Stabilization of surgical access ports

Abstract

To provide a surgical system.SOLUTION: A system comprises: an access port configured for percutaneous insertion into a patient to define a channel to a surgical site; an extension tower configured to couple an implant into the spine of the patient; and a linkage having a first connection to receive the access port, a second connection to receive the extension tower, and a plurality of rigid segments extending between the first connection and the second connection. The linkage can selectively lock a position of the access port relative to the extension tower.SELECTED DRAWING: Figure 15

Description

Technical Field

[0001] The present disclosure generally relates to surgical instruments, systems, and methods, and more particularly to instruments, systems, and methods for stabilizing surgical access ports that can be used in various procedures such as orthopedic or neurosurgical procedures, for example spinal fixation.

Background Art

[0002] Surgical procedures are used to treat and manage a wide range of diseases, illnesses, and injuries. In surgical procedures, it is often necessary to access internal tissues through open or minimally invasive surgical procedures. The term "minimally invasive" refers to any type of minimally invasive surgical procedure such as endoscopic surgery, laparoscopic surgery, arthroscopic surgery, natural opening transluminal endoscopic surgery, and natural opening transesophageal surgery. Minimally invasive surgery can have a number of advantages over traditional open surgical procedures, such as less trauma, faster recovery, less risk of infection, and smaller scars.

[0003] Regardless of whether it is minimally invasive or not, in many surgical procedures, it may be desirable to form a working channel within the patient to provide access to the surgical site within the patient. One such example is an orthopedic or neurological surgical procedure, for example spinal fixation, where it may be desirable to form a working channel through the patient's tissue to access these vertebrae and / or the intervertebral disc disposed between adjacent vertebrae.

[0004] A variety of surgical access devices are known, including various devices that are fixed to the surgical table on which the patient is positioned or devices that penetrate tissue without being fixed to any other structure. In such configurations, the support of the access device may be inadequate, or the access device may move undesirably relative to the patient if the patient moves relative to the operating table. For example, Patent Document 1 discloses a pioneering device, which is an example of an access device. [Patent Document 1] U.S. Patent Application Publication No. 2014 / 275793 [Overview of the project] [Problems that the invention aims to solve]

[0005] Therefore, there is a need for improved access port stabilization devices, systems, and methods that can streamline the instruments and methods used in various surgical procedures. [Means for solving the problem]

[0006] According to one aspect of the present invention, the surgical access system described in claim 1 is provided.

[0007] Optional further features of the surgical access system are defined in the dependent claims.

[0008] According to another aspect of the present invention, the surgical method described in claim 20 is provided.

[0009] Optional further features of the surgical method are defined in the dependent claims.

[0010] According to another aspect of the present invention, the surgical method described in claim 31 is provided.

[0011] Optional further features of the surgical method are defined in the dependent claims.

[0012] According to the present invention, improved ipsilateral access port stabilization can be provided via an access port configured to connect to an anchor, such as a bone screw implanted in the patient, near the surgical site, for example, at an ipsilateral position. The access port may be connected to the anchor via a linkage mechanism and may have various degrees of freedom to adjust its position relative to the anchor and the patient. Furthermore, the access port may be configured to be selectively locked in a desired position to enable stable access to the surgical site. The systems, apparatus, and methods described herein can be used in a variety of surgical procedures, but they may be particularly useful in a variety of orthopedic or neurosurgical procedures, such as spinal surgery.

[0013] In one embodiment, a surgical system is provided which may include an access port configured to be inserted percutaneously into a patient to define a channel to a surgical site, and an anchor configured to be inserted into the patient's bone. Furthermore, the access port may be connected to the anchor such that the longitudinal axis of the access port and the longitudinal axis of the anchor are non-coaxial.

[0014] The apparatus and methods described herein may have many additional features and / or variations, all of which are included within the scope of this disclosure. In some embodiments, for example, the access port may be configured to connect to an anchor on the same side, i.e., the same side, of the patient's body. For example, in the context of spinal orthopedic procedures, this may mean that the access port may be connected to an anchor located on the same side of the patient's vertebrae, spine, or midline as the patient. This is in contrast to other techniques, such as those described above, which connect the access port to an anchor located on the opposite side, i.e., the opposite side, of the patient's body. In some embodiments, the access port may be configured to connect to an anchor on the opposite side of the patient's body.

[0015] The position of the access port relative to the anchor can be selectively locked to maintain the access port in a desired position relative to the anchor. This can be useful, for example, to maintain the access port aligned with a desired surgical site. Various locking mechanisms are possible, as described below.

[0016] Optionally, the access port may be connected to an anchor by a linkage mechanism. The linkage mechanism may take various forms. Optionally, the linkage mechanism may be a single shaft protruding from the access port. Optionally, the linkage mechanism may be a multi-component structure that is adjustable and selectively lockable.

[0017] Optionally, the link mechanism may be deformable. For example, the link mechanism may optionally be formed from a metal that is deformable under force (i.e., operation by the user). Optionally, the link mechanism may be selectively lockable so that it is not further deformable. For example, the link mechanism may be selectively locked by applying electricity to it, or it may be selectively locked by an adjustment screw or other mechanical locking mechanism.

[0018] The length of the access port can be optionally adjusted. For example, the length of the access port can be adjusted by telescoping the inner sleeve of the access port relative to the outer sleeve of the access port. This allows the access port to have various heights and to extend to various distances both into the patient's body and away from the patient's skin surface.

[0019] Optionally, a linkage mechanism may form part of the outer periphery of the access port and be pivotable relative to the access port. Optionally, the access port may include a deformable portion. Optionally, the deformable portion may be connected to an anchor. Furthermore, the deformable portion may be optionally connected to an anchor below the multi-axis head of the anchor. Many additional components may be included in and connected to the access port in various ways. For example, a nerve shield or other soft tissue retractor may be optionally connected to the deformable portion of the access port.

[0020] Optionally, the anchor may include opposing extensions extending proximal to the distal portion, and an access port may be connected to the anchor by compressing a portion of the access port between the opposing extensions. Optionally, the system may further include clamps configured to compress the opposing extensions toward each other.

[0021] The clamp can take various forms. For example, the clamp can optionally define an inner lumen configured to receive opposing extensions so that the clamp slides along the length of the opposing extensions. Optionally, the access port may include a shaft extending laterally with respect to the longitudinal axis of the access port and a split ball positioned between the opposing extensions around the shaft. The clamp can compress the extensions against the split ball and shaft, thereby locking the position of the access port relative to the anchor. Optionally, the clamp may be connected to the split ball and pivoted relative to the split ball to compress the opposing extensions against the split ball.

[0022] In another aspect, a surgical method is provided that may include inserting an anchor into a patient's bone, connecting an access port to the anchor, and positioning the access port relative to the anchor on the same side of the patient's body such that the longitudinal axis of the access port and the longitudinal axis of the anchor are non-coaxial. Additionally, the access port can define a channel to the surgical site.

[0023] Similar to the system described above, numerous variations and additional features are possible. For example, the anchor can optionally be inserted into a patient's vertebra during orthopedic spine procedures.

[0024] Furthermore, the method can optionally further include locking the position of the access port relative to the anchor. Optionally, positioning the access port can include deforming a linkage mechanism that extends between the access port and the anchor.

[0025] Optionally, the method can include applying electricity to the linkage mechanism to lock the position of the access port relative to the anchor. Optionally, the method can include actuating an adjustment screw to lock the position of the access port relative to the anchor. Optionally, the method can further include adjusting the length of the access port by telescopically extending and retracting an inner sleeve of the access port relative to an outer sleeve of the access port.

[0026] Optionally, the method can further include deforming a portion of the access port. Additionally, connecting the access port to the anchor can optionally include connecting the anchor to a deformable portion of the access port. Still further, the method can optionally further include connecting a nerve shield or other soft tissue dissector to the deformable portion of the access port.

[0027] Optionally, connecting the access port to the anchor may include compressing a portion of the access port between opposing extensions of the anchor that extend proximally away from the distal portion of the anchor.

[0028] In another aspect, the surgical method not only includes introducing the access port and the anchor into the patient's body with the longitudinal axis of the access port and the longitudinal axis of the anchor being coaxial, but also includes adjusting the position of the access port relative to the anchor such that the longitudinal axis of the access port and the longitudinal axis of the anchor are non - coaxial and the access port and the anchor are on the same side of the patient's body.

[0029] Optionally, the anchor may be inserted into the patient's vertebra, or the method may include inserting the anchor into different parts of the patient's body. Optionally, the access port and the anchor may be coupled to a driver for introduction into the patient's body. The driver can optionally maintain component alignment and rotate the anchor for implanting the anchor into the patient's bone. The method can further optionally include removing the driver before adjusting the position of the access port relative to the anchor, for example, to freely move the access port relative to the anchor when the driver is maintaining alignment between the access port and the anchor. [[ID=I0]]

[0030] Optionally, the method can further include inserting a second anchor into the patient's body through the access port and readjusting the position of the access port relative to the anchor such that the longitudinal axis of the access port and the longitudinal axis of the anchor are coaxial. The method can further include inserting a multi - axis receiving head into the access port and coupling the receiving head to the anchor, coupling the anchor and the second anchor to a spinal fixation element, and removing the access port. Optionally, the method may further include locking the position of the access port relative to the anchor after adjusting the position of the access port relative to the anchor.

[0031] Any of the features or modifications described above can be applied in many different combinations to any particular aspect or embodiment of this disclosure. There is no explicit description of any specific combination, but this is simply to avoid redundancy in this abstract. [Brief explanation of the drawing]

[0032] [Figure 1] This is a schematic diagram of one embodiment of a surgical system as taught herein. [Figure 2] This is a front perspective view of one embodiment of a surgical system including a deformable link mechanism for adjusting the position of an access port. [Figure 3] Figure 2 is a side perspective view of the surgical system. [Figure 4] This is a front perspective view of one embodiment of a surgical system, which includes opposing extensions connected to anchors that selectively compress to lock the position of an access port. [Figure 5] Figure 4 is a partially transparent detail view of the system. [Figure 6] Figure 4 is a top perspective view of the system's access port. [Figure 7] This is a front perspective view of one embodiment of a surgical system including a ratchet clamp. [Figure 8] Figure 7 is a rear perspective view of the system after the clamping device has been removed. [Figure 9] This is a front perspective view of one embodiment of a surgical system including a pivoting lever clamp. [Figure 10] Figure 9 is a detailed diagram of the system. [Figure 11] This is a side view of one embodiment of a surgical system including a sliding ring clamp. [Figure 12A] Figure 11 is a front perspective view of the sliding ring clamp. [Figure 12B] Figure 11 is a front view of the sliding ring clamp. [Figure 12C] Figure 11 is a side view of the sliding ring clamp. [Figure 13A] This is a side view of one embodiment of a surgical system including an adjustable link mechanism in the first configuration. [Figure 13B] This is a side view of the system shown in Figure 13A, which is part of the second configuration. [Figure 14] This is a top perspective view of one embodiment of a surgical system including an adjustable linkage mechanism. [Figure 15] This is a top perspective view of one embodiment of a surgical system including an adjustable linkage mechanism. [Figure 16] Figure 15 is a top view of the system. [Figure 17] Figure 15 is a perspective view of the anchor. [Figure 18] Figure 15 is a perspective view of the access port. [Figure 19A] This is a perspective view of one embodiment of a telescopic access port. [Figure 19B] Figure 19A is a perspective cross-sectional view of a telescopic access port. [Figure 19C] Figure 19A is an alternative perspective cross-sectional view of the telescopic access port. [Figure 20A] This is a perspective view of one embodiment of an access port connected to an anchor. [Figure 20B] This is an alternative perspective view of one embodiment of an access port connected to an anchor. [Figure 21] This is a perspective view of one embodiment of an access port configured to be connected to an anchor and to be selectively locked to the anchor. [Figure 22] Figure 21 is a perspective view of the access port and anchor. [Figure 23A] This is a front view of one embodiment of an access port, anchor, and driver. [Figure 23B] This is a side view of the access port and anchor in Figure 23A, which is part of the first configuration. [Figure 23C] This is a side view of the access port and anchor in Figure 23A, which is part of the second configuration. [Figure 23D]Figure 23A is a side view of the access port and anchor, showing that the receiving member is introduced through the access port. [Figure 23E] This is a side view of the receiving member shown in Figure 23D, which is connected to the anchor. [Figure 23F] Figure 23E is a side view of the access port, anchor, and receiving member adjacent to the second anchor. [Figure 23G] Figure 23F is a side view of the anchor receiving member and the spinal fixation element inserted through the adjacent anchor. [Figure 23H] This is an alternative diagram of the spinal fixation elements in Figure 23G. [Figure 23I] This is a side view of the anchor in Figure 23H after the access port and adjacent screw extension have been removed. [Figure 24A] This is a side perspective view of one embodiment of an access port having a deformable portion. [Figure 24B] Figure 24A is a front perspective view of the access port. [Figure 25] This is a front view of the access port of Figure 24A, which receives a light and / or camera. [Figure 26] This is a bottom perspective view of the access port shown in Figure 24A, connected to the anchor. [Figure 27] Figure 26 is a detailed diagram of the link mechanism for connecting the access port to the anchor. [Figure 28A] Figure 25 is a side view of the access port and light and / or camera connected to the anchor in the first configuration. [Figure 28B] Figure 28A shows a side view of the access port and the light and / or camera in the second configuration. [Figure 29] This is a bottom perspective view of the access port shown in Figure 24A, connected to the nerve shield. [Figure 30] Figure 29 is a detailed view of the nerve shield. [Figure 31A] This is a front view of the access port in Figure 24A before it is connected to the nerve shield. [Figure 31B]This is a front view of the access port in Figure 31A after it has been connected to the nerve shield. [Figure 31C] This is a front view of the access port in Figure 31B after the nerve shield has been advanced. [Figure 31D] This is a front view of the access port in Figure 31C after the nerve shield has been retracted. [Figure 32] This is a schematic diagram of a selectively deformable link mechanism between the anchor and the access port. [Modes for carrying out the invention]

[0033] Specific exemplary embodiments will now be described so that the structure, function, manufacturing and use principles of the apparatus, systems and methods disclosed herein can be understood comprehensively. One or more examples of these embodiments are shown in the accompanying drawings. Those skilled in the art will understand that the apparatus, systems and methods described in detail herein and shown in the accompanying drawings are non-limiting exemplary embodiments. Features illustrated or described in relation to one exemplary embodiment can be combined with features of other embodiments. Such modifications and variations are included within the scope of this disclosure.

[0034] Furthermore, to the extent that linear or circular dimensions are used in the description of the disclosed apparatus and method, such dimensions are not intended to limit the types of shapes that may be used with such apparatus and method. Those skilled in the art will recognize that dimensions equivalent to such linear and circular dimensions can be readily determined for any geometric shape. Furthermore, in this disclosure, similarly numbered components of the embodiments generally have similar characteristics. Moreover, the dimensions and shape of the apparatus, and its components, may depend at least on the anatomical form of the patient in whom the apparatus will be used, the dimensions and shape of the components in which the apparatus will be used, and the methods and procedures in which the apparatus will be used.

[0035] Surgical devices, systems, and methods described herein provide stabilization of an access port via an access port configured to be connected to an anchor, such as a bone screw, which can be implanted near the surgical site of the patient, such as ipsilateral stabilization to a point on the same side of the patient's body or contralateral stabilization to a point on the opposite side of the patient's body. The access port may be connected to the anchor in a manner that provides various degrees of freedom for adjusting its position relative to the anchor and the patient. Furthermore, the access port may be configured to be selectively locked in a desired position to enable stable access to the surgical site. The devices, systems, and methods described herein can be used in a variety of surgical procedures, but they may be particularly useful in a variety of orthopedic or neurosurgical procedures, such as spinal surgery.

[0036] Figure 1 shows an exemplary surgical system 100 as taught herein, but it will be understood that components of such a system may be used in various other applications, either instead or in addition. Further details relating to a system similar to that shown in Figure 1 can be found in U.S. Patent Application Publication No. 2017 / 0156814, filed February 21, 2017, titled "Multi-Shield Spinal Access System," which is incorporated herein by reference in its entirety. System 100 can be used in a variety of surgical procedures, including spinal surgeries such as microsurgical osteotomy, spinal decompression, and spinal fusion. Generally, system 100 may include any one or more of the pedicle column or other anchors 102 and access ports 104. Other possible components not shown herein may include tissue retractors, cameras or visualization systems, and various other surgical instruments. The access port 104 may have an adjustable length, for example, as described in U.S. Patent Application No. 15 / 786,858, filed concurrently with this specification, titled "DEVICES AND METHODS FOR PROVIDING SURGICAL ACCESS". The access port 104 can be used with a surgical visualization system, for example, as described in U.S. Patent Application No. 15 / 692,845, filed August 31, 2017, titled "SURGICAL VISUALIZATION SYSTEMS AND RELATED METHODS". The access port 104 can be used with a nerve retractor or nerve shield, for example, as described in U.S. Patent Application No. 15 / 786,846, filed concurrently with this specification, titled "DEVICES AND METHODS FOR SURGICAL RETRACTION". Each of the above applications is incorporated herein by reference in its entirety.

[0037] An exemplary method using the system in Figure 1 involves the following steps, which are performed in any of a variety of sequences: a) making an incision in the patient's skin; b) percutaneously inserting a substantially tubular access device (such as a tube or a retractor with multiple slots) through the incision, wherein the access device has a length adapted to extend from the incision to the boundary between sensitive and non-sensitive tissues of the patient's spine (e.g., superior articular process (SAP) or vertebral arch); c) stabilizing the access device against an anchor (e.g., a pedicle anchor); d) inserting an optical visualization device integrated with the access device; e) inserting a portion of the superior articular process. The procedure may include one or more of the following steps: f) a step of excising tissue and / or performing decompression surgery by microsurgery; g) a step of inserting or deploying a tissue retractor via or from an access device such that the distal end of the tissue retractor extends to the intervertebral disc, wherein the retractor has an outer surface; g) a step of shielding the nerve root by bringing the outer surface of the retractor into contact with the nerve root; h) a step of decompressing all tissues thought to be causing the nerve damage by microsurgery; i) a step of excising intervertebral disc material, including the removal of cartilaginous material from the vertebral endplate; j) a step of inserting an intervertebral device; and k) a step of deploying a stabilization mechanism to stabilize the intervertebral portion.

[0038] As shown in Figure 1, stabilization of the access port or device 104 can be achieved by connecting it to an anchor 102. In some embodiments, this can be achieved through a link mechanism 106. In further embodiments, the system may be configured to selectively lock the position of the access port 104 relative to the anchor 102 so that the lumen, channel, or passage 108 through the access port is aligned with the desired surgical site. In some surgical procedures, the access port can be attached to a contralateral anatomical anchor point (e.g., a pedicle screw extension tab or tower) on the patient's body, opposite the access port. For example, in spinal surgery, the anchor may be located opposite the access port with the spine or the patient's midline in between. Exemplary connectors for such stabilization are described herein and disclosed in U.S. Patent Application No. 15 / 786,923, filed concurrently with this specification and incorporated herein by reference in whole. In some cases, it may be desirable to stabilize the access port against an anchor located on the same side of the patient's body (ipsilateral). In system 100 of Figure 1, the access port 104 is stabilized against anchor 102, and both components are located on the same side of the patient's spine 110 or midline axis ML (ipsilateral). In other configurations, the access port 104 may be stabilized against a contralateral anchor 102 or other structure. Figures 2 to 32 illustrate various systems, devices, and methods for access port stabilization.

[0039] In some embodiments, it may be advantageous to use an access device or system that is fixed to the patient's body, as opposed to an external structure such as an operating table. For example, fixation to the patient's body can offer advantages by maintaining the relative position between the access device and the patient even if the patient moves during the procedure. Furthermore, in other embodiments, it may be advantageous to fix all devices to the same side of the patient's body, for example, one side or the same side of the patient's spine. In some procedures, this can reduce the complexity of the instruments used in the surgical procedure and allow parallel operations to proceed in parallel on both sides of the patient's spine or midline axis. Furthermore, this can reduce the number of devices or steps required to perform the procedure.

[0040] Figures 2 and 3 show one embodiment of the system 200, which includes an access port 202 connected to an extension tower 204 by a deformable link mechanism 206. The access port or device 202 may have a substantially cylindrical shape with an inner lumen 208 through which any of a variety of surgical instruments can pass. The access port 202 may have any of a variety of sizes, including the inner lumen diameter, length, and sidewall thickness, based on the intended use (e.g., the size of the surgical site accessed through the port, its position relative to the patient's body, etc.). Furthermore, the access port 202 may be formed from any of a variety of materials, including metals such as stainless steel and titanium, as well as various polymers.

[0041] The extension tower 204 shown in Figures 2 and 3 may be configured to connect, for example, to a bone screw or anchor embedded in the patient's spine 210 (anchor not shown). For example, the extension tower 204 may be configured to connect to the proximal end of a uniaxial or multiaxial receiving head connected to the proximal portion of a bone anchor. Although not shown in Figures 2 and 3, such bone anchor assemblies are known in the art and are described, for example, in U.S. Patent Application No. 15 / 208,872, filed July 13, 2016, titled "BONE ANCHOR ASSEMBLIES AND RELATED INSTRUMENTATION," which is incorporated herein by reference in its entirety. Furthermore, the extension tower 204 may be any of a variety of towers known in the art, including, for example, one of the towers described in U.S. Patent No. 7,179,261, titled "PERCUTANEOUS ACCESS DEVICES AND BONE ANCHOR ASSEMBLIES," which is incorporated herein by reference in its entirety.

[0042] The access port 202 may be connected to the extension tower 204 by a deformable link mechanism 206 which may include a length of metal or other deformable material that is rigid enough to maintain its position without force applied by a user. Furthermore, the link mechanism 206 may be connected to the extension tower 204 via a sleeve 212 positioned around the outer circumference of the tower. The sleeve 212 may include a cam lever 214 or other locking mechanism that can selectively lock the sleeve to the extension tower 204. This allows the sleeve to be positioned at any of several different heights relative to the extension tower 204. In certain embodiments, the sleeve 212 may also be configured to selectively lock rotation around the extension tower 204 by the actuation of the cam lever 214.

[0043] The link mechanism 206 can be connected at each end to one of the access port 202 and the extension tower 204 via any of the various clamping mechanisms known in the art. For example, in the illustrated embodiment, a clamping assembly 216 including a bolt and several nuts is used to connect one end of the link mechanism 206 to an extension post 218 extending from the side wall of the access port 202. The opposite end of the link mechanism 206 can be connected to a sleeve 212 using a similar assembly 302 including a bolt and thumbscrew. These mechanisms can provide a selective locking capability similar to the cam lever 214, allowing adjustment of the relative positions of the various components before fastening any of the cam lever 214, the clamping assembly 216, and the thumbscrew assembly 302. After each of these mechanisms is fastened, it may be necessary to apply enough force to deform the link mechanism 206 to adjust the position of the access port 202 relative to the extension tower 204.

[0044] As shown in Figure 2, the access port 202 may be positioned such that its longitudinal axis L1 is non-coaxial with the longitudinal axis L2 of the extension tower 204, or with the longitudinal axis of any anchor to which the extension tower is connected. For example, axis L1 may be offset with respect to axis L2 and / or angled obliquely. As shown in Figure 2, for example, the access port 202 can provide access to a surgical site such as an intervertebral disc space or vertebra adjacent to a vertebra to which the extension tower 204 is connected ipsilaterally (e.g., on the same side with respect to the patient's spine or midline axis ML).

[0045] Figures 4 to 12C illustrate embodiments of a system that utilizes extension tabs extending proximal to the distal portion of an anchor to capture and selectively lock the position of an access port. As shown in Figures 4 to 6, a first embodiment of such a system 400 may include an access port 402 connected to an anchor assembly 404 and a locking device 406 (e.g., forceps) configured to selectively lock the position of the access port relative to the anchor assembly. In the illustrated embodiment, the anchor assembly 404 is a multi-axis pedicle screw including not only a shank 408 configured to be inserted into the bone of a patient, but also a receiving head 410 connected to the proximal portion of the shank. The receiving head 410 may include extension tabs 412a, 412b extending proximal from opposing arms of the receiving head. The extension tabs 412a, 412b may be integrally formed with the receiving head 410, or, in other embodiments, may be connected to the receiving head 410 via any of a variety of mounting mechanisms.

[0046] The access port 402 may include a shaft 414 or other fitting mechanism which is formed integrally with or connected to the access port 402 and extends laterally or radially away from the access port 402, such that the longitudinal axis L3 of the access port and the longitudinal axis L4 of the shaft intersect or are oblique to each other. The shaft 414 may be formed integrally with the access port 402 or connected to the access port 402 via a clamp or other connecting mechanism. In some embodiments, the shaft 414 may have a series of repeating surface features 418, such as ridges or ribs, threaded along its length to position a split ball 416 or other locking element.

[0047] The split ball 416 is positioned around the shaft 414 and can be placed between the extension tabs 412a and 412b as shown in the detailed views of Figures 5 and 6. The relief slot 502 formed within the ball can be adjusted along the length of the shaft 414, for example by translational sliding movement or rotation along the threads 418 of the shaft 414. The split ball 416 can adjust its orientation relative to the extension tabs 412a and 412b by performing multiaxial movements, including sliding and rotating along the length of the extension tabs, in the absence of pressure applied to the tabs by, for example, the locking device 406. Once the desired position of the ball 416 relative to the shaft 414 and the extension tabs 412a and 412b is achieved, the locking device 406 is activated to bias the extension tabs toward each other, thereby clamping the split ball between the extension tabs. More specifically, in the illustrated embodiment, user action of moving the locking device handles 420a, 420b toward each other moves the distal arms 422a, 422b toward each other, allowing them to slide along the length of the extension tabs 412a, 412b. This movement of the distal arms 422a, 422b biases the extension tabs 412a, 412b toward each other, thereby applying a compressive force to the split ball 416 positioned between them. This compressive force prevents multi-axial movement of the split ball 416 relative to the extension tabs 412a, 412b, thereby locking the position of the ball relative to the extension tabs. Furthermore, the compressive force biases the opposing portions of the split ball separated by the relief slot 502 toward each other, thereby clamping the ball to the shaft 414 and preventing relative movement between these components. As a result, the operation of the locking device allows for selective locking of the position and orientation of the access port 402 relative to the anchor assembly 404.

[0048] Similar to the preceding embodiments described above, the extension of a shaft 414 or other fitting mechanism horizontally, radially, or laterally away from the access port 402, in combination with a split ball 416 positioned along its length, may allow the access port 402 to be positioned and selectively locked such that the longitudinal axis L3 of the access port and the longitudinal axis L5 of the anchor assembly 404 are non-coaxial. For example, the access port 402 may be positioned to access a surgical site adjacent to the anchor assembly 404 on the same side of the patient's body.

[0049] A wide variety of mechanisms exist that can achieve selective clamping of extension tabs 412a, 412b to lock the position of the access port 402 relative to the anchor assembly 404. In the embodiments shown in Figures 4 and 5, for example, the locking device 406 can make direct contact with the extension tabs 412a, 412b via distal arms 422a, 422b. In such embodiments, releasing the handles 420a, 420b releases the pressure applied to the extension tabs 412a, 412b, thereby unlocking the split ball 416 and the access port 402. However, in another embodiment shown in Figures 7 and 8, the locking device 702 may include a ratchet clamp 704 that can maintain the position of the distal arms 706a, 706b even if the user releases the device handles 708a, 708b, thereby maintaining the position lock of the access port 402 relative to the anchor assembly 404. In fact, the instrument handles 708a and 708b are configured to separate from the ratchet clamp 704 after operation, which can result in a more streamlined or lower profile assembly, including the distal arms 706a and 706b and the ratchet clamp 704, as shown in Figure 8.

[0050] The ratchet clamp 704 may include a ratchet track 710 with a plurality of teeth 802 formed on its upper surface, and a chock 712 configured to engage with the teeth to move distal arms 706a, 706b toward each other but resist movement of the arms toward each other in the opposite direction. A release device may be included to disengage the chock 712 from the ratchet track 710, thereby enabling the unlocking of the access port 402 toward the anchor assembly 404.

[0051] In another embodiment shown in Figures 9 and 10, the clamp 902 can replace the locking devices 406 and 702 described above. The clamp 902 includes a body 904 pivotably connected to the proximal portion 602 of the split ball 416, the body 904 being rotatable about axis R1 relative to the split ball 416. A fork including a pair of arms 1002a, 1002b may extend from the body 904 and be configured to contact and slide along the outer surfaces of the extension tabs 412a, 412b as the clamp body 904 and arms rotate toward the extension tabs. The arms 1002a, 1002b can apply compressive force to the opposing extension tabs 412a, 412b in the same manner as the distal arms 422a, 422b and 706a, 706b described above, thereby locking the position of the access port 402 relative to the anchor assembly 404. Here too, this locking is achieved by biasing the extension tabs 412a and 412b toward each other, thereby applying a compressive force to the split ball 416 and preventing relative movement between the split ball and the extension tabs. This compression also compresses the opposing portions of the split ball 416 into the shaft 414, thereby preventing relative movement between the split ball and the shaft. These dual locking functions can effectively prevent relative movement between the access port 402 and the anchor assembly 404.

[0052] The handle 906 extends from the body 904 and can provide a levering action to the user when the lock is activated by rotating the body 904 and arms 1002a, 1002b toward the extension tabs 412a, 412b. In some embodiments, the handle 906 may be configured to be removably connected to the body 904 by screws or by other means, so that the handle can be removed after activation once the position of the access port 402 is locked, allowing for a more streamlined or lower profile assembly.

[0053] In yet another embodiment shown in Figures 11 to 12C, a ring lock 1102 can be used instead of the locking device described above. The ring lock 1102 can be slidably positioned on the extension tabs 412a, 412b so as to be able to translate along the length of the extension tabs 412a, 412b. The ring lock 1102 may include a closing proximal portion 1202 that defines an inner lumen 1208 through which the extension tabs 412a, 412b can extend. The ring lock 1102 may further include a pair of opposing distally extending arms 1204a, 1204b that, when the ring lock is translated to a position around the extension tabs 412a, 412b and the split ball 416, define a U-shaped recess 1206 that can receive a shaft 414.

[0054] In some embodiments, the diameter of the inner lumen 1208 may be smaller than the stationary outer diameter of the extension tabs 412a, 412b so that the ring lock 1102 applies a compressive force to the extension tabs when translated along the extension tabs. In other embodiments, the inner diameter of the ring lock 1102 may be tapered so that a compressive force is applied by the distal arms 1204a, 1204b but not to the proximal portion 1202. In yet another embodiment, the ring lock 1102 may include opposing spring arms 1210a, 1210b which can be configured to apply a compressive force to the extension tabs 412a, 412b so that the selective locking described above can be enabled when the ring lock 1102 slides to a position on the extension tabs 412a, 412b and the split ball 416. These spring arms 1210a, 1210b can be used instead of, or in addition to, different inner lumen diameters to apply various compressive forces to the extension tabs 412a, 412b and the split ball 416.

[0055] Figures 13A to 18 show yet another example of a link or mating mechanism that can connect an access port to an anchor to define a channel to a surgical site, such as a surgical site located co-located with the anchor on the patient's body. More specifically, these figures show various embodiments of a selectively lockable and multi-axially adjustable link mechanism. For example, Figures 13A and 13B show one embodiment of a multi-axially adjustable link mechanism 1302 that is selectively lockable via a bolt and a thumb screw 1304 that compresses opposing body portions of the link mechanism together, thereby compressing a first connection at one end of the link mechanism against an access port 1306, and a second connection at the opposite end of the link mechanism against an extension tower 1308 that can be connected to, for example, a pedicle screw or other anchor (not shown). By changing the tightness of the thumb screw 1304, the movement of the access port relative to the extension tower 1308 can be selectively permitted. Furthermore, since the link mechanism 1302 is multi-axially adjustable with respect to both the access port 1306 and the tower 1308, the access port can be adjusted multi-axially with respect to the tower, as shown in Figures 13A and 13B in various relative positions of these components.

[0056] While a thumb screw 1304 is shown in Figures 13A and 13B, various other locking mechanisms may be employed to selectively allow or prevent relative movement between the access port 1306 and the tower 1308. For example, Figure 14 shows one embodiment in which a cam 1404 is used to selectively lock the position of the access port 1306 relative to the extension tower 1308 by selectively compressing opposing portions of link mechanisms 1402a, 1402b. Furthermore, in some embodiments, the link mechanism may include multiple rigid segments, as shown in Figures 15 and 16. For example, link mechanism 1502 may include a first segment 1504 connected to the access port 1306 and a second segment 1506 connected to the extension tower 1308. The first and second segments 1504, 1506 may be pivotably connected to each other in a pivot joint 1508. Such configurations can provide greater flexibility and reach in positioning the access port 1306 relative to the extension tower 1308. For example, the link mechanism 1502 in Figure 15 may be positioned to extend to or around other fixtures located between the access port 1306 and the extension tower 1308. Any number of link mechanism segments may be included, each segment of which may receive a locking mechanism such as a thumb screw, a cam lock, or other locking mechanism that selectively locks the movement of a component connected thereto by compressing opposing portions 1504a, 1504b (i.e., the first pair of segment portions 1504a, 1504b) or opposing portions 1506a, 1506b (i.e., the second pair of segment portions 1506a, 1506b) together. In the illustrated embodiment, for example, the first and second segments 1504, 1506 include through holes 1510, 1512 for receiving a thumb screw or cam lock mechanism, as shown in Figures 13A to 14.

[0057] Embodiments shown in Figures 13A to 16 can be connected to the access port 1306 and extension tower 1308 using, for example, split ring clamps. For example, the link mechanism 1402 in Figure 14 may include a first split ring clamp 1406 positioned around the access port 1306 and a second split ring clamp 1408 positioned around the extension tower 1308. The split ring clamps 1406 and 1408 may include a spherical inner surface that can interface with the spherical outer surface of the bushing ring connected to the access port 1304 and extension tower 1308. For example, Figure 17 shows an embodiment of a bushing ring 1702 connected to the extension tower 1308, and Figure 18 shows an embodiment of a bushing ring 1802 connected to the access port 1306. The bushing rings 1702 and 1802 may include outer spherical surfaces and relief slots 1704 and 1804 that allow the bushing rings to slide along and / or rotate around the extension tower 1308 and access port 1306 when no clamping force is applied to them. The ability to selectively move the bushing rings 1702 and 1802 relative to the extension tower 1308 and access port 1306 may, for example, allow for adjustment of the height of the access port relative to the extension tower. However, in other embodiments, the bushing rings 1702 and 1802 may be formed integrally with the extension tower 1308 and access port 1306 so that relative movement between these components is not possible. In such embodiments, the relief slots 1704 and 1804 may be eliminated.

[0058] The interface between the inner and outer spherical surfaces of the split ring clamps 1406, 1408 and the bushing rings 1702, 1802 allows for multi-axial movement between components in the absence of compressive force. For example, when a compressive force is applied to the split ring clamps 1406, 1408 via a thumb screw 1304 or cam lock 1404, the split ring clamps 1406, 1408 compress around the bushing rings 1702, 1802, thereby compressing the bushing rings around the access port 1306 and extension tower 1308, preventing relative movement between these components. This effectively locks the entire link mechanism, preventing relative movement between the access port 1306 and extension tower 1308. In the multi-component link mechanism 1502 of Figures 15 and 16, it may be possible to individually and selectively lock each segment 1504, 1506 of the link mechanism.

[0059] In some embodiments, the height of the access port may be adjustable so that the access port can extend from various heights above the patient's skin surface (e.g., along an extension tower or screw extension tab) to various depths within the patient's body (e.g., to surgical sites located at various positions below the patient's skin surface). Figures 19A–19C show one embodiment of an access port 1902 having an adjustable height achieved by the relative movement of an inner tube or sleeve 1904 and an outer tube or sleeve 1906. More specifically, the inner tube 1904 can translate relative to the outer tube 1906. Such movement may, in some embodiments, be guided by various positioning mechanisms 1908, such as cooperating ridges and notches, formed on the surfaces of the inner tube 1904 and the outer tube 1906. In some embodiments, a flat spring arm may be provided on the inner tube 1904, and the outer tube 1906 may include a plurality of teeth for engaging with the spring arm. Furthermore, in some embodiments, the relative movement of the inner sleeve 1904 and the outer sleeve 1906 can be selectively locked to prevent further adjustment of the access port height. For example, a relief slot 1910 formed in the outer sleeve 1906 allows a split ring clamp, such as clamp 1406, to compress the outer sleeve 1906 or a bushing 1802 positioned around the outer sleeve 1906, thereby compressing the outer sleeve around the inner sleeve 1904 and locking their relative positions. Thus, in some embodiments, a locking mechanism such as a thumb screw 1304 or a cam lock 1404 can be used to lock both the relative position of the access port and the anchor, as well as the height of the access port.

[0060] Figures 20A to 31D show yet another embodiment of an access port that can be connected to an anchor on the same side of the patient's body, for example, so that the longitudinal axes of the access port and the anchor are non-coaxial. However, in the exemplary embodiments, the link mechanism connecting the anchor to the access port may form a portion of the outer circumference of the access port that pivots relative to the access port. In certain configurations, such embodiments may be adjustable so that the longitudinal axis of the access port aligns with the longitudinal axis of the anchor. In certain procedures, such as spinal fixation or deformity correction procedures, this may advantageously allow the access port to also function as a screw tower for inserting a spinal fixation rod between different parts of the procedure.

[0061] Figures 20A and 20B show alternative diagrams of one embodiment of a split-tube access port 2000 that can be connected to an anchor 2002, such as a pedicle screw. The access port 2000 may include a substantially cylindrical body 2004 defining an inner lumen 2006 extending along its longitudinal axis L6. A linkage mechanism portion 2008 of the body 2004 is separated from the rest and can pivot relative to the rest about axis R2. A thumb screw 2010 may be included to selectively lock the pivoting motion between the body 2004 and the linkage mechanism portion 2008. Needless to say, a cam lock or any of various other locking mechanisms may be used instead of the thumb screw 2010. In addition to the inner lumen 2006, a secondary lumen 2012 may be provided for receiving additional surgical instruments. For example, the secondary lumen 2012 in the illustrated embodiment may be configured to receive a camera and / or light source to assist the user in performing a surgical procedure. The secondary lumen 2012 may extend parallel or laterally to the inner lumen 2006, and the two lumens may merge in certain embodiments. For example, in some embodiments, the secondary lumen 2012 may extend laterally to the inner lumen 2006 so that a light source and / or camera passing through the secondary lumen 2012 extends into the inner lumen 2006 located distal to the proximal end of the access port 2000. In other embodiments, the lumens may remain separate, but the secondary lumen 2012 may be angled with respect to the inner lumen 2006 so, for example, that an endoscope camera emerging from the distal end of the secondary lumen 2012 can see the surgical site located beyond the distal end of the inner lumen 2006.

[0062] The link mechanism portion 2008 can be connected to the anchor 2002 in any of the following ways. For example, in some embodiments, a fork 2014 including a pair of opposing arms may be formed at the distal end of the link mechanism portion 2008 and configured to receive the anchor 2002 in a recess between the arms. In some embodiments, for example, the arms of the fork 2014 may be configured to receive a narrowed neck or shank portion 2016 of the anchor 2002 that extends distally from a wider proximal head portion 2018. For example, the bone anchor portion of a multi-axis pedicle screw typically includes a cylindrical shank extending from a more spherical proximal head portion that interfaces with a multi-axis receiving head. By positioning the opposing arms of the fork 2014 below the proximal head portion 2018 of the anchor 2002, the link mechanism portion 2008 can be selectively locked to the anchor by applying an upward or proximal force to frictionally lock the arms of the fork 2014 against the proximal head 2018 of the anchor 2002.

[0063] Such locking forces can be applied in various ways. For example, in some embodiments, the tissue forming the incision wall surrounding the anchor 2002 can exert sufficient force on the fork 2014 to prevent relative movement between the fork 2014 and the anchor 2002. Such force may be an inward or compressive force exerted by the tissue surrounding the anchor 2002, or the fork 2014 may be pulled upward, resulting in the patient's skin surface being positioned below the fork and exerting an upward force on the fork. As another example, the anchor 2002 can be tightened to compress the fork 2014 between the head portion of the anchor 2018 and the bone surface.

[0064] In other embodiments, any of a variety of locking mechanisms may be provided to selectively lock the link mechanism portion 2008 relative to the anchor 2002. In Figures 20A and 20B, for example, a locking screw 2020 may be used to drive the link mechanism portion 2008 upward relative to the anchor 2002. More specifically, the distal end of the locking screw 2020 may be configured to contact the proximal surface of the anchor 2002, and a hook 2022 may be screwed onto the locking screw 2020. The hook 2022 may engage with a through hole 2024 formed in the link mechanism portion 2008 so that when the locking screw 2020 rotates, the hook 2022 translates upward and exerts an upward force on the link mechanism portion 2008, thereby bringing the fork 2014 into contact with the proximal head 2018 of the anchor 2002. The locking screw 2020 can exert sufficient force to lock the relative position of the link mechanism portion 2008 with respect to the anchor 2002. When combined with the thumb screw 2010, the position of the access port 2000 relative to the anchor 2002 can be selectively locked, or movement can be allowed to enable multi-axial movement between these components.

[0065] Figures 21 and 22 show an alternative embodiment of an access port 2100 comprising a pivot link mechanism portion 2102 and a locking mechanism 2104 for selectively locking the position of the access port relative to an anchor 2106, such as a pedicle or other bone screw. Similar to the embodiments described above, the access port 2100 may include a substantially cylindrical body 2108 defining an internal lumen 2110 that can function as a channel for accessing the surgical site. The link mechanism portion 2102 may be pivotably connected to the body 2108. The locking mechanism 2104 may include an actuator arm 2112 screwed into a proximal locking screw 2114 at its proximal end. The distal portion of the actuator arm 2112 may include a wedge-shaped or dovetail shape 2116 positioned within a tapered slot 2118 formed in the proximal portion of the link mechanism portion 2102.

[0066] To operate the locking mechanism 2104, the user can rotate the locking screw 2114 at the proximal end of the access port 2100. Rotation of the screw 2114 allows the actuator arm 2112 to translate proximal to the body 2108. Proximal movement of the actuator arm 2112 allows the wedge portion 2116 to contact the side wall of the tapered slot 2118 formed in the proximal portion of the link mechanism portion 2102. As a result, the opposing proximal arms 2120a and 2120b of the link mechanism portion 2102 are biased laterally outward and can contact the side wall of the body 2108. Friction between the side wall of the body 2108, the proximal arms 2120a and 2120b, and the actuator arm 2112 locks the position of the link mechanism portion 2102 relative to the body 2108 of the access port 2000.

[0067] Furthermore, the link mechanism portion 2102 may include a slot 2122 formed in its distal portion such that a fork is formed at the distal end of the link mechanism portion, which includes opposing distal arms 2124a, 2124b. The opposing distal arms 2124a, 2124b may be configured to interface with the anchor 2106 in the same manner as described above, for example, around a narrowed shank or neck located below a wider proximal anchor head. In such embodiments, the proximal translation of the actuator arm 2112, which biases the proximal arms 2120a, 2120b laterally outward to frictionally engage with the side wall of the body 2108, can further produce a corresponding laterally inward movement of the arms 2124a, 2124b, thereby increasing the friction of the arms 2124a, 2124b with respect to the anchor 2106. This is because the central portion 2126 of the link mechanism portion 2102 can function as a fulcrum around which the two sides of the link mechanism portion can pivot relative to each other. Therefore, the operation of the locking screw 2114 simultaneously locks the movement of the link mechanism portion 2102 relative to the access port body 2108 and the anchor 2106, thereby locking the position of the access port 2000 relative to the anchor.

[0068] Other embodiments of the locking mechanism are also possible. For example, in one embodiment, the locking mechanism may include an actuator arm driven distally to push a fork that interfaces with an anchor. Distal advance of the actuator arm allows the link mechanism portion, including the fork, to pivot and return toward the center of the access port. This pivotal movement allows a screw or anchor head to be clamped between the fork and the outer surface of the access pipe, thereby locking the pipe in place relative to the screw. In yet another embodiment, a hook extending in a plane perpendicular to the longitudinal axis of the access pipe can be utilized. The hook can be attached to a longitudinal screw extending downward along the length of the access pipe. As the screw rotates, the hook can rotate about an axis parallel to the longitudinal axis of the access pipe. The rotating hook can grasp an embedded bone anchor and pull it firmly out of the access pipe, locking the pipe in place.

[0069] The access ports 2000 and 2100 described above can be advantageously transitioned between a first configuration in which the link mechanism portion forms part of the outer circumference of the access port and a second configuration in which the link mechanism portion pivots or separates from the rest of the access port body. This allows the access ports 2000 and 2100 to be inserted in a configuration in which the longitudinal axis of the inner lumen of the access port is coaxial with the longitudinal axis of the anchor, and then moved to a configuration in which the longitudinal axis of the inner lumen of the access port and the longitudinal axis of the anchor are not coaxial, as shown, for example, in Figures 20A to 22. Furthermore, the access ports can be repeatedly moved between these configurations during surgical procedures. Thus, both access ports 2000 and 2100 not only define a channel to the surgical site adjacent to the anchor, but also function as screw extensions that provide a channel to the anchor itself, thereby facilitating other procedural steps, including insertion of the receiving head, insertion of the spinal fixation element, and insertion of the lock cap.

[0070] Figures 23A to 23I illustrate one embodiment of a surgical procedure utilizing an access port 2300 similar to those shown in Figures 20A and 20B. A similar procedure is also possible using the access port 2100 shown in Figures 21 and 22. As shown in Figure 23A, the procedure may involve embedding a bone screw or other anchor 2302 pre-assembled in the access port 2100, configured such that the longitudinal axis L7 of the access port is aligned with the longitudinal axis L8 of the anchor. The components can be maintained in this position by inserting an expander and / or driver 2304 through the lumen or channel of the access port 2300 and engaging it with the proximal end of the anchor 2302. The position of the anchor between the distal end of the driver 2304 and the fork 2306 of the access port 2300 can be firmly restrained by applying a distal force to the anchor 2302 with the driver 2304. In some embodiments, the driver 2304 and the fork 2306 cooperate to restrain the axial movement of the anchor 2302 along its longitudinal axis L8, but allow rotational movement of the driver and anchor relative to the fork during insertion into the patient's bone.

[0071] After percutaneous insertion of the access port 2300 and anchor 2302 using the expander and / or driver 2304, the driver can be withdrawn proximal to the access port channel or lumen, thereby leaving the access port connected to and aligned with the anchor. In some embodiments, as also described above, the access port fork 2306 may be held against the proximal head 2308 of the anchor 2302 by upward or inward forces applied to the fork from the tissue surrounding the anchor and access port, or by inserting locking elements such as the locking screw 2020 and hook 2022 described above in relation to the access port 2000.

[0072] To provide access to a surgical site, such as the intervertebral disc space adjacent to the vertebra in which the anchor 2302 is embedded, the user may angle a portion of the access port 2300, such as the access port body 2310, relative to the anchor, or move it in another way to align its channel 2312 with the surgical site. As shown in Figure 23B, in such a position, the longitudinal axis L7 of the access port 2300 may be non-coaxial with the longitudinal axis L8 of the anchor 2302. The access port body 2310 is connected to the anchor 2302 via a pivotable link mechanism portion 2314 relative to the body and can maintain a state stabilized by the anchor 2302. Furthermore, in some embodiments, a lock, such as a thumbwheel lock 2316, can be used to selectively lock the position of the link mechanism portion 2314 relative to the body 2310.

[0073] As shown in Figure 23B, after positioning the access port 2300, the user can perform any of the various surgical procedures at the surgical site by introducing one or more instruments through the access port channel 2312. For example, in an embodiment in which the access port is positioned to access the intervertebral disc space, the user can perform a spinal fixation cage insertion procedure through the channel 2312 of the access port 2300 while the access port is fixed in place against the anchor 2302.

[0074] After the completion of intervertebral disc treatment or any other surgical procedure, any locks (e.g., thumbwheel lock 2316 and / or fork / anchor locks such as screw 2020 and hook 2022) may be at least partially disengaged, and the access port body 2310 may return to its insertion position, where the longitudinal axes L7 and L8 are aligned. Any locks may be reengaged in a configuration such that the access port 2300 can function as an anchor extension tower for further surgical procedures such as receiving head insertion, spinal fixation element insertion, lock cap insertion and tightening. Figure 23C shows the access port 2300 returning to the configuration of Figure 23A, but without the expander and / or driver 2304. Figure 23D shows a multi-axis screw receiving head 2318 inserted into channel 2312 of the access port 2300 using tool 2320. The receiving head 2318 may advance distally through channel 2312 of the access port and connect to the proximal head 2308 of anchor 2302. Since the fork engages with the anchor distal to, or below in the figure, the spherical proximal head 2308 of the anchor, the head 2318 can be connected to the anchor 2302 without interference from the access port fork 2306 (if lock screws 2020 and hooks 2022 are used, these components may need to be removed before connecting the receiving head 2318 to the anchor 2302). Figure 23E shows the receiving head 2318 positioned above the proximal head (invisible) of the anchor 2302. Following the connection of the receiving head 2318 to the anchor 2302, the insertion tool 2320 used to introduce the head through the access port channel 2312 can be removed.

[0075] Figure 23F shows a further step in which an adjacent anchor 2322 is introduced into the patient's bone, for example, an adjacent vertebra on the same side of the patient's body. The anchor 2322 may be introduced pre-assembled into a receiving head 2324 and an extension tower 2326 that allows manipulation and access to the anchor 2322 from outside the patient's body. As shown in Figure 23G, a spinal fixation element such as a rod 2328 can pass through the receiving heads 2324 and 2318 using a tool 2330. It should be noted that the extension tower 2326 and access port 2300 may include opposing through-holes formed in their side walls to allow passage of the rod 2328 or other spinal fixation elements. For example, the link mechanism portion 2314 of the access port 2300 may include a through-hole 2332 that can be used as a rod passage and interface with a locking mechanism such as the locking screw 2020 and hook 2022 described above. The access port body 2310 may further include through holes 2334 or slots or other notches formed inside, which are aligned with the through holes 2332 to allow the rod 2328 to pass through during insertion. Following the insertion of the rod, the user can introduce locking caps, such as the locking caps or set screws 2336 and 2338 shown in Figure 23I, through the extension tower 2326 and the access port channel 2312 to secure the rod 2328 or other spinal fixation elements to each receiving head / anchor assembly.

[0076] As shown in Figure 23H, a further step may include removing the extension tower 2326 and access port 2300 to leave the final in situ fixed structure as shown in Figure 23I. In some embodiments, the removal of the access port 2300 may include loosening the thumbwheel lock 2316 to allow the link mechanism portion 2314 to be released from the rod 2328 and anchor 2302.

[0077] Figures 24A to 31D show further embodiments of the access port, which include one or more ductile or flexible tabs to facilitate the use of the access port in the procedures described above. For example, Figures 24A and 24B show one embodiment of an access port 2400 having a substantially cylindrical body 2402 defining an access channel 2403, which may be formed from a ductile material such as any of a variety of metals and polymers. The body 2402 may include a plurality of slots or slits 2404a to 2404k formed inside it and extending axially from either its proximal end 2406 or distal end 2408 to form one or more flexible tabs at each end of the access port 2400. For example, the slots 2404a to 2404k shown in Figures 24A and 24B may form a plurality of tabs 2410a to 2410g that are deformable or bendable away from the illustrated configuration, and these form part of the outer circumference of the cylindrical body 2402. The positioning of the slots or slits 2404a to 2404k, combined with the ductility of the material, can allow for isolated deformation at desired locations, such as the virtual hinge line 2411 of tab 2404a shown in Figure 24A.

[0078] One or more tabs 2410 can serve various purposes in different surgical procedures. For example, in some embodiments, corresponding proximal and distal tabs (e.g., tabs 2410a and 2410b) may each include through-holes 2412, 2414 formed inside them to accommodate surgical visualization systems, cameras, scopes, or lights, similar to the secondary lumen 2012 described above in relation to the access port 2000. Figure 25 shows an access port 2400 having a visualization system 2502 positioned through the through-holes 2412, 2414 of tabs 2410a, 2410b which are deformed or bent away from the cylindrical body 2402.

[0079] At the distal end 2408 of the access port 2400, the tab 2410g can be used as a link mechanism for connecting to the anchor 2602, as shown in Figure 26. More specifically, the tab 2410g may be configured to connect to a link 2604 that connects to the anchor 2602. The link 2604, shown in detail in Figure 27, may include a distal portion having a fork 2606 with opposing arms 2702a, 2702b configured to engage with the anchor 2602 below the proximal head portion of the anchor 2602. The proximal head portion of the anchor may include a spherical head in the case of an unassembled bone anchor, or the distal end of the receiving head 2608 in the case of an assembled multi-axis bone screw. The proximal portion of the link 2604 may include a pair of opposing arms 2704a, 2704b that can capture the tab 2410g and connect the link to the access port body 2402, as shown in Figure 26.

[0080] The link 2604 of the access port 2400 may include a mechanism to facilitate securing the link to the anchor 2602, as described above. For example, the link may include a through hole 2610 formed inside it, which can receive a hook 2612 that forms part of a locking mechanism, similar to the locking screw 2020 and hook 2022 in Figures 20A and 20B. In some embodiments, the locking mechanism may not be used, and the fork 2606 may be secured to the anchor 2602 by relying on upward and / or inward forces exerted by the surrounding tissue.

[0081] During use, the access port 2300 can be inserted into the configuration shown in Figure 28A, where the longitudinal axis L9 of the access port 2300 is the longitudinal axis of the anchor 2602. 10The components are then aligned. In some embodiments, a pre-assembled assembly, such as the one shown in Figure 28A, can be inserted using a screwdriver, similar to the embodiment shown in Figure 23A. In other embodiments, the access port 2400 can be positioned above the embedding site, and the anchor 2602 and link 2604 can be embedded by passing them through the central channel or lumen of the access port from its proximal end to its distal end. Subsequently, as shown in Figures 28A and 28B, the link 2604 can be connected to the distal portion of the access port 2400, for example, by sliding the tab 2410f between the opposing arms 2704a and 2704b of the link. In yet another embodiment, the anchor 2602 can be embedded independently by passing it through the access port channel or by embedding it without the assistance of the access port, and then the link 2604 can be connected to the anchor 2602 and the access port 2400. In yet another embodiment, the access port 2400 may be inserted downward onto a link 2604 that is already connected to an anchor 2602 embedded in the patient's bone.

[0082] In this embodiment, instead of having a lock / unlock thumbwheel or knob on the top of the access port to which the port is attached to the link mechanism, the access port 2400 may include a bendable tab 2410f or 2410g that allows the port to be moved relative to the anchor 2602 and subsequently held in place. Comparing Figures 26 to 28B, it is clear that the access port 2400 may include multiple distal tabs, such as tabs 2410f and 2410g, facing each other about the centerline of the access port 2400, to connect the link 2604 in various orientations. Regardless of which tab is used, the port 2400 can be positioned / oriented to a desired position / orientation by bending or deforming the tab and can be positioned and then held in that position by the inherent stiffness of the material.

[0083] As shown in Figures 28A and 28B, the access port 2400 is configured to be aligned in the axial direction as described above in Figure 28A, and as shown in Figure 28B, the longitudinal axis L9 of the access port is aligned with the longitudinal axis L of the anchor. 10 It can be moved to a configuration that is non-coaxial. Furthermore, the access port 2400 can be repeatedly moved between the configuration in Figure 28A and the configuration in Figure 28B so that it can be used in various procedures such as those described above in relation to Figures 23A to 23I.

[0084] The access port 2400 may also be configured to connect to other surgical components such as nerve shields or soft tissue retractors 2902. Figure 29 shows several retractors 2902a, 2902b connected to tabs 2410c, 2410d, respectively. Figure 30 shows the retractor 2902 in more detail. The retractor 2902 may include a proximal handle 3002 for manipulating the retractor and any tab to which the retractor is connected, as well as an elongated body 3004 and a distal retraction tip 3006 configured to shield and / or retract soft tissue. The retractor 2902 may further include a pair of opposing arms 3008a, 3008b, similar to the opposing arms 2704a, 2704b of the link 2604 described above, for capturing the tab 2410 of the access port 2400.

[0085] Figures 31A to 31D show one embodiment of a method for utilizing a soft tissue retractor or nerve shield 2902 in relation to an access port 2400. As shown in Figure 31A, the method may include deforming or bending a tab 2910d away from the central longitudinal axis L9 at the proximal end 2406 of the access port 2400 such that the tab separates from an initial configuration in which the tab forms part of the outer circumference of the cylindrical body 2402 of the access port. The soft tissue retractor 2902 can then be introduced into the channel or lumen 2403 of the access port 2400 in a manner that engages with the tab 2410d and the opposing arms 3008a, 3008b of the retractor 2902, as shown in Figures 31B and 31C. At this time, the distal retracted tip 3006 can cross the longitudinal axis L9 or the centerline of the channel 2403 and protrude from the distal end 2408 of the access port opposite the tab 2410d of the port. After distal advancement of the retractor 2902 is complete, the user can use the handle 3002 to bend or deform the tab 2910d back to its original position aligned with the outer circumference of the cylindrical body 2402 of the access port, as shown in Figure 31D. As the tab moves, the distal retractor tip 3006 can return across the longitudinal axis L9 or centerline of the access tube so that the tip is positioned on the same side as the tab 2910d. As the retractor tip moves, it can capture and move any soft tissue that the tab encounters, such as nerves. Such a retractor 2902 may be useful, for example, for moving nerves that are commonly encountered during surgical procedures on a patient's vertebrae. As shown in Figure 29, in some embodiments, multiple retractors can be used simultaneously. For example, the proximal end 2406 of the access port 2400 may include four slits or slots 2404c to 2404f that form three identical tabs 2410c to 2410e, from which retractors 2902 can be connected.

[0086] In another embodiment, a method for utilizing the access port 2400 may include deforming the proximal and distal tabs 2410a, 2410b and positioning an endoscope or surgical visualization system 2502 through holes 2412, 2414 formed within the tabs 2410a, 2410b. The access port 2400 and the endoscope or other visualization system 2502 can be introduced into the patient using a pedicle screw or other anchor 2602 (the screw may be pre-assembled to one of various receiving heads such as multi-axis, uniaxial, or angled, or it may be headless). For introduction into the patient's body, the port 2400 may be aligned with the anchor 2602 such that the longitudinal axis of the port 2400 aligns with the longitudinal axis of the anchor 2602. Introduction and insertion may be facilitated by inserting a dilator and / or driver tool through the working channel of the access port 2400 to interface with the anchor 2602. Following the introduction and insertion of anchor 2602 into the patient's bone, any expander or driver tool can be removed, and port 2400 can be manipulated to a desired position, for example, on the intervertebral disc space adjacent to the vertebra into which anchor 2602 is inserted, by deforming one of the tabs 2410f, 2410g connected to the anchor by link 2604. In some embodiments, the desired position may be on the same side of the patient's body (e.g., adjacent to anchor 2602 on the same side of the patient's spine or midline axis). When in the desired position, the longitudinal axis of access port 2400 may be non-coaxial with the longitudinal axis of the anchor. In some embodiments, the position of link 2604 and port 2400 can be locked relative to anchor 2602, for example using a locking screw and hook 2612, to drive the distal fork 2606 of link 2604 upward relative to the proximal portion of the anchor.

[0087] The method may further include deforming one or more of the proximal tabs 2410c, 2410d, and 2410e outward so as to move away from the central longitudinal axis of the access port. The retractor 2902 is connected to the deformed tab 2410 and may advance distally, for example, beyond the distal end of the port 2400 where soft tissue creep may be occurring. The distal retractor tip 3006 of the retractor 2902 can be positioned on the opposite side of the soft tissue from the deformed tab 2910 connected to the proximal portion of the retractor. The retractor can then be operated in a manner that deforms the tab connected to the retractor back to its original position. This movement allows the distal retractor tip 3006 to capture the soft tissue and retract it to the side of the access port 2400 to which the tab 2410 is connected to the retractor 2902, thereby clearing the central portion of the access tube lumen 2403. The force exerted by the captured tissue may be less than the force required to deform the tab 2410, thus allowing the retractor 2902 and the captured tissue to be maintained in this position.

[0088] The user can complete any of the various surgical procedures through the lumen 2403 of the access port 2400. For example, procedures on the intervertebral disc cavity, such as disc replacement, discectomy, endplate preparation, fixation cage insertion, and bone graft delivery, can be performed by passing instruments or implants through the access port 2400. Once completed, all locks on the anchor 2602 may be released, and all tissue retractors 2902, if present, may be removed, and either tab 2410f, 2410g connected to link 2604 may be deformed and returned to its original position, thereby returning the access port 2400 to its insertion configuration in which the longitudinal axis of the access port is aligned with the longitudinal axis of the anchor. The access port 2400 can continue to function as a screw tower on the anchor 2602 to assist in the insertion and connection of the anchor receiving head, the insertion of the spinal fixation element, and the insertion and tightening of the lock cap, as described above in relation to Figures 23A to 23I. Once all operations are complete, link 2604 can be disengaged from anchor 2602, and port 2400 can be removed.

[0089] Figure 32 shows yet another embodiment of the link mechanism 3200 for connecting an access port and an anchor in a selectively lockable manner. The distal portion 3202 of the link mechanism 3200 may be configured to connect to an anchor such as a pedicle screw. The connection can be achieved using a variety of known mechanisms, including screw engagements, which interface with one or more notches or other mating mechanisms formed on the anchor. Similarly, the proximal portion 3204 of the link mechanism 3200 may be configured to connect to an access port using any of a variety of known mechanisms. The proximal portion 3202 and the distal portion 3204 can be connected to each other by a “smart” material 3206 having mechanical properties that can be changed by the application of an electric current or other input. For example, the material 3206 may normally be freely movable and bendable, but can become rigid by the application of an electric current 3208 or other input. Alternatively, the material 3206 may be reversed, normally rigid, and become flexible by the application of an electric current or other input.

[0090] In these embodiments, the access port can be positioned relative to a bone screw or other anchor as desired, and then an electric current or other input can be applied to the smart material 3206 to hold it in place. The configuration in Figure 32 is an example of how such materials can be used, but they can also be used in various ways in relation to the systems and apparatus described herein. For example, such materials can be used to achieve clamping of extension tabs, such as tabs described in relation to Figures 4 to 12C above. Such materials can also be used to clamp connectors to screw towers or ports, etc.

[0091] An example of such "smart" material 3206 may be an electroplastic elastomer hydrogel that can exhibit a change in tensile strength (e.g., from flexible to rigid) based on an applied electric current. Other exemplary materials include electroactive polymers (EAPs), nitinol or shape memory materials, and hydrogels.

[0092] It should be noted that any order of method steps expressed or suggested in the above description or accompanying drawings should not be construed as limiting the disclosed method to performing the step steps in that order. Rather, each of the various steps of the method disclosed herein can be performed in any various order. Furthermore, the described method is merely an exemplary embodiment, and various other methods, including additional or fewer steps, are also within the scope of this disclosure.

[0093] The instruments disclosed herein may be composed of any of a variety of known materials. Exemplary materials include, for example, metals such as stainless steel, titanium, nickel, cobalt-chromium, or alloys and combinations thereof; polymers such as PEEK; ceramics; and carbon fibers, all of which are suitable for use in surgical applications. The various components of the instruments disclosed herein may have varying degrees of rigidity or flexibility appropriate for their use. The size of the instrument may also vary considerably depending on the intended use and the biomimetic structure of the surgical site. Furthermore, certain components may be formed from different materials than other components. One or more components or parts of an instrument may be formed from radiopaque materials to facilitate visualization under fluoroscopy and other imaging techniques, or from radiopaque materials so as not to interfere with the visualization of other structures. Exemplary radiopaque materials include carbon fibers and high-strength polymers.

[0094] The apparatus and methods disclosed herein can be used in minimally invasive surgery and / or open surgery. Although the apparatus and methods disclosed herein are generally described in the context of spinal surgery in human patients, it will be understood that the methods and apparatus disclosed herein can be used in any of the various surgical or non-surgical procedures on any human or animal subject.

[0095] The devices disclosed herein may be designed to be discarded after a single use or to be designed for multiple uses. However, in either case, the devices may be readjusted for reuse after at least one use. Readjustment may include any combination of disassembly of the device, subsequent cleaning or replacement of specific parts, and subsequent reassembly. In particular, the device may be disassembled, and any number of specific parts or components of the device may be selectively replaced or removed in any combination. After cleaning and / or replacing specific parts, the device may be reassembled for subsequent use either in a readjustment facility or by a surgical team immediately before a surgical procedure. Those skilled in the art will understand that various techniques for disassembly, cleaning / replacement, and reassembly are available for readjusting the device. The use of such techniques and the resulting readjusted devices are all within the scope of this application.

[0096] The apparatus described herein may be treated before use in surgery. First, new or used instruments may be obtained and cleaned as necessary. Then, the instruments can be sterilized. In one sterilization technique, the instruments may be placed in a closed and sealed container, such as a plastic bag or a TYVEK bag. The container and its contents may then be placed in a radiation field that can penetrate the container, such as gamma rays, X-rays, or high-energy electrons. The radiation can kill bacteria on the instruments and inside the container. After this, the sterilized instruments can be stored in the sterile container. The sealed container can keep the instruments sterile until it is opened in a medical facility. Other forms of sterilization known in the art are also possible. These include beta rays or other radiation, ethylene oxide, steam, or liquid baths (e.g., cold immersion). Depending on the materials used, the presence of electrical components, etc., certain forms of sterilization techniques may be more suitable for use in different parts of the apparatus.

[0097] Those skilled in the art will understand further features and advantages based on the embodiments described above. Therefore, this disclosure is not limited to what is specifically shown and described. All publications and references cited herein are expressly incorporated herein by reference in their entirety.

[0098] [Implementation Method] (1) An access port configured to be inserted percutaneously into the patient to define a channel to the surgical site, An anchor configured to be inserted into the bone of the patient, Equipped with, The access port is connected to the anchor such that the longitudinal axis of the access port and the longitudinal axis of the anchor are non-coaxial. Surgical system. (2) The system according to Embodiment 1, wherein the position of the access port relative to the anchor can be selectively locked. (3) The system according to Embodiment 1, wherein the access port is connected to the anchor by a link mechanism. (4) The system according to embodiment 3, wherein the link mechanism is deformable. (5) The system according to embodiment 4, wherein the link mechanism is formed of metal.

[0099] (6) The system according to embodiment 4, wherein the link mechanism is selectively lockable. (7) The system according to embodiment 6, wherein the link mechanism is selectively locked by applying electricity to the link mechanism. (8) The system according to embodiment 6, wherein the link mechanism is selectively locked by an adjustment screw. (9) The system according to Embodiment 1, wherein the length of the access port can be adjusted by telescopically extending and retracting the inner sleeve of the access port relative to the outer sleeve of the access port. (10) The system according to Embodiment 3, wherein the link mechanism forms a part of the outer circumference of the access port and pivots relative to the access port.

[0100] (11) The system according to Embodiment 1, wherein the access port includes a deformable portion. (12) The system according to embodiment 11, wherein the deformable portion is connected to the anchor. (13) The system according to embodiment 12, wherein the deformable portion is connected to the anchor below the multi-axis head of the anchor. (14) The system according to embodiment 11, further comprising a nerve shield connected to the deformable portion. (15) The anchor includes opposing extensions that extend proximal to the distal portion, The access port is connected to the anchor by compressing a portion of the access port between the opposing extensions. The system described in Embodiment 1.

[0101] (16) The system according to embodiment 15, further comprising a clamp configured to compress the opposing extensions toward each other. (17) The system according to embodiment 16, wherein the clamp defines an inner lumen configured to receive the opposing extensions so that the clamp slides along the length of the opposing extensions. (18) The system according to embodiment 15, wherein the access port includes a shaft extending laterally with respect to the longitudinal axis of the access port, and a split ball positioned between the opposing extensions around the shaft. (19) The system according to embodiment 18, further comprising a clamp connected to the split ball and configured to pivot with respect to the split ball to compress the opposing extensions with respect to the split ball. (20) Inserting an anchor into the patient's bone, Connecting the access port to the aforementioned anchor, Position the access port relative to the anchor on the same side of the patient's body such that the longitudinal axis of the access port and the longitudinal axis of the anchor are non-coaxial, The access port defines a channel to the surgical site, Surgical method.

[0102] (21) The method according to embodiment 20, wherein the anchor is inserted into the patient's vertebra. (22) The method according to embodiment 20, further comprising locking the position of the access port relative to the anchor. (23) The method according to Embodiment 20, wherein positioning the access port includes deforming a link mechanism extending between the access port and the anchor. (24) The method according to embodiment 23, further comprising applying electricity to the link mechanism to lock the position of the access port relative to the anchor. (25) The method according to embodiment 22, further comprising acting on an adjustment screw to lock the position of the access port relative to the anchor.

[0103] (26) The method according to embodiment 20, further comprising adjusting the length of the access port by telescopically extending and retracting the inner sleeve of the access port relative to the outer sleeve of the access port. (27) The method according to embodiment 20, further comprising deforming a portion of the access port. (28) The method according to embodiment 27, wherein connecting the access port to the anchor includes connecting the anchor to the deformable portion of the access port. (29) The method according to embodiment 27, further comprising connecting a nerve shield to the deformable portion of the access port. (30) The method according to Embodiment 20, wherein connecting the access port to the anchor involves compressing a portion of the access port between opposing extensions of the anchor that extend in the proximal direction away from the distal portion of the anchor.

[0104] (31) The access port and the anchor are introduced into the patient's body in a configuration in which the longitudinal axis of the access port and the longitudinal axis of the anchor are coaxial, The longitudinal axis of the access port and the longitudinal axis of the anchor are not coaxial, and the position of the access port relative to the anchor is adjusted so that the access port and the anchor are on the same side of the patient's body. Surgical methods including [specific procedure]. (32) The method according to embodiment 31, wherein the anchor is inserted into the patient's vertebra. (33) The method according to embodiment 31, wherein the access port and the anchor are connected to a driver for introduction into the patient's body. (34) The method of embodiment 33, further comprising removing the driver before adjusting the position of the access port relative to the anchor. (35) Inserting a second anchor into the patient's body via the access port, The position of the access port relative to the anchor is readjusted so that the longitudinal axis of the access port and the longitudinal axis of the anchor are coaxial, Insert the multi-axis receiving head into the access port and connect the receiving head to the anchor, The aforementioned anchor and the second anchor are connected to the spinal fixation element, Removing the aforementioned access port, The method according to embodiment 31, further comprising:

[0105] (36) The method according to embodiment 31, further comprising adjusting the position of the access port relative to the anchor and then locking the position of the access port relative to the anchor.

Claims

1. It is a surgical system, An access port (1306) configured to be inserted percutaneously into the patient to define a channel to the surgical site, An extension tower (1308), which is a tubular member configured to connect to an implant that is embedded in the spine of the patient, A link mechanism (1502) having a first connection (1406) for receiving the access port (1306), a second connection (1408) for receiving the extension tower (1308), and a plurality of rigid segments (1504, 1506) extending between the first connection (1406) and the second connection (1408), Equipped with, The link mechanism (1502) is selectively lockable to lock the position of the access port (1306) relative to the extension tower (1308), The plurality of rigid segments (1504, 1506) of the link mechanism (1502) include a first segment (1504) and a second segment (1506) pivotably connected to the first segment (1504), wherein the first segment (1504) includes a first pair of segment portions (1504a, 1504b), and the second segment (1506) includes a second pair of segment portions (1506a, 1506b), wherein one segment portion (1504a) and the other segment portion (1504b) of the first pair of segment portions (1504a, 1504b) face each other, and the second pair of segment portions (1506a, 1506 b) A system in which one segment portion (1506a) and the other segment portion (1506b) of the first segment are opposite to each other, the first segment is configured to receive a first locking mechanism that selectively locks the movement of a component connected to the first segment by integrally compressing the opposing first pair of segment portions (1504a, 1504b), and the second segment is configured to receive a second locking mechanism that selectively locks the movement of a component connected to the second segment by integrally compressing the opposing second pair of segment portions (1506a, 1506b).

2. The system according to claim 1, wherein the first pair of segment portions (1504a, 1504b) includes the first connecting portion (1406) at its distal end, and the second pair of segment portions (1506a, 1506b) includes the second connecting portion (1408) at its distal end, and the first and second connecting portions are each a split ring clamp.

3. The system according to claim 1, wherein the first connection is configured to removably receive the access port, and the second connection is configured to removably receive the extension tower.

4. The system according to claim 1, wherein the first connection is configured to lock to the access port independently of each other, and the second connection is configured to lock to the extension tower.

5. The system according to claim 1, further comprising an extension post extending from the side wall of the access port, wherein the link mechanism is configured to connect to the extension post to form the first connection.

6. The system according to claim 1, wherein the link mechanism is capable of positioning the access port with respect to the extension tower such that the longitudinal axis of the access port is not coaxial with the longitudinal axis of the extension tower.

7. The system according to claim 1, wherein the link mechanism is capable of positioning the access port relative to the extension tower such that the longitudinal axis of the access port is angled obliquely with respect to the longitudinal axis of the extension tower.

8. The system according to claim 1, wherein the access port further comprises a secondary lumen configured to receive one or more devices therein, the secondary lumen extending parallel to the channel through the length of the access port.

9. The system according to claim 8, wherein the secondary lumens cross a portion of the access port and merge with the channel.

10. The system according to claim 8, wherein the secondary lumen is configured to receive a camera or light source in order to assist the user in performing a surgical procedure.

11. The system according to claim 10, wherein the camera is configured to exit from the distal end of the secondary lumen in order to view the surgical site located beyond the distal end of the channel.

12. The system according to claim 1, further comprising the first and second locking mechanisms arranged in the link mechanism for locking the position of the access port (1306) relative to the extension tower (1308).

13. The system according to claim 1, wherein the link mechanism is configured to pivot relative to the access port.

14. The system according to claim 1, wherein the link mechanism is connected to the extension tower via a sleeve arranged around the outer circumference of the extension tower.

15. The system according to claim 14, wherein the sleeve further comprises a cam lever for selectively locking the sleeve to the extension tower.

16. The system according to claim 1, wherein the access port is a single unit.

17. The system according to claim 1, wherein the access port further comprises at least one tab extending proximal therefrom.

18. The system according to claim 17, wherein the at least one tab further comprises at least one opening configured to receive therein at least a portion of an instrument passing through the access port.

19. The system according to claim 1, wherein the implant is a bone screw.

20. The system according to claim 1, wherein the component connected to the first segment is one of the access port and the extension tower, and the component connected to the second segment is the other of the access port and the extension tower.

21. The system according to claim 1, wherein the component connected to the first segment is the access port, and the component connected to the second segment is the extension tower.

22. The system according to claim 3 or 4, wherein the component connected to the first segment is the access port, and the component connected to the second segment is the extension tower.

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