outer surface of the second extension. 42. The system described in embodiment 39, wherein the first slot of the second extension is on a first side of the wall of the second extension, the second extension further comprising a second slot extending through the second side of the wall of the second extension, the second side of the wall of the second extension facing the first side of the wall of the second extension, and the second slot of the second extension configured to allow a connecting element configured to extend between the first screw and the second screw in an operable state to advance through the second slot of the second extension. 43. The system of embodiment 42, wherein the second slot of the second extension portion extends proximally from the distal end of the second extension portion and has a length that is greater than or equal to about 40% of the length of the second extension portion. 44. A method for stabilizing spinal vertebrae, comprising: implanting a first screw coupled to a first extension through the incision and into the first vertebra; advancing a second extension coupled to the second screw through the incision and through a first opening formed in the first extension such that an axial centerline of the second extension is at an acute angle with respect to an axial centerline of the first extension; implanting a second screw into the second vertebra; moving a proximal portion of the first extension toward a proximal portion of the second extension until an outer surface of the second extension contacts at least a distal edge of the first opening in the first extension; further moving the proximal portion of the first extension toward the proximal portion of the second extension and rotating the second extension about at least the distal edge of the first opening to move the distal end portion of the first extension toward the distal end portion of the second extension, thereby moving the first vertebra toward the second vertebra; A method comprising: 45. The method of embodiment 44, further comprising coupling a rigid connector to the first screw and the second screw to generally fix the position of the first screw relative to the second screw. 46. ​​A system for bone stabilization, comprising: a first screw having a first screw head; a first guide element configured to extend away from the first screw, the first guide element comprising: a partially enclosed tubular body extending along a first longitudinal axis between a proximal end and a distal end, the distal end of the partially enclosed tubular body configured to engage the first screw head; an opening extending through an intermediate portion of the partially enclosed tubular body, the opening being oriented at an angle relative to the first longitudinal axis; A system comprising: 47. A partially enclosed tubular body is a proximal portion proximal to the intermediate section, the proximal portion comprising a partially enclosed tubular section having an inner concave surface facing a first direction and an outer convex surface facing a second direction opposite the first direction; a distal portion distal to the intermediate section, the distal portion comprising a partially enclosed tubular section having an inner concave surface facing the second direction and an outer convex surface facing the first direction; 47. The system of embodiment 46, comprising: 48. The system of embodiment 47, wherein the proximal portion encircles a surface of at least 180°. 49. A system according to embodiment 47 or 48, wherein the distal portion encircles a surface of at least 180°. 50. A system according to any one of embodiments 47 to 49, wherein the distal portion comprises a longitudinal slot extending to the distal end of the partially enclosed tubular body. 51. A second screw having a second screw head; a second guide element configured to extend away from the second screw; Further provided with The second guide element is configured to pass through the opening of the first guide element; A system described in any one of embodiments 47 to 50. 52. The second inductive element is a partially enclosed tubular body extending along a second longitudinal axis between a proximal end and a distal end, the distal end of the partially enclosed tubular body configured to engage the second screw head; an opening extending through an intermediate portion of the partially enclosed tubular body, the opening extending at an angle relative to the second longitudinal axis; 52. The system of embodiment 51, comprising: 53. The partially enclosed tubular body of the second guide element a proximal portion proximal to the intermediate section, the proximal portion comprising a partially enclosed tubular section having an inner concave surface facing a third direction and an outer convex surface facing a fourth direction opposite the third direction; a distal portion distal to the intermediate section, the distal portion comprising a partially enclosed tubular section having an inner concave surface facing in the fourth direction and an outer convex surface facing in the third direction; 53. The system of embodiment 52, comprising: 54. A third screw having a third screw head; a third guide element configured to extend away from the third screw; and Further provided with the third guide element is configured to pass through the openings of the first guide element and the second guide element; The system described in embodiment 53. 55. The system of embodiment 54, wherein the third guide element comprises a tubular body. 56. The system of embodiment 55, wherein the third guiding element includes a longitudinal slot to facilitate passage of the rod. 57. The system of any one of embodiments 46 to 56, further comprising a rod inserter configured to deliver the rod. 58. The system of embodiment 57, further comprising a rod capture configured to release the rod from the rod inserter. 59. A system for bone stabilization, comprising: A plurality of inductive elements, each of which comprises: a partially enclosed tubular body extending between a proximal end and a distal end, the distal end of the partially enclosed tubular body configured to engage the screw head; an opening extending through an intermediate portion of the partially enclosed tubular body, the opening being oriented at an angle relative to a longitudinal axis of the guide element; Equipped with the opening of each of the plurality of guide elements is sized and configured to allow passage of another guide element therethrough; system. 60. The plurality of inductive elements includes a first inductive element and a second inductive element, and the first inductive element and the second inductive element each include: a proximal portion proximal to the intermediate section, the proximal portion comprising a partially enclosed tubular section having an inner concave surface facing a first direction and an outer convex surface facing a second direction opposite the first direction; a distal portion distal to the intermediate section, the distal portion comprising a partially enclosed tubular section having an inner concave surface facing the second direction and an outer convex surface facing the first direction; Equipped with the second guide element is configured to pass through an opening in the first guide element, and inner concave surfaces of the proximal portions of the first and second guide elements face each other when the second guide element passes through the opening in the first guide element; The system described in embodiment 59. 61. The system described in embodiment 59 or 60, wherein the plurality of guide elements comprises a first guide element, a second guide element, and a third guide element, wherein an opening extending through an intermediate section of the first guide element is sized and configured to allow the second guide element to pass therethrough, and an opening extending through an intermediate section of the third guide element is sized and configured to allow the first and second guide elements to pass therethrough when the second guide element passes through the opening of the first guide element.

[0173] The systems, devices and methods of Figures 5A-5K Described below are embodiments directed to a system 500 for stabilizing spinal vertebrae through a skin incision S. In any embodiment disclosed herein, any component, feature, or other detail of system 500 can have any of the components, features, or other details of any other system embodiment disclosed herein, or can be used according to any of the steps of any other method embodiment disclosed herein, including, without limitation, any of the aforementioned systems 200, 300, and / or 400 or method of use thereof, in any combination with any of the components, features, or details of system 500 or method of use disclosed below. Similarly, any component, feature, step, or other detail of any of the other system or method embodiments disclosed herein can have any of the components, features, steps, or other details of any of the system components, features, or details of any of the system embodiments disclosed herein, or method of use thereof.

[0174] In any embodiment disclosed herein, the system 500 can have a blade with an opening that can be positioned at various lengths relative to the screw head, for example, and the opening can be sized and configured to allow other screws and towers or other guide elements or extensions to pass through the opening.

[0175] In any embodiment disclosed herein, the blades can then be attached to or coupled to the screw by any suitable attachment mechanism. In some embodiments, one or more wires, including but not limited to wires 140a, 140b, can be used to couple the blades to the screw head. Then, once the desired number of towers are engaged with the screw head, in any embodiment disclosed herein, one or more connectors or caps can couple each pair of blades together, closing the towers and increasing the stiffness of the blades and towers. Additionally, in any embodiment disclosed herein, the blades can have one or more stiffeners or reinforcements proximal or distal to the opening to increase the bending stiffness of the blades, or the proximal and distal portions of the blades can have increased stiffness to reduce the flexibility of the towers during use.

[0176] In some embodiments, the system 500 can include a first screw 502 that can include a first screw head 504, the first screw head 504 including a first side 506 and a second side 508, the first side 506 and the second side 508 being opposite one another, and a first guide element 510 configured to extend away from the first screw 502. In any embodiment disclosed herein, the first guide element 510 can include a first blade 520 extending along a first longitudinal axis A1 between a proximal end 520 a and a distal end 520 a of the first blade 520. The first blade 520 can include a curved mid-section 524 between the proximal end 520 a and the distal end 520 b. The distal end 520 b of the first blade 520 can be configured to engage or couple with the first side 506 of the first screw head 504.

[0177] The first guide element 510 may further include a second blade 530 extending along the second longitudinal axis A2 between a proximal end 530a and a distal end 530b. The second blade 530 may include a curved intermediate section 534 between the proximal end 530a and the distal end 530b. The distal end 530b of the second blade 530 may be configured to engage with the second side surface 508 of the first screw head 504. The first guide element 510 may be configured such that when the distal end 520b of the first blade 520 and the distal end 530b of the second blade 530 are engaged with the first screw head 504, the inner surface 520c of the first blade 520 faces and is spaced apart from the inner surface 530c of the second blade 530. Further, in some embodiments, the curved intermediate sections 524, 534 of the first and second blades 520, 530 can form an enlarged opening 540 having increased spacing between the inner surfaces 520c, 530c of the first and second blades 520, 530 relative to the spacing between the inner surfaces of the first blade 520 and the second blade 530 proximal and distal to the intermediate sections 524, 534.

[0178] In any embodiment, the first and second longitudinal axes A1, A2 can be parallel to one another when the distal ends 520b, 530b of the first blade 520 and the second blade 530 are engaged with the first screw head 504. Furthermore, in some embodiments, the curved mid-section of each of the first blade 520 and the second blade 530 can be bowed outward and have a curved or rounded shape. In any other embodiment, the mid-section of each of the first blade 520 and the second blade 530 can be bent outwardly toward a midpoint of the mid-section and can have an angled or tapered shape. The first blade 520 and the second blade 530 can be bent inward proximal to the midpoint of the mid-section.

[0179] In some embodiments, the enlarged opening 540 of the first guide element 510 can be oriented parallel or substantially parallel to the inner surfaces of the first and second blades 520, 530. Furthermore, in any embodiment disclosed herein, each of the first blade 520 and second blade 530, and / or any blade of any guide element disclosed herein, can have a substantially uniform cross-sectional thickness from the proximal end to the distal end.

[0180] In some embodiments, the enlarged opening 540 of the first guide element 510 can be configured to allow passage of a subsequently advanced guide element or multiple subsequently advanced guide elements, including, but not limited to, an enlarged mid-section of the subsequently advanced guide element or multiple subsequently advanced guide elements. For example, but not limited to, in some embodiments, the enlarged opening 540 between the first blade 520 and the second blade 530 can be sized and configured to allow passage of the second screw and the second guide element 510, including an enlarged mid-section of the second guide element.

[0181] 5B , some embodiments of the guide element 510 can be configured such that the first blade 520 has a proximal section 540 and a distal section 542, the second blade 530 has a proximal section 544 and a distal section 546, the middle section 524 of the first blade 520 is between the proximal section 540 and the distal section 542 of the first blade 520, and the middle section 534 of the second blade 530 is between the proximal section 540 and the distal section 542 of the second blade 530. In any embodiment disclosed herein, the proximal sections 540, 544 of the first and second blades 520, 530 and / or the distal sections 542, 546 of the first and second blades 520, 530 can be planar or substantially planar and parallel to one another.

[0182] In some embodiments, the increased spacing distance between the inner surface of the third blade 560 and the inner surface of the fourth blade 564 of the second guide element 550 (e.g., at the enlarged opening 540) can be smaller than the increased spacing distance between the inner surface of the first blade 520 and the inner surface of the second blade 530 (e.g., at the enlarged opening 540). For example, without limitation, in any embodiment disclosed herein, the width WO of the guide element from the inner surface of the first blade to the inner surface of the second blade at the widest point of the opening (as shown in FIG. 5B ) can be about 100% greater (i.e., twice as wide) than the width WP from the inner surface of the first blade to the inner surface of the second blade at the proximal portion (e.g., proximal portions 540, 544 of first and second blades 520, 530), or 80% (or about 80%) greater to 400% (or about 400%) or more greater than the width WP from the inner surface of the first blade to the inner surface of the second blade at the proximal portion. In any embodiment disclosed herein, the proximal and distal portions of the guide element can have approximately the same width, or can have different widths.

[0183] In any embodiment disclosed herein, the guide element can have any of a range of lengths suitable for a range of different sized anatomy, thereby allowing the surgeon to select the desired length(s) of the blade and the location of the enlarged opening, for example, after measuring the depth of the tissue. Referring to FIG. 5D , the guide element 510 can be provided in various lengths, and the length of the distal portion LD to the distal edge of the enlarged opening 540 can vary. For example, without limitation, a system can be provided with a kit having a range of guide elements 510 with a range of total lengths of the distal portion of the guide element and a range of lengths LD. As shown in FIG. 5D , some embodiments of the guide element 510 can have a distal portion with a length LD1 that is shorter than a second guide element 510 having a distal portion with a length LD2. LD2 can also be shorter than a third guide element 510 having a distal portion with a length LD3, which can be shorter than a fourth guide element 510 having a distal portion with a length LD4. LD4 can be shorter than the length of the fifth guide element 510, which has a distal portion with length LD5. In any embodiment, the length of the overall length and / or distal portion LD can be 10% (or less than or equal to about 10%) greater between each successive size, or 15% (or less than or equal to about 15%) greater between each successive size, or 20% (or more than or equal to about 20%) greater between each successive size.

[0184] For example, without limitation, the enlarged opening of any of the guide element embodiments disclosed herein can be oriented at any desired angle (e.g., a perpendicular angle, or any acute or non-perpendicular angle) relative to the longitudinal axis of the guide element such that when the distal ends of the first blade and second blade are engaged with the first screw head, the enlarged opening in the guide element can be at any desired angle.

[0185] 5E-5G, in some embodiments, the enlarged opening 540 of the first guide element 510 can be oriented at an angle relative to the axial centerline axis C (also referred to as the longitudinal axis) when, for example, but not by way of limitation, the distal ends of the first blade 520 and the second blade 530 are engaged with the first screw head 504. For example, as shown in FIG. 5E, the first opening 540 of the first guide element 510 (or any other guide element, including the second guide element, third guide element, etc.) can be at an angle A1 relative to the centerline axis C, which can be 90° (or approximately 90°). As shown in FIG. 5F, the first opening 540 of the first inductive element 510 (or any other inductive element, including the second inductive element, the third inductive element, etc.) may be at an angle A2 with respect to the centerline axis C, which may be less than 90°, such as, for example, 70° (or about 70°) with respect to the centerline axis C, or 50° (or about 50°) to 75° (or about 75°) with respect to the centerline axis C. As shown in FIG. 5G, the first opening 540 of the first inductive element 510 (or any other inductive element, including the second inductive element, the third inductive element, etc.) may be at an angle A3 with respect to the centerline axis C that is less than A2, such as, for example, 45° (or about 45°) with respect to the centerline axis C, or 30° (or about 30°) to 50° (or about 50°) with respect to the centerline axis C.

[0186] In this arrangement, referring to FIG. 5H , the first guide element 510 can have an enlarged opening 540 at an angle A relative to the centerline axis C of the first guide element 510 through which the second guide element 550 can pass. As a result, the second guide element 550 can be oriented such that, in the operable state shown in FIG. 5H , the centerline axis C of the second guide element 550 is also inclined at the same angle A relative to the centerline axis as the enlarged opening 540 of the first guide element. Again, the angle A of the first guide element can be any desired angle. In any embodiment, the angle of the enlarged opening can be an acute or non-perpendicular angle, such as angle A2 or angle A3 shown in FIGS. 5E and 5F . This angle can range from 20° (or about 20°) or less to 70° (or about 70°) or more, or from 40° (or about 40°) to 60° (or about 60°) in the kit. In any embodiment disclosed herein, the second guide element 550 or the third guide element 582 can have a generally planar blade as shown, or can also have an enlarged opening configured to allow passage of the third guide element.

[0187] 5C , the system 500 can further include a second guide element 550, which can have any of the same features, components, and / or other details as any of the embodiments of the first guide element 510 disclosed herein, including any desired angle of enlarged opening. The second guide element 550 can include a second screw 552, which can include a second screw head 554 having a first side 556 and a second side 558, the first side 556 and the second side 558 being opposite each other. The second guide element 550 can be configured to extend away from the second screw 552 and can include a third blade 560 extending along a third longitudinal axis between a proximal end 560 a and a distal end 560 b, the distal end 560 b of the third blade 560 configured to engage the first side 556 of the second screw head 554. The second guide element 510 may also include a fourth blade 564 extending along a fourth longitudinal axis A4 between a proximal end 564a and a distal end 564b, the distal end 564b of the fourth blade 564 configured to engage with a second side surface 558 of the second screw head 554.

[0188] Similar to the first blade 520, the third blade 560 can include a curved intermediate section 566 between the proximal and distal ends 560 a, 560 b, and the fourth blade 564 can include a curved intermediate section 568 between the proximal and distal ends 564 a, 564 b. Additionally, in some embodiments, the curved intermediate sections 566, 568 of the third and fourth blades 560, 564 can form an enlarged opening 570 having increased spacing between the inner surfaces 560 c, 564 c of the third and fourth blades 560, 564 relative to the spacing between the inner surfaces of the first blade 560 and second blade 564 proximal and distal to the intermediate sections 566, 568.

[0189] In some embodiments, the distal ends 560b, 564b of the third and fourth blades can be engaged with the second screw head 554. Additionally, the inner surface 560c of the third blade 560 can face the inner surface 564c of the fourth blade 564 and can be spaced apart therefrom.

[0190] 5C and 5I-5K, the enlarged opening 570 of the second guide element 550 can be configured to allow passage of a subsequently-advanced guide element or multiple subsequently-advanced guide elements, including, but not limited to, an enlarged mid-section of a subsequently-advanced guide element or multiple subsequently-advanced guide elements, or a subsequently-advanced guide element having a generally straight or planar blade. For example, but not limited to, in some embodiments, the enlarged opening 570 between the third blade 560 and the fourth blade 564 can be sized and configured to allow passage of a third screw 580 and a third guide element 582, where the third guide element 582 has a generally flat blade or a guide element with an enlarged mid-section.

[0191] In any embodiment, as shown in Figures 5I-5K, the size and / or orientation of the enlarged opening 570 between the third blade and the fourth blade of the second guide element 550 can be different from the orientation of the enlarged opening 540 between the first blade 520 and the second blade 530 of the first guide element 540. Furthermore, in any embodiment disclosed herein, the longitudinal position of the enlarged opening of the second guide element can be different from the longitudinal position of the enlarged opening of the second guide element.

[0192] In some embodiments, the third guide element can have an enlarged opening configured to allow passage of the first guide element and the second guide element. In some embodiments, the third guide element can have an enlarged opening having any of the features or details of any of the embodiments disclosed herein, and the first guide element can have an enlarged opening having any of the features or details of any of the embodiments disclosed herein. The second guide element can have an enlarged opening therein or can have a generally flat blade. In some embodiments, the enlarged opening of the third guide element can be sized and configured to allow passage of the first and second guide elements, and the first guide element can be sized and configured to allow passage of the second guide element.

[0193] In some embodiments, the third guide element can include a fifth blade extending along a fifth longitudinal axis between a proximal end and a distal end, the fifth blade including either a straight or curved intermediate section between the proximal end and the distal end, and the distal end of the fifth blade configured to engage with a first side surface of the third screw head. In some embodiments, the third guide element can have a sixth blade extending along a second longitudinal axis between the proximal end and the distal end, the sixth blade including either a straight or curved intermediate section between the proximal end and the distal end, and the distal end of the sixth blade configured to engage with a second side surface of the third screw head. The inner surface of the fifth blade can face and be spaced apart from the inner surface of the sixth blade, as shown in the figures. In some embodiments, the curved midsection of the fifth and sixth blades can form an enlarged opening having increased spacing between the inner surfaces of the fifth and sixth blades relative to the spacing between the inner surfaces of the fifth and sixth blades proximal and distal to the midsection.

[0194] Further, in some embodiments, the increased spacing distance in the enlarged opening between the inner surfaces of the fifth blade and the sixth blade can be greater than the increased spacing distance, if any, between the inner surfaces of the first blade 520 and the second blade 530, such that the enlarged opening between the fifth blade and the sixth blade can be sized and configured to allow the passage of the second screw and the second guide element 510 and to allow the passage of the first screw 502 and the first guide element 510.

[0195] Some embodiments of the system 500 for bone stabilization may include a plurality of guide elements, each of the plurality of guide elements including a first blade 520 that may include a proximal end 520a and a distal end 520b, the first blade 520 including a curved mid-section 524 between the proximal end 520a and the distal end 520b, and a second blade 530 that may include a proximal end 530a and a distal end 530b, the second blade including a curved mid-section 534 between the proximal end 530a and the distal end 530b. In some embodiments, the distal ends 520 b, 530 b of the first blade 520 and the second blade 530 can be configured to engage the bone screw 502 such that, when engaged with the bone screw 502, the inner surface 520 c of the first blade 520 faces and is spaced apart from the inner surface 530 c of the second blade 530. Additionally, the curved middle sections 524, 534 of the first blade 520 and the second blade 530 can form an enlarged opening 540 with increased spacing between the inner surfaces 520 c, 530 c of the first blade 520 and the second blade 530 relative to the spacing between the inner surfaces 520 c, 530 c of the first blade 520 and the second blade 530 proximal and distal to the middle sections 524, 534. Furthermore, in some embodiments, the first blade 520 and the second blade 530 of the first guide element 510 of the plurality of guide elements may form an enlarged opening 540 having a different longitudinal position, a different spacing between the inner surfaces of the first blade 520 and the second blade 530, and / or a different orientation compared to the enlarged opening formed by the first blade 560 and the second blade 564 of the second guide element 550 of the plurality of guide elements.

[0196] Furthermore, in some embodiments, the system 500 includes a third guide element having an enlarged opening, wherein the first blade and the second blade of the third guide element of the plurality of guide elements can form an enlarged opening having a different longitudinal position, a different spacing between the inner surfaces of the first and second blades, and / or a different orientation compared to the enlarged opening formed by the first and second blades of the second guide element of the plurality of guide elements and compared to the enlarged opening formed by the first and second blades of the first guide element of the plurality of guide elements. The third guide element can be coupled to the screw head of the third screw.

[0197] Furthermore, in some embodiments, the system 500 includes a fourth guide element having an enlarged opening, wherein the first and second blades of the fourth guide element of the plurality of guide elements can form an enlarged opening having a different longitudinal position, a different spacing between inner surfaces of the first and second blades, and / or a different orientation compared to the enlarged opening formed by the first and second blades of a third guide element of the plurality of guide elements, compared to the enlarged opening formed by the first and second blades of a second guide element of the plurality of guide elements, and compared to the enlarged opening formed by the first and second blades of a first guide element of the plurality of guide elements. The fourth guide element can be coupled to the screw head of a fourth screw.

[0198] Furthermore, in some embodiments in which the system 500 includes a fifth guide element having an enlarged opening, the first and second blades of the fifth guide element can form an enlarged opening having a different longitudinal position, a different spacing between the inner surfaces of the first and second blades, and / or a different orientation compared to the enlarged opening formed by the first and second blades of a fourth guide element of the plurality of guide elements, compared to the enlarged opening formed by the first and second blades of a third guide element of the plurality of guide elements, compared to the enlarged opening formed by the first and second blades of a second guide element of the plurality of guide elements, and compared to the enlarged opening formed by the first and second blades of a first guide element of the plurality of guide elements. The fifth guide element can be coupled to the screw head of a fifth screw.

[0199] Certain aspects of the systems, devices, components, and / or methods described above or illustrated with respect to Figures 5A-5K are also encompassed by the following numbered embodiments, which are believed to be directed to systems, devices, components, and / or methods including, but not limited to, the embodiments of Figures 5A-5K, and thus may encompass other embodiments as described throughout this specification. 1. A system for bone stabilization, comprising: a first screw having a first screw head, the first screw head having a first side surface and a second side surface, the first side surface and the second side surface facing each other; a first guide element configured to extend away from the first screw, the first guide element comprising: a first blade extending along a first longitudinal axis between a proximal end and a distal end, the first blade including a curved intermediate section between the proximal end and the distal end, the distal end of the first blade configured to engage a first side of the first screw head; a second blade extending along a second longitudinal axis between a proximal end and a distal end, the second blade including a curved intermediate section between the proximal end and the distal end, the distal end of the second blade configured to engage a second side of the first screw head; Equipped with When the distal ends of the first and second blades are engaged with the first screw head, an inner surface of the first blade facing and spaced apart from an inner surface of the second blade; The system, wherein the curved midsections of the first and second blades form an enlarged opening having an increased spacing between the inner surfaces of the first and second blades relative to the spacing between the inner surfaces of the first and second blades proximal and distal to the midsection. 2. The system of embodiment 1, wherein each of the first blade and the second blade includes a proximal section and a distal section, the intermediate section is between the proximal section and the distal section, and the proximal section and the distal section are planar or substantially planar and parallel to each other. 3. The system of any one of the preceding embodiments, wherein the enlarged opening is oriented at an angle relative to the first and second longitudinal axes when the distal ends of the first and second blades are engaged with the first screw head. 4. The system of any one of the previous embodiments, wherein the enlarged opening is oriented parallel or substantially parallel to the inner surfaces of the first and second blades. 5. The system of any one of the preceding embodiments, wherein when the distal ends of the first and second blades are engaged with the first screw head, the first and second longitudinal axes are parallel to one another. 6. The system of any one of the preceding embodiments, wherein each of the curved intermediate sections of the first blade and the second blade is curved outward. 7. A system according to any one of the preceding embodiments, wherein each of the first and second blades has a substantially uniform cross-sectional thickness from the proximal end to the distal end. 8. A second screw having a second screw head, the second screw head having a first side surface and a second side surface, the first side surface and the second side surface facing each other; a second guide element configured to extend away from the second screw, the second guide element comprising: a third blade extending along a third longitudinal axis between a proximal end and a distal end, the distal end of the third blade configured to engage the first side of the second screw head; a fourth blade extending along a fourth longitudinal axis between a proximal end and a distal end, the distal end of the fourth blade configured to engage the second side of the second screw head; Equipped with an enlarged opening between the first blade and the second blade sized and configured to allow a second screw and a second guide element to pass through the opening; 10. The system of any one of the preceding embodiments. 9. The third blade of the second guide element has a curved intermediate section between a proximal end and a distal end, and the fourth blade of the second guide element has a curved intermediate section between a proximal end and a distal end, and when the distal ends of the third and fourth blades are engaged with the second screw head, an inner surface of the third blade facing and spaced apart from an inner surface of the fourth blade; the curved midsections of the third and fourth blades form an enlarged opening having an increased spacing between the inner surfaces of the third and fourth blades relative to the spacing between the inner surfaces of the third and fourth blades proximal and distal to the midsection; 9. The system of embodiment 8. 10. The system of embodiment 9, wherein the increased spacing distance between the inner surfaces of the third and fourth blades is less than the increased spacing distance between the inner surfaces of the first and second blades. 11. The system of embodiment 9 or 10, wherein the orientation of the enlarged opening between the third blade and the fourth blade is different from the orientation of the enlarged opening between the first blade and the second blade. 12. A system described in any one of embodiments 9 to 11, wherein the longitudinal position of the enlarged opening between the third blade and the fourth blade is different from the longitudinal position of the enlarged opening between the first blade and the second blade. 13. The system of embodiment 8, wherein each of the third and fourth blades of the second guide element is completely planar or completely substantially planar from the proximal end to the distal end. 14. A third screw having a third screw head, the third screw head having a first side surface and a second side surface, the first side surface and the second side surface facing each other; and a third guide element configured to extend away from the third screw, the third guide element comprising: a fifth blade extending along a fifth longitudinal axis between a proximal end and a distal end, the fifth blade including a curved intermediate section between the proximal end and the distal end, the distal end of the fifth blade configured to engage a first side of the third screw head; a sixth blade extending along the second longitudinal axis between a proximal end and a distal end, the sixth blade including a curved intermediate section between the proximal end and the distal end, the distal end of the sixth blade configured to engage a second side of the third screw head; Equipped with When the distal ends of the fifth and sixth blades are engaged with the third screw head, an inner surface of the fifth blade facing and spaced apart from an inner surface of the sixth blade; the curved midsections of the fifth and sixth blades form an enlarged opening having an increased spacing between the inner surfaces of the fifth and sixth blades relative to the spacing between the inner surfaces of the fifth and sixth blades proximal and distal to the midsection; an increased spacing distance between the inner surfaces of the fifth and sixth blades is greater than an increased spacing distance between the inner surfaces of the first and second blades, such that an enlarged opening between the fifth and sixth blades is sized and configured to allow passage of the second screw and the second guide element and to allow passage of the first screw and the first guide element; A system described in any one of embodiments 8 to 13. 15. A system for bone stabilization, comprising: A plurality of inductive elements, each of which comprises: a first blade having a proximal end and a distal end, the first blade having a curved midsection between the proximal end and the distal end; a second blade having a proximal end and a distal end, the second blade having a curved midsection between the proximal end and the distal end; Equipped with The distal ends of the first and second blades are configured to engage the bone screw, and when engaged with the bone screw: an inner surface of the first blade facing and spaced apart from an inner surface of the second blade; the curved intermediate sections of the first and second blades form an enlarged opening having an increased spacing between the inner surfaces of the first and second blades relative to the spacing between the inner surfaces of the first and second blades proximal and distal to the intermediate sections; The system, wherein the first blade and the second blade of a first guide element of the plurality of guide elements form an enlarged opening having a different longitudinal position, a different spacing between the inner surface of the first blade and the inner surface of the second blade, and / or a different orientation compared to the enlarged opening formed by the first blade and the second blade of a second guide element of the plurality of guide elements. 16. The system of embodiment 15, wherein the first and second blades of a third guide element of the plurality of guide elements form an enlarged opening having a different longitudinal position, a different spacing between the inner surfaces of the first and second blades, and / or a different orientation compared to the enlarged opening formed by the first and second blades of a second guide element of the plurality of guide elements and compared to the enlarged opening formed by the first and second blades of a first guide element of the plurality of guide elements. 17. The system of embodiment 16, wherein the first and second blades of a fourth guide element of the plurality of guide elements form an enlarged opening having a different longitudinal position, a different spacing between the inner surfaces of the first and second blades, and / or a different orientation compared to the enlarged opening formed by the first and second blades of a third guide element of the plurality of guide elements, compared to the enlarged opening formed by the first and second blades of a second guide element of the plurality of guide elements, and compared to the enlarged opening formed by the first and second blades of a first guide element of the plurality of guide elements. 18. The system of embodiment 17, wherein the first and second blades of a fifth guide element of the plurality of guide elements form an enlarged opening having a different longitudinal position, a different spacing between the inner surfaces of the first and second blades, and / or a different orientation compared to the enlarged opening formed by the first and second blades of a fourth guide element of the plurality of guide elements, compared to the enlarged opening formed by the first and second blades of a third guide element of the plurality of guide elements, compared to the enlarged opening formed by the first and second blades of a second guide element of the plurality of guide elements, and compared to the enlarged opening formed by the first and second blades of a first guide element of the plurality of guide elements.

[0200] The systems, devices and methods of Figures 6A-6V The embodiments disclosed herein are directed to a system 600 for stabilizing spinal vertebrae through a skin incision S. In any embodiment disclosed herein, any component, feature, or other detail of system 600 can have any of the components, features, or other details of any other system embodiment disclosed herein, or can be used according to any of the steps of any other method embodiment disclosed herein, including, without limitation, any of the aforementioned systems 200, 300, 400, and / or 500 or method of use thereof, in any combination with any of the components, features, or details of system 600 or method of use disclosed below. Similarly, any component, feature, step, or other detail of any of the other system or method embodiments disclosed herein can have any of the components, features, steps, or other details of any of the system components, features, or details of any of the system embodiments disclosed herein, or method of use thereof.

[0201] In any embodiment disclosed herein, the system 600 can have guide elements with various widths or spacing between the blades of the guide elements, which can be sized and configured to allow other screws and towers or other guide elements or extensions to pass between the blades.

[0202] In some embodiments, the system 600 may include a first screw 612 that may include a first screw head 613, the first screw head 613 including a first side and a second side, the first side and the second side facing one another, and a first guide element 610 configured to extend away from the first screw head 613. In any embodiment disclosed herein, the first guide element 610 may include a first pair of blades 618 extending along a first longitudinal axis between a proximal end 610 a and a distal end 610 b of the first guide element 610. The first pair of blades 618 can include a transition portion 616 between the proximal end 610a and the distal end 610b of the first guide element 610, where a first spacing (also referred to herein as a separation distance) between inner surfaces of the first pair of blades 618 at the transition portion 616 increases such that the proximal spacing between the first pair of blades at the proximal end 610a of the first guide element 610 is greater than the distal spacing between the first pair of blades 618 at the distal portion 610b of the first guide element. The distal end 610b of the first pair of blades 618 can be configured to engage or couple with the first screw head 613.

[0203] The system 600 can further include a second screw 622 that can include a second screw head 623, the second screw head 623 including a first side and a second side, the first side and the second side facing each other, and the second guide element 620 configured to extend away from the second screw head 623. In some embodiments, the second guide element 620 can have straight blades. In any embodiment disclosed herein, the second guide element 620 can include a second pair of blades 628 extending along a second longitudinal axis between the proximal end 620 a and the distal end 620 b of the second guide element 620. The second pair of blades 628 can include a transition portion 626 between the proximal end 620a and the distal end 620b of the second guide element 620, where a second spacing (also referred to herein as a separation distance) between inner surfaces of the second pair of blades 628 at the transition portion 626 increases such that the proximal spacing between the second pair of blades 628 at the proximal end 620a of the second guide element 620 is greater than the distal spacing between the second pair of blades 628 at the distal portion 620b of the second guide element 620. The distal end 620b of the second pair of blades 628 can be configured to engage or couple with the second screw head 622.

[0204] In any embodiment disclosed herein, the second spacing between the second pair of blades 628 can be less than the first spacing between the first pair of blades 618. In this configuration, the second guide element 620 can be advanced through the first spacing between the first pair of blades 618 of the first guide element 610.

[0205] Some embodiments of the system 600 can further include a third screw 632 that can include a third screw head 633, the third screw head 633 including a first side and a second side, the first side and the second side being opposite one another, and the third guide element 630 configured to mate with and extend away from the third screw head 633. In some embodiments, the third guide element 630 can have straight blades. In any embodiment disclosed herein, the third guide element 630 can include a third pair of blades 638 extending along a third longitudinal axis between the proximal end 630 a and the distal end 630 b of the third guide element 630. The third pair of blades 638 can include a transition portion 636 between the proximal end 630a and the distal end 630b of the third guide element 630, where a third spacing (also referred to herein as a separation distance) between inner surfaces of the third pair of blades 638 at the transition portion 636 increases such that the proximal spacing between the third pair of blades 638 at the proximal end 630a of the third guide element 630 is greater than the distal spacing between the third pair of blades 638 at the distal portion 630b of the third guide element 630. The distal end 630b of the third pair of blades 638 can be configured to engage or couple with the third screw head 632.

[0206] In any embodiment disclosed herein, the third spacing between the third pair of blades 638 can be less than the second spacing between the second pair of blades 624. Furthermore, the third spacing between the third pair of blades 638 can be less than the first spacing between the first pair of blades 614. In this configuration, the second guide element 620 and the third guide element 630 can be advanced through the first spacing between the first pair of blades in the first guide element 614.

[0207] In any embodiment, the transition portion of first guide element 610, second guide element 620, third guide element 630, and / or any guide element can be angled outwardly away from the longitudinal centerline axis, curved outwardly away from the longitudinal centerline axis, straight along the length of the transition portion, curved along the length of the transition portion, or otherwise curved. Furthermore, in any embodiment disclosed herein, each of first pair of blades 618, second pair of blades 624, third pair of blades 638, and / or any blade of any guide element disclosed herein can have a substantially uniform cross-sectional thickness from its proximal end to its distal end. In any embodiment disclosed herein, the proximal portion of the first, second, and / or third pair of blades (i.e., from the proximal end of the transition portion to the proximal end) can be straight, planar, substantially straight, and / or substantially planar. Additionally, each of the blades in the proximal portions of the first, second, and / or third pairs of blades may be parallel or substantially parallel to one another.

[0208] In some embodiments, the third spacing between the inner surfaces of the third pair of blades 638 of the third guide element 630 can be 25% (or about 25%) smaller, or 15% (or about 15%) to 35% (or about 35%) or more smaller than the second spacing between the inner surfaces of the second pair of blades 624 of the second guide element 620. In any embodiment disclosed herein, the third spacing of the third guide element 630 can be smaller than the second spacing of the second guide element 620 by an amount greater than the thickness of each of the blades of the third pair of blades 638. Furthermore, the second spacing between the inner surfaces of the second pair of blades 628 of the second guide element 620 can be 25% (or about 25%) smaller, or 15% (or about 15%) to 35% (or about 35%) or more smaller than the first spacing between the inner surfaces of the first pair of blades 614 of the first guide element 610. In any embodiment disclosed herein, the second spacing of the second inductive element 620 can be less than the first spacing of the first inductive element 620 by an amount greater than the thickness of each of the blades of the second pair of blades 628.

[0209] In any embodiment disclosed herein, the guide element can have any of a range of lengths suitable for a range of different sized anatomy, thereby allowing the surgeon to select the desired length(s) of the blade and the location of the enlarged opening, for example, after measuring the depth of the tissue.

[0210] 6A , any embodiment of system 600 can further include a restraint 650 configured to engage first pair of blades 618 and / or second pair of blades 628. In some embodiments, the restraint can be configured to engage an intermediate portion of first pair of blades 618, second pair of blades 628, and / or third pair of blades 638. The restraint 650 can be configured in some embodiments to at least create a hinge point or fulcrum between the first, second, and / or third guide elements 610, 620, 630. In some embodiments, the restraint 650 can be configured to surround at least the first, second, and / or third guide elements 610, 620, 630 at an intermediate portion thereof when the first, second, and / or third guide elements 610, 620, 630 pass through the other or other portion of the first, second, and / or third guide elements 610, 620, 630 and when the first, second, and / or third guide elements 610, 620, 630 are engaged with the first, second, and / or third bone screws, respectively, and the first, second, and / or third bone screws are implanted within the patient.

[0211] In some embodiments, the restraint 650 may be configured to limit relative movement between and / or restrain the first, second, and / or third guide elements 610, 620, 630 at their mid-portions so that the first, second, and / or third guide elements 610, 620, 630 are hinged or rotationally restrained to one another at their mid-portions. In any embodiment disclosed herein, the restraint 650 may be positioned at or near the intersection of the first, second, and / or third guide elements 610, 620, 630.

[0212] In some embodiments, restrainer 650 may be a ring configured to engage an outer portion along an intermediate portion or intersection of first, second, and / or third guide elements 610, 620, 630. Referring to FIG. 6F , some embodiments of restrainer 650 may have a ring portion 652 (which may be permanently closable or openable, like a carbiner, hook, or keychain), first and / or second pins 654, and / or first and second restraining bars 658. In other embodiments, restrainer 650 may be configured such that ring portion 652 matches restraining bars 652 so that a separate restraining bar is not required. Any embodiment of restrainer 650 may be rigid and made from metal, plastic, rubber, or a composite material.

[0213] 6G, some embodiments of the first pair of blades 618 may include a plurality of holes 660 configured to receive pins 654 of a restraint 650. The restraint 650 may be selectively openable such that the restraint 650 can be opened to advance around the first, second, and / or third pair of blades, and closeable to restrain the first, second, and / or third pair of blades.

[0214] Additionally, as shown in Figures 6M et seq., any embodiment of system 600 may further include caps 680, 682, 684 configured to be secured to the proximal ends of the first, second, and / or third pairs of blades. The caps may provide an interface for other tools and devices or robotic grippers, as shown in Figures 6S-6V. Additionally, some embodiments of the caps may be configured to limit relative movement of the first, second, and / or third pairs of blades.

[0215] In some embodiments, the system can include a cap extending from the proximal end of at least one of the first and second pair...

Claims

1. 1. A system for stabilizing spinal vertebrae through a skin incision, the system comprising: a first screw having a first screw head; a second screw having a second screw head; a third screw having a third screw head; a first tower having a distal portion, a proximal portion, and a bend between the distal portion and the proximal portion, the first tower configured to be removably coupled to the first screw at a distal end of the first tower; a second tower having a distal portion and a proximal portion, the second tower configured to be removably coupled to the second screw at a distal end of the second tower; a third tower having a distal portion, a proximal portion, and a bend between the distal portion and the proximal portion, the third tower configured to be removably coupled to the third screw at a distal end of the third tower; Equipped with the first tower is configured to removably couple with the first screw such that, when the first tower is coupled to the first screw, an axial centerline of a distal portion of the first tower is generally collinear with an axial centerline of the first screw; the second tower is configured to removably couple to the second screw such that, when the second tower is coupled to the second screw, an axial centerline of a distal portion of the second tower is generally collinear with an axial centerline of the second screw; the third tower is configured to removably couple with the third screw such that, when the third tower is coupled to the third screw, an axial centerline of a distal portion of the third tower is generally collinear with an axial centerline of the third screw; the proximal portion of the first tower extends at a non-zero acute angle away from an axial centerline of the distal portion of the first tower; the proximal portion of the third tower extends at a non-zero acute angle away from an axial centerline of the distal portion of the third tower; The system, wherein in an operational state, the first tower, the second tower, and the third tower are configured to intersect with one another.

2. 10. The system of claim 1, wherein in an operable state, the first tower, the second tower, and the third tower are configured to intersect at or adjacent to a patient's skin level.

3. 2. The system of claim 1, wherein in an operable state, the first tower, the second tower, and the third tower are configured to intersect while implanted at or adjacent to a patient's skin level, and a distance from the skin level to a proximal-most end of a distal portion of the first tower is less than or equal to 10% of a length of the distal portion of the first tower, and a distance from the skin level to a proximal-most end of a distal portion of the third tower is less than or equal to 10% of a length of the distal portion of the third tower.

4. 2. The system of claim 1, wherein the first tower has a fully enclosed opening therein, the opening being sized and configured to receive the second tower and the third tower therein, in an operative state, such that an outer wall of a portion of the first tower surrounds outer surfaces of a portion of the second tower and a portion of the third tower.

5. 2. The system of claim 1, wherein a proximal portion of the first tower is configured such that in an operational state of the system, the proximal portion of the first tower also extends away from an axial centerline of the proximal portion of the second tower at a non-zero acute angle such that the proximal portion of the first tower forms an acute angle with the proximal portion of the second tower, and wherein a proximal portion of the third tower is configured such that in an operational state of the system, the proximal portion of the third tower also extends away from an axial centerline of the proximal portion of the second tower at a non-zero acute angle such that the proximal portion of the third tower forms an acute angle with the proximal portion of the second tower.

6. 2. The system of claim 1, wherein a distal portion of the first tower is configured to extend away from an axial centerline of the distal portion of the second tower at a non-zero acute angle such that, in an operational state of the system, the distal portion of the first tower forms an acute angle with respect to the distal portion of the second tower, and a distal portion of the third tower is configured to extend away from an axial centerline of the distal portion of the second tower at a non-zero acute angle such that, in an operational state of the system, the distal portion of the third tower forms an acute angle with respect to the distal portion of the second tower.

7. 2. The system of claim 1, wherein the first tower is sized and configured such that, in an implanted state, a proximal portion of the first tower extends away from a skin incision in a first direction and a proximal portion of the third tower also extends away from the skin incision in the first direction.

8. The system of claim 1 , wherein in an operable state, a proximal portion of the third tower is positioned between a proximal portion of the first tower and a proximal portion of the second tower.

9. 2. The system of claim 1, wherein a proximal portion of the first tower is configured to be grasped by a surgeon such that the surgeon can apply a counter torque force to the first tower about at least an axial centerline of a distal portion of the first tower.

10. 2. The system of claim 1, wherein in an operable state, the system is configured such that moving a proximal portion of the first tower toward a proximal portion of the third tower creates a compressive force on at least a first vertebra in which the first screw is implanted relative to a third vertebra in which the third screw is implanted.

11. The system of claim 1 , wherein the system is configured such that the first screw, the second screw, and the third screw are implanted through a same skin incision.

12. 2. The system of claim 1, wherein the first tower has a pair of hooks configured to receive a pair of wires used during an implantation procedure, the hooks configured to provide a surface relative to which the third tower can rotate.

13. The system of claim 1 , wherein a distal portion of the first tower and / or the third tower is open along one side thereof and is not completely enclosed.

14. The system of claim 1 , wherein at least a distal portion of the first tower and a distal portion of the third tower have an adjustable length.

15. 10. The system of claim 1, wherein a proximal portion of the first tower and a proximal portion of the third tower have a planar shape configured to mate with graspers, coupling mechanisms, and other components of a surgical robotic system.

16. The system of claim 1, further comprising a rigid connecting element, a first receiving element coupled to the first screw head, a second receiving element coupled to the second screw head, and a third receiving element coupled to the third screw head, wherein the first receiving element, the second receiving element, and the third receiving element are configured to operably receive the connecting elements, and wherein, in an operative state, the connecting elements extend between the first receiving element, the second receiving element, and the third receiving element when the first screw, the second screw, and the third screw are embedded in the first vertebra, the second vertebra, and the third vertebra, respectively.

17. 1. A system for stabilizing spinal vertebrae through a skin incision, the system comprising: a first screw having a first screw head; a second screw having a second screw head; a third screw having a third screw head; a first tower having a distal portion and a proximal portion, the first tower configured to be removably coupled to the first screw at a distal end of the first tower; a second tower having a distal portion and a proximal portion, the second tower configured to be removably coupled to the second screw at a distal end of the second tower; a third tower having a distal portion and a proximal portion, the third tower configured to be removably coupled to the third screw at a distal end of the third tower; Equipped with the first tower is configured to removably couple with the first screw such that, when the first tower is coupled to the first screw, an axial centerline of a distal portion of the first tower is generally collinear with an axial centerline of the first screw; the second tower is configured to removably couple to the second screw such that, when the second tower is coupled to the second screw, an axial centerline of a distal portion of the second tower is generally collinear with an axial centerline of the second screw; the third tower is configured to removably couple with the third screw such that, when the third tower is coupled to the third screw, an axial centerline of a distal portion of the third tower is generally collinear with an axial centerline of the third screw; the proximal portion of the first tower extends at a non-zero acute angle away from an axial centerline of the distal portion of the first tower; the proximal portion of the third tower extends at a non-zero acute angle away from an axial centerline of the distal portion of the third tower; In an operable state, a proximal portion of the first tower extends in a first direction away from the second tower; In an operable state, a proximal portion of the third tower also extends in the first direction away from the second tower.

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