KR101157312B1 - Surgical navigational and neuromonitoring instrument - Google Patents

Abstract

The present invention relates to a surgical instrument that can apply electrical stimulation to the nerve structure. The surgical instrument also includes a tracking system associated with the instrument to provide navigation tracking during the surgical procedure.

Surgical navigation, nerve integrity, computed tomography, biopsy needles, scoliosis, preoperative rendering, active tracking

Description

Surgical Navigation and Neurosurgical Instruments {SURGICAL NAVIGATIONAL AND NEUROMONITORING INSTRUMENT}

TECHNICAL FIELD The present invention relates to the field of neuro-related surgery, and more particularly to integrated systems and methods for surgical navigation and neuromonitoring.

Surgical navigational systems are often used in surgical procedures and in particular neuro-related procedures to help the surgeon move and locate surgical instruments or probes. Conventional surgical navigation systems use reflectors and / or markers to provide positional information of the surgical tool for preoperative rendering of the patient's anatomy. . Surgical navigation systems, however, do not have a neurosurveillance function to determine the integrity of the neural structure or the proximity of the surgical tool to such a neural structure. On the other hand, neural integrity monitoring systems are designed to use electrostimulation to identify nerve location to predict and prevent nerve damage. However, neural integrity monitoring systems are not helpful for visual navigation. Thus, not only visually assisting the surgeon in manipulating surgical instruments or probes, but also neurosurgery that can be supervised to assess surgical tool proximity to the neurostructure, the integrity of the neurostructure, and the overall health and function of the neurostructure. And there is a need for an integrated navigation system for surgery. There is a further need for having surgical instruments that can be applied for electrical stimulation and tracked for surgical navigation.

[Summary of invention]

In one aspect, the present invention relates to a surgical tool capable of applying electrostimulation. The surgical tool includes a mechanism having a handle portion and a body member extending from the handle portion. The body member may have an electrically conductive portion connected to an energy source and may apply electrostimulation energy supplied by the energy source. The surgical instrument includes a tracking system associated with the instrument and operable to provide information related to the position of the instrument.

According to another aspect of the invention, a surgical tool assembly is disclosed. The surgical instrument assembly includes a handle, an insulating sheath and a mechanism having a conductive member connected to the handle and residing within the insulating sheath. A portion of the conductive member protrudes distal from the insulating sheath. The surgical instrument assembly is operable by an instrument and conducts electrical energy to apply electrical stimulation to the neurostructure when a neural structure is in contact with a portion of the conductive member and electrical energy is provided to the conductive member. It further includes an energy source designed to provide the member. The surgical instrument assembly further includes a tracking system associated with the instrument and operable to provide information related to the position of the instrument.

According to another aspect, the present invention relates to a surgical method comprising inserting a surgical instrument into a vertebral structure through tissue and tracking the position of the surgical instrument relative to the vertebral structure in a user interface. The method includes delivering an electrical stimulus to the spinal structure using a surgical instrument and monitoring a neuralological response to the electrical stimulus.

According to another aspect, the present invention relates to a neuromonitoring instrument capable of applying electrical stimulation to a neural structure. The neuromonitoring mechanism has a handle and a stylet extending from the distal end of the handle. The neuromonitoring mechanism further includes a navigation sensor associated with at least one of the handle and the stylet. The navigation sensor is operative to provide feedback regarding the position of the instrument.

These and other aspects, forms, objects, features, and advantages of the present invention will become apparent from the detailed drawings and description.

TECHNICAL FIELD The present invention relates to the field of neuro-related surgery, and more particularly, to integrated systems and methods for surgical navigation and neurosurgery.

To enhance understanding of the principles of the present invention, reference will be made to the embodiments and embodiments shown in the drawings and special terminology will be used to describe the embodiments and embodiments. It will be understood, however, that this is not intended to limit the scope of the claims. Any modifications and additional variations in the described embodiments, and any additional applications for the principles of the invention described herein, are also contemplated as possible to one of ordinary skill in the art to which this invention belongs.

Referring to FIG. 1, there is shown an apparatus for comprehensively displaying surgical navigation information and neurosurgery information to assist a physician in diagnosing and treating various neuro-related diseases. In this regard, the present invention provides a number of surgical procedures such as spinal discectomy, spine reductions, disc replacements, joint replacements, scoliosis-related procedures, and a variety of others. Can provide benefits. The imaging-based surgical navigation and neurosurveillance integration system 10 allows the surgeon to monitor the trajectory of the instrument 14 on the monitor 12, preferably a surgical instrument that can facilitate the acquisition of neural information. Create and display visualizations of anatomy Data representing one or more pre-acquired images 16 is input to the computer 18. Computer 18 tracks the position of instrument 14 in real time using detector 20. The computer 18 then registers and displays the trajectory of the instrument 14 in real time with the pre-acquired images 16. An icon representing the trajectory of the instrument 14 is superimposed on the pre-acquired images 16 and displayed on the monitor 12. According to the surgeon's instructions, the real-time trajectory of the instrument 14 may be stored in the computer 18. In accordance with this command, a new stop icon is created on the display 12 indicating the trajectory of the instrument at the time of the surgical command. The surgeon can issue additional commands, with each command saving the real-time trajectory by default and creating a new stop icon on the display. The surgeon can override this default and choose not to display any stop icon. The surgeon can also perform multiple geometric measurements using real time and stored instrument trajectories.

In addition to displaying and storing the trajectory of the instrument 14 relative to the anatomy of the patient, the computer system 18 also displays the patient's view on the display 12 by an indicator representing neural information obtained from the patient. Update the visualization of the anatomy. As described in more detail below, neuralological indicators may be used for color coding of specific anatomical structures, textual or graphical annotations superimposed on pre-acquired images or their visualizations, or otherwise. May include identifying markers. The visualization of the anatomy of the patient referred to herein may comprise pre-acquired images, graphical representation derived from one or more pre-acquired images, atlas information or a combination thereof. have.

Referring to FIG. 2, there is shown a surgical suite 22 equipped with an image-based surgical navigation and neurosurgery system 10. When the patient 24 lying on the table 26 is placed in a C-arm imaging device 28, pre-acquired images of the patient 24 are collected. As used herein, the term "pre-acquired" does not mean any designated time sequence. However, preferably the images are obtained at some point before surgical navigation is performed. Typically, the images are obtained in two substantially orthogonal directions of the corresponding anatomy, such as anterior-posterior (A-P) and lateral. The imaging device 28 includes an x-ray source 30 and an x-ray receiving section 32. The x-ray receiver 32 includes target tracking markers 34. Operation of the C-arm imaging device 28 is controlled by a doctor or other user with a C-arm control computer 36.

Although C-cancer imaging device 28 is shown to acquire images from patient 24, it should be understood that other imaging devices may also be used to obtain anatomical and / or functional images of the patient. For example, computed tomography (CT), magnetic resonance (MR), positron emission tomography (PET), ultrasound, and single photon emission computed tomography Images can be acquired using SPECT. O-arm imaging systems can also be used for image acquisition. It is also noted that images may be obtained in a non-operating room 22 by one type of imaging modality before surgery and images may be acquired in the operating room 22 by another type of imaging technique before or during surgery. Consideration should be given. Such multi-technological images can be registered using known registration techniques.

The acquired images are transmitted to the computer 36 and again to the surgical navigation computer 18. Computer 18 may display images received via monitor 12. Other devices such as, for example, heads up displays can also be used to display the images.

With further reference to FIG. 2, the system 10 generally performs a real time tracking of the instrument 14 and also tracks the position of the receptacle 32 and the position of the reference frame 38. The detector 20 detects the presence of tracking markers on each object to be tracked. The detector 20 is connected to a computer 18 programmed by software modules that analyze the signals transmitted therefrom and determine the position of each object in the detector space. The manner in which the detector designates an object is well known in the art.

In general, an instrument 14, which is part of an optical tracking system (not shown) that uses attached tracking markers 40, such as reflectors, is tracked by the detector so that a three-dimensional position within the detector space is achieved. It is determined. The computer 18 is in communication with the optical tracking system to integrate this information with the pre-acquired images of the patient 24 to form a display that assists the surgeon 42 when the surgery is performed. An icon representation of the trajectory of the instrument 14 is displayed on the monitor 12 at the same time as the image of the pre-acquired patient 24. In this way, the surgeon 42 can see the trajectory of the instrument in real time with respect to the patient's anatomy.

With further reference to FIG. 2, the system according to the invention preferably has the ability to store the real time trajectory of the dynamic instrument 14. For example, using a foot-switch 44 to issue a command, the computer 18 receives the signal and stores the real-time trajectory of the instrument in the storage of the computer 18. Alternatively, the surgeon or other user can issue commands using other input devices such as push-buttons, voice commands, touchpad / touchscreen inputs, and the like. This "storage command" also causes the computer 18 to create a new stop icon representing the trajectory of the stored instrument, in particular "freezing" the icon at the point when the input was received. The still icon can be superimposed simultaneously on the pre-acquired image with an icon representing the real-time trajectory of the instrument. If multiple images are displayed, both still and real time icons can be superimposed on all the displayed images. Other means of issuing a store command, for example via a graphical user interface (GUI), may also be used. The surgeon may store multiple instrument trajectories. Whenever a desired save command is issued, the real-time trajectories of the instrument are stored and a new still icon representing the stored trajectory is displayed on the pre-acquired image and, if more than one image is displayed, on all the pre-acquired images. do.

The system according to the invention can further measure the angles between the real-time trajectory and one or more stored trajectories, or between the stored trajectories, preferably in a manner similar to that described in US Pat. No. 6,920,347, and the entirety of the patent The contents are incorporated herein by reference.

In addition to tracking and storing instrument trajectories, neural information is obtained from the patient, as described, the information may appear in a viewable form that can be shown on the display 12. For example, using pre-acquired images and orbital information, surgeon 42 may move instrument 14 in a manner that is guided to an anatomical site that includes the neurostructure and then the electrodes (shown in FIG. Or other neurostimulating devices may be used to obtain neural information from the neurostructure. The obtained neural information is transmitted to a computer 18 and registers neural information with the neural structure, where the neural information is obtained from the neural structure. Based on the position of the instrument 14, the computer 18 determines the position of the stimulated neurostructure and then updates the visualization of the neural structure on the display 12 to indicate a marker or other representation of the neural information obtained. May contain indices. For example, based on location, orientation, and neural response, computer 18 may determine a stimulated group of neurostructures and annotate the visualization of the neurostructures on display 12. Alternatively, the neurostructures may be assigned to a particular color in the visualization of the display 12 according to these groups or other defined characteristics.

In addition to characterizing the stimulated neural structures, the computer 18, along with the location information of the neural structures, can predict the structure of the nerves and graphically display the predicted structures on the display 12 to the surgeon. In this regard, some nerves are stimulated but the entire neural structure is predicted and graphically displayed. In addition, the pre-acquired images and / or visualizations thereof provide the surgeon with a comprehensive understanding of the patient's anatomy of the instrument being tracked, and the acquired neuroinformation supplements this understanding to provide a more accurate view of the neurostructure. Help understanding Thus, by measuring neural structures, the integrated system enhances the surgeon's understanding of the anatomy of a particular patient. To further assist the surgeon, through localizing the neurostructures, indicators that can be seen or heard when the instrument 14 is in close proximity to the neurostructure can be automatically given to the surgeon by the computer 18. In addition, the indicators can be tailored to match the class, location, or other characteristics of the neurostructure.

Using speech recognition software and hardware or other input devices, the surgeon 42 or other user can add notes about the neural structure from which the neural response was measured. These records can then be stored in the storage of computer 18. In one embodiment, the surgeon 42 may wear headphones (headphone 46) and microphone (48) to record in a surgical operation without using a hand. As will be described further below, the computer 18 may provide on-demand audio information to the surgeon through an audio system connected to headphones or other speakers.

Referring now to FIG. 3, shown is a block diagram of a surgical navigation and neurosurgery integration system 10. Computer 18 includes a graphical user interface system that operates in conjunction with a display screen of display monitor 12. The graphical user interface system is implemented with an operating system 46 for operating the computer 18. The graphical user interface may be implemented as part of the computer 18 from a user interface 47 such as a keyboard, mouse, lightwand, touchpad, touchscreen, voice recognition module, foot switch, joystick, or the like. Receives input data and commands. For simplicity in the drawings and description, many components of a conventional computer, such as address buffers, memory buffers, and other standard control circuits, are known in the art. Known configurations and descriptions thereof will not be described as they are not necessary to the understanding of the invention.

Computer programs for implementing the various steps of the present invention are generally located in a memory unit 48 and the processes of the present invention are performed by a central processing unit (CPU) 50. Memory 48 represents read-only memory and random access memory. The storage device contains information such as the positions of the stored instrument, extension values, and geometric transform parameters used in the present invention, such as image data and tables, for example. It also includes a database (database: 52) that stores data. Database 52 may also be used to store data, such as quantitative and qualitative assessments of monitored neurostructures. The memory device may be used, for example, for surgery, general anatomical structure information, videos, publications, instructions, or the like that may be used by a surgeon or other user for diagnosis and treatment. It may further include a technical data database 53 for storing data related to presentations, anatomical diagrams, surgical guides, and the like. A communication software module 60 is also included in the storage 48 so that the remote database, such as the technical data database 64 and the computer 18, can be easily communicated via a modem 62. .

Single representations of an image archival database and a technical data database are understood for illustrative purposes only, and it is assumed that multiple databases are required for such a system. In addition, the computer 18 may access a database via a network (not shown). According to the present invention, any acceptable network may be applied, such as a public, open, dedicated, private network. Communications links to the network may include any conventional telephone line, optical fiber, cable modem links, digital subscriber lines, wireless data transfer systems, and the like. It may be an acceptable type of. In this regard, the computer 18 is provided with communications interfaces hardware 62 and software 60 of known design to connect networks and exchange data between databases.

Operating system 46, tracking software module 54, calibration software module 56, display software module 58, communication module 60 and neural monitoring In combination with computer software, including a software module 66, the CPU 50 controls the operation and processes of the system 10. Processes implemented by the CPU 50 may be communicated to the I / O interface 70 and the video interface 72 along the bus 68 as electrical signals. In addition to being connected to the user interface 47, the I / O interface is connected to a printer 74, a (remote or local) image archive 76, and an audio (speaker) system 78.

The tracking software module 54 performs processes for tracking objects in an image guided system described herein and known to those skilled in the art. Correction software module 56 calculates geometric transformations to correct image distortions and register the images in an anatomical frame of reference 38, and eventually in the anatomy of the patient.

The display software module 58 applies offsets between the guide tracking markers 40 and the instrument 14 and calculates the offset if necessary to indicate the trajectory of the instrument superimposed on the images. Create an icon. For instruments of fixed length and angle, this offset may be measured once and stored in the database 52. The user then selects one from the list of instruments used for the procedure and the appropriate offset is applied by the display software module 58. For instruments of varying length and angle, the offset is manually measured and entered by the keyboard 47, or a tracked pointer (not shown) or a tracked registration jig (not shown). Can be measured together with.

Pre-acquired image data stored locally in image database 52 or remotely in image archive 76 may be digitized via I / O interface 70 and transmitted directly to computer 18 or video interface 72. Via video data. In addition, items that are shown to be stored in storage may also be stored at least partially in other storage devices, such as hard disks (not shown) or flash memory if the storage capacity is insufficient. Also not explicitly shown, image data may be provided via a network and through mass storage devices such as hard drives, optical disks, tape drives or any other type of data transmission and storage devices.

In addition to the modules and interfaces described above, the computer 18 includes an instrument navigation interface 82 as well as a neuromonitoring interface 80. The neurosurgery interface 80 receives electrical signals from electrodes 84 in proximity to the patient 24. The electrical signals are detected by electrodes 84 in response to an electrical stimulus applied to the neurostructure of the patient by instrument 14 or other electrostimulating probe (not shown). In this example, the electrodes are electromyography (EMG) electrodes and record muscle responses to neurostimulation. Alternatively, other neurosurveillance techniques can be used, such as motor evoked potentials (MEP) neuromonitoring and somatosensory evoked potentials (SSEP) neurosurveillance techniques. A stimulator control 86 is interfaced with the instrument 14 to control the intensity, direction, and pattern of the stimulus applied by the instrument 14. Input defining the desired stimulus characteristics may be given by a surgeon or other user through an input interface 47 or in the instrument 14 itself.

As described above, the integrated system 10 also performs markers, reflectors or other tracking devices to perform real time tracking of the instrument 14 (and the patient 24). Alternatively, the instrument may include active devices such as signal emitters in communication with tracking equipment for determining the position or orientation of the instrument. For example, the emitter can emit infrared, RF or other signals that track the instrument. In one embodiment, the instrument 14 includes markers 40 and its movement is tracked by an instrument tracker 88 that includes a camera or other known tracking device. Similarly, a patient can include a marker or reflector to track the patient's movement. In order to apply electrical stimulation, the instrument 14 is connected to a power supply 90. As shown, the instrument 14 may be powered by a self-contained battery, a power supply housed in a computer cabinet, or induced. Thus, if active devices such as emitters or transmitters are used for tracking, these devices can be powered similarly.

Surgical navigation and neurosurgery integration systems are designed to help surgeons manipulate instruments such as surgical instruments, probes or other instruments through visualization of the instrument to the patient's anatomy. As described herein, using tracking tools and techniques, real-time position and orientation information of the instrument with respect to the patient's anatomy may be superimposed on the patient's anatomical, functional or derived image. In addition to helping the surgeon track the instrument, the integrated system 10 also performs neurosurgery to assess the position and integrity of the neurostructure. In this regard, the surgeon measures the response to the electrical stimulus by moving the instrument to a desired point and applying electrical stimulation to the nerve structures proximate the instrument while viewing the placement of the instrument relative to the patient's anatomy with the display 12. The collected neural information may be transferred to the patient through labeling techniques that can convey neural information collected from graphic or text annotations, color or other coding of neural structures, or the application of electrical stimulation in a form that can be identified by a human. It can be added to the visualization of anatomy of. The integrated system also visualizes the anatomy of the patient, such as, for example, the major neural structures, and assists the surgeon in positioning the patient's anatomy with respect to location or integrity. As shown with respect to Figures 4-5, a graphical user interface is used to easily communicate the interaction with surgical navigation information and neurosurgery information.

Referring now to FIG. 4, a graphical user interface 92 is shown that is designed to assist the surgeon in manipulating surgical instruments such as, for example, probes or bone drivers. In the illustrated embodiment, the graphical user interface 92 is bifurcate into an image portion 94 and a menu portion 96. In the illustrated embodiment, the imaging section comprises three image panes 98, 100 and 102 each having a coronal, sagittal and axial image of the patient's anatomy. ). The image portion also includes a rendering pane 104. The menu portion 96 provides an optional link and, when selected by the surgeon, enables connection with those displayed in the image compartments 98, 100, 102 or other data obtained from the patient.

The image compartments provide an anatomical map and framework for the surgeon to track the instrument and can be represented and displayed by a pointer 106. The integrated system described herein tracks the movement of the instrument to provide real time visualization of the position of the pointer superimposed on the images contained in the compartments 98, 100, 102. Note that the displayed images can be derived from one or more diagnostic images, an atlas model, or a combination thereof obtained from the patient. As the instrument is moved relative to the patient's anatomy, the images displayed in the image compartments are automatically updated so that the instantaneous position of the instrument provides position information to the surgeon via pointer 106.

Moreover, the integrated system provides both surgical instrument navigation and neurosurgery, thereby separating the neural structures for neurosurgery through positional feedback provided by the imaging compartments and the pointer 106 to assist the surgeon. Can give In other words, it is possible to understand the whole nerve position from the images included in the image partitions 98, 100, 102. By visually observing the compartments, the surgeon moves the instrument in close proximity to the nervous structure to apply electrical stimulation and to measure the nervous response. This neural response can be used to assess the integrity of the neurostructure in the same manner as known neurosurveillance methods. Neural information can also be used to more accurately specify the location of the stimulated neural structure. For example, visualization of the anatomy of the patient, such as images included in the compartments 98, 100, 102, provides a general understanding of anatomical position, orientation, and location. The neuronal response of the stimulated neurostructure can then be used to accurately indicate the location and orientation of the neurostructure in the anatomy of the patient using color-coding or other indices.

Moreover, based on the overall location of the neurostructure and its local location, the assessment of the neurostructure can be improved. That is, the computer compares the measured response with the data contained in the database using the measured response of the neural structure and its location information as the surgeon moves the instrument in close proximity to the neural structure. Can be determined.

In addition to completeness assessment and positional localization, neural maps can be developed by integrating navigation information and neurosurgery information. That is, through repeated instrumental movements and neurosurgery, the combined information is integrated to position the neural structures, classify these neural structures based on position and / or response, and identify the patient through color or other indexes. Map neurologically and anatomically driven maps.

Note that in the illustrated embodiment, the tip of the instrument is represented by the pointer 106. However, tip, hind or whole instrumental representations can also be used in navigation. Three images are also shown with the same anatomy, but from different perspectives, but other image display approaches are possible.

4, one of the image compartments 104 is for three-dimensional rendering of the anatomy of the patient, such as a neural structure bundle 108. The rendering may be formed by registering multi-angle images of the patient's anatomy, graphic information or a combination thereof. In practice, the surgeon positions the instrument proximate to the target anatomical structure. The surgeon then selects the “3D Rendering” tab 110 of the menu 96 if necessary. According to this selection, the computer determines the location of the pointer 106 and generates a 3D rendering of the anatomical structure “pointed at” by the pointer. In this manner, the surgeon can select an anatomical feature and examine the anatomical feature visually in 3D rendering in a graphical user interface 92.

As also referenced above, the integrated system may maintain or access a technical library contained in one or more databases. The surgeon may select the "technical data" tab 112 to access technical data. With this choice, the computer can display the resources (not shown) available in the menu 96. Other windows may be displayed, but a preferred implementation is to use a single graphical user interface to avoid superimposing screens and windows on the navigation image. Technical resources may include links to Internet web pages, intranet web pages, posts, publications, presentations, maps, instructions, and the like. Also in a preferred embodiment, the list of resources is tailored to the location of a given instrument when the surgeon selects the technical data tab 112. Thus, technical resource information can be efficiently accessed during the surgical procedure.

The menu 96 also includes a tracker sub-menu 114 and an annotation sub-menu 116. In the illustrated embodiment, the tracker sub-menu 114 includes a "current" tab 118, a "past trajectory tab 120" and a "anticipated trajectory" tab 122 Provides on-demanded view options to display instrument navigation information: When the user selects tab 118, the current position of the tool is displayed in the image panes. The traveled trajectory is displayed The predicted trajectory is displayed based on the current position of the head of the instrument when the user selects tab 122. It is contemplated that one or more tabs may be active or selected at the same time.

Annotation sub-menu 116 includes a "New" tab 124, a "View" tab 126, and an "Edit" tab 128. Tabs 123, 126, 128 facilitate the creation, viewing and editing of annotations relating to surgical procedures and anatomical and neurological observations. In this regard, the surgeon may annotate or record an overall observation of an anatomical observation, such as a particular surgical procedure or neurostructure, its location, completeness, or nerve response. In one preferred embodiment, the computer automatically associates the annotation with the location of the instrument when the annotation is made. Thus, annotations may be made during surgery and associated with neural structures or other structures. In addition, by clicking on the “View” tab 126, the computer can cause the list of annotations to appear in the pane 116. Alternatively, or in addition, annotations associated with the neurostructure may be shown by positioning the instrument in proximity to the neurostructure. Similar to the mouse-over technique, any previous annotations will automatically appear if this feature is activated when the instrument is placed close to an annotated neurostructure.

It should be appreciated that a patient example tab 130 or certain other tabs and selectors may be incorporated into the menu pane 96 as a general example. It should also be understood that the presentation and arrangement of menu compartment 96 is just one embodiment contemplated.

Referring now to FIG. 5, an image compartment 102 is shown that further illustrates instrument tracking. As described above, when the user selects the appropriate input tap, the instantaneous position of the instrument can be shown relative to the patient's anatomy through localization of the pointer 106. Also, when the “past trajectory” tab 120 of the menu 96 of FIG. 4 is selected, the past or moving trajectory of the instrument is shown with a dashed trajectory line 132. Similarly, predictive trajectory 134 may also be shown for the patient's anatomy based on the instantaneous position and orientation of the tip or tip of the instrument.

Orbital paths are also stored and the stored orbits can be recalled and viewed against the anatomy of the patient. In this regard, current or real time instrument trajectories can be compared with past trajectories. In addition, not all instrument movements are recorded. In this regard, the surgeon or other user can turn the instrument tracking function on or off as desired. In addition, although the above-described look-ahead technique projects a graphical representation of the instrument into the images, it is not necessary that the graphical representation of the instrument exists in the space of the image to be projected into the image. That is, for example, the surgeon may place the instrument on top of the patient and outside the space of the image, so that the representation of the instrument does not appear in the image. However, it may still be desirable to project into the image at a fixed length for easy planning of the procedure.

In the illustrated embodiment, the trajectory is represented by a directional line. However, other expressions can also be used. For example, trajectories can be automatically assigned to different colors or unusual numeric labels. Other types of direction indicators may also be used, and different shapes, styles, sizes, and textures may also be applied to distinguish the trajectories. The surgeon can also make the sign invisible for any trajectory if desired. The surgeon may also change the default color or label text for any trajectory with appropriate control in menu 96. In one embodiment, past trajectories may be designated one color and predictive or predicted trajectories may be designated different colors. In addition, although a single trajectory is shown in FIG. 5, several instruments can be tracked simultaneously so that these trajectories can be tracked, predicted and displayed in an image.

As illustrated in FIGS. 1-5, the integrated system 10 tracks the position of an instrument, such as a surgical tool or probe, using markers, reflectors, and the like relative to the anatomy of the patient. In one aspect, the instrument can also apply electrical stimulation to the neurostructure so that neural information, such as nerve position and nerve integrity, can be determined without introducing another instrument into the patient's anatomy. The instrument may be connected to a computer via a stimulator control interface 86 and a power supply 90, and in an alternative embodiment the instrument is wirelessly connected to and guided to the stimulator controller interface 86. The power may be supplied by power or by a self-contained battery.

FIG. 6 is operational circuitry for powering a tool by induction and wirelessly determining positional information of the instrument without using markers and reflectors. The operation circuit 136 includes a signal generator 138 for generating an electromagnetic field. Signal generator 138 preferably includes multiple coils (not shown). Each coil of the signal generator 138 is successively activated to induce a plurality of magnetic fields and thus to induce a corresponding voltage signal in the sensing coil.

The signal generator 138 applies a separate magnetic assembly so that the induced voltage of the sense coil 140 corresponding to the time-dependent magnetic field transmitted is determined by the point of the instrument, e. Provide sufficient information to explain the direction. Coil as used herein refers to an electrically conductive, magnetically sensitive member that generates an induced voltage signal representing it as a function of the applied time varying magnetic field in response to time-varying magnetic fields. The signal generated by the signal generator 138 and having enough information to describe the position of the instrument is referred to as reference signals hereinafter.

The signal generator is also configured to induce a voltage in the sense coil 140, which is used to power electronic components of the instrument, such as the nerve stimulation unit 142 and the transmitter 144. Suffice. In a preferred embodiment, the signal transmitted by the signal generator 138 to power the device is hereinafter referred to as the power signal and is frequency multiplexed with the reference signal. The frequency ranges of the reference and power signals are modulated to occupy mutually exclusive frequency intervals. Due to this technique, the signals are simultaneously transmitted through a common channel such as a radio channel, so that the signals do not interfere with each other. The reference signal and the position signal are preferably frequency modulated (FM), but amplitude modulation (AM) may also be applied.

Alternatively, power signals may be transmitted at different frequencies by separate signal generators. As implemented herein, the portion receiving the reference signal further includes a sensing unit 146 and a power circuit 148. Each of the sensing unit 146 and the power circuit 148 may receive a frequency multiplexed reference signal of the sensing / power coil 140 and a voltage signal induced by the power signal. Both the sensing unit 146 and the power supply circuit 148 can separate voltage signals induced by multiplexed magnetic signals into position signals and power signals.

The sensing unit 146 measures the portion of the induced voltage signal corresponding to the reference signal as a position signal representing the current position of the instrument. The position signal is transmitted by the transmitter 144. Similarly, power supply circuit 148 has a portion of the induced voltage signal corresponding to the power signal to generate sufficient power to power transmitter 144 and apply electrical stimulation to the neural structure. The power supply circuit 148 rectifies the induced voltage generated in the coil 140 by the power supply signal to generate a DC power supply, which is used to supply power to the transmitter 144 and the signal stimulation unit 142. The power supply circuit 148 may store the DC power using a capacitor, a small battery or other storage device for later use.

The integrated system 10 includes an electromagnetic control unit 150 that includes a receiver (not shown) for adjusting the operation of the signal generator 138 and for receiving location information wirelessly transmitted by the transmitter 144. It includes. In this regard, the control unit 150 receives the magnetic field mode position signals and transmits these position signals to the CPU to determine the position and / or orientation of the instrument. Preferably the CPU first determines the angular orientation of the sense coil 140 to determine the position of the instrument and begins using the orientation of the coil 140 to determine the position of the instrument. However, the present invention is not limited to any particular method of determining the position of the instrument. Although a single sense / power coil 140 is shown, separate sense coils and power coils may be used.

As described above, in one aspect of the invention, surgical instruments such as probes, retractors, or bone drivers may also be used to apply electrical stimulation to the neurostructure. In addition to applying electrical stimulation, surgical instruments may be equipped with appropriate circuitry and controls to remotely control the neurosurveillance and navigation system. 7-14 and 18 illustrate surgical and electrostimulation integration tools of various embodiments.

7 shows a surgical probe comprising a handle 154 that is elongated, preferably surfaced, and has a proximal end 156 and a distal end 158. probe 152 is shown. The surgical probe 152 may be connected to the neurosurgery interface 80 of FIG. 3 by jacks 160 extending from the proximal end 156 of the handle. The handle includes a transversely projecting actuator 162 proximate to the tapered distal segment 164, the distal segment terminated at the handle distal end 158, Supports a stainless steel shaft 166 protruding distally. The shaft 166 is tapered and preferably has a larger outer diameter close to the handle distal end 158, tapered to have a smaller outer diameter closer to the shaft distal end 168, and from the handle distal end 158. The distal protruding length to the shaft distal end 168 is wrapped in a shrink tube having a thin wall of transparent plastic. Anode 172 and cathode 174 extend from handle 154 and are electrically connected to conductors 170. The anode and cathode 172, 174 extend slightly further from the shaft distal end 168 and are used to apply electrical stimulation to the neurostructure.

The outer surface of the handle 154 also includes a reflector / marker network 176 to facilitate tracking the position and orientation of the probe 152. Probe 152 is shown having three reflectors 176 secured to handle 154 either permanently or detachably. As is known in conventional surgical instrument tracking systems, the size, shape and position of the reflectors 176 are recognized by the surgical navigation system, so the position and orientation of the probe 152 is immediately identified when captured by the camera. Can be. Three or more or less reflectors can be used.

The surgeon applies electrical stimulation to the anatomy of the patient through the actuator 162 in the surgical procedure. Therefore, the probe 152 may be used for surgical purposes without applying electrical stimulation, and may be used to obtain a neural response from the neural structure if necessary by the doctor. In the embodiment shown in FIG. 7, the probe 152 is powered by a power supply (not shown) external to the probe 152 via jacks 160.

8 illustrates a battery powered retractor in accordance with another embodiment of the present invention. Retractor 178 includes a handle 180 that is long and preferably surface treated and has a proximal end 182 and a distal end 184. Tapered shaft 186 extending from distal end 184 terminates at a curved head 188 that includes an anode tip 190 and a cathode tip 192 coplanar with each other. do. Alternatively, the anode and cathode electrodes 232, 234 can be oriented concentrically with one another as described in FIGS. 12-14 for the exemplary surgical tab. The handle 180 provides an interior volume 194 made of a size and shape to accommodate batteries 196 that provide sufficient power to electrostimulate the neurostructures, if desired by the surgeon. In one embodiment, the batteries 196 are permanently sealed within the interior space 194 of the handle 180 to prevent contact with body fluids and wash fluid. In other embodiments not shown herein, the cap portion of the handle can be screwed to remove and replace the battery. It is contemplated that a rechargeable battery could also be used and that the battery could be charged without removing it from the handle.

Handle 180 also includes three reflectors 198 that provide visual feedback to a camera (not shown) or other detector to determine the position and orientation of the retractor. Similar to that described in FIG. 7, the retractor 178 further includes an actuator 200 so that the surgeon can selectively activate the electrical stimulation function of the retractor 178 to apply electrical stimulation to the neurostructure.

9 illustrates a corded retractor 202 according to the present invention. In this embodiment, retractor 202 is powered by a remote battery or other power supply through a conventional jack connection using jacks 204. As described with respect to FIG. 8, the handle 206 of the retractor 202 includes reflectors 208 that allow surgical navigation hardware and software to track the position and orientation of the retractor 202. The retractor 202 also optionally includes an actuator 210 that applies electrical stimulation to the neurostructure. It is easily electrostimulated by an anode conductor 212 and a cathode conductor 214 extending beyond the shaft 216. The positive and negative conductors 212, 214 extend along the entire length of the shaft 216 and are connected to the power supply through connection with jack connectors 217.

It is contemplated that for both retractor embodiments the position and orientation of the retractor can be monitored, so that the retractor can be opened or closed automatically to prevent nerve-related damage caused by extended traction.

In another embodiment as shown in FIG. 10, a bone screwdriver 218 is configured to supply electrical stimulation in addition to turning the bone screw. Driver 218 includes a handle 220 and a driving shaft 222 extending from its distal end. The handle 220 is sized to accommodate batteries 224 that provide power for electrical stimulation. The handle 20 also includes reflectors 226 that are permanently or detachably attached. The drive shaft 222 extends from the distal end 228 of the handle 220 to a driving head 230 that is sized and shaped to turn a bone screw. Anode and cathode electrodes 232, 234 are coated parallel to the drive shaft 222. When the coated electrodes 232, 234 extend, the electrodes extend beyond the drive head 230 of the drive shaft 222. The coated anode and cathode electrodes 232, 234 may be preferably retracted unobstructed while the surgeon turns the bone screw.

The covered electrodes 232, 234 are manually extended or retracted by a surgeon using an eyelet 236. Preferably, the eyelet is positioned close enough to the handle 220 such that the surgeon can press the actuator 238 to extend and retract the electrodes 232 and 234 and apply electrical stimulation even when holding the handle 220. have. The handle thus comprises a cavity (not shown) formed by suitable stops that define the range of movement of the electrodes.

11 is a front view of a surgical tab in accordance with another aspect of the present invention. In the present embodiment, the surgical tab 240 is for making pedicle holes, but may give nerve stimulation and provide navigation information. In this regard, surgical tab 240 includes handle 242 and a conductive shaft 244 extending therefrom. An insulating sheath 246 surrounds only a portion of the shaft to limit the electrical stimulation to only the conductive tip 248. Conductive tip 248 includes a series of threads 250 that engage the pedicle or other bone structure while the tab is inserted. Threads 250 are configured such that longitudinal recesses or channels 252 are formed along the length of the tip.

The handle 242 has an actuator switch 254 that allows the user to selectively apply electrical stimulation while the tip is inserted. Thus, electrical stimulation can be applied while the surgical tab forms a pedicle screw pilot hole or during pedicle examination. Energy is applied to the conductive chip 248 via a conductor 256 connectable to the energy source of the neural monitoring system of FIG. 1. Alternatively, batteries may be disposed in the handle and used to supply electrical stimulation energy to the conductive tip 248.

The handle 242 also includes reflectors 258 that provide visual feedback to a camera (not shown) or other detection device to determine the position and orientation of the tab. Those skilled in the art will appreciate that other techniques may be used to track the position of the tab, for example electronic position sensors on the handle.

12 illustrates a surgical probe 260 according to another embodiment of the present invention. Similar to the embodiment described above, the probe 260 has a handle 262 to which a series of reflectors 264 are connected or otherwise formed. Jacks 266 extend from the proximal end of the handle to connect probe 260 to the energy source of the neurosurgery system of FIG. 2. Conductive shaft 268 extends from the distal end of handle 262 and is partially covered by an insulating sheath 270. The uncoated portion of the shaft 268 is a conductive tip 272 that can inspect the pedicle or other bone structure. The handle also has an actuator 274 that selectively powers the conductive tip 272 to apply electrical stimulation during inspection.

13 is a cross sectional view of the conductive tip 272. As shown, the conductive shaft 268 includes an anode conductive portion 274 and a cathode conductive portion 276 separated from the anode conductive portion 274 by an insulator 278. This is shown in more detail in FIG. 14. According to this configuration, an electrical stimulus is applied between the anode conducting portion 276 and the electrically insulated cathode conducting portion 274 for bipolar electrostimulation.

The exemplary tools described above are designed to perform surgical functions as well as to apply electrical stimulation to the nervous structures of the patient. As described herein, with the aid of image based navigation, a surgeon can move an instrument and view this movement in real time, if desired, without any additional stimulation instrument at various instrument locations. Polarity and bipolarity) can be applied. The electrical stimulation may also be applied to improve navigation by applying the preceding electrical stimulation pattern. In this regard, electrical stimulation is automatically applied in front of the tip of the instrument when the instrument crosses the patient's anatomy. Therefore, neural information is automatically acquired when the instrument moves and the visualization of the anatomy of the patient is automatically updated to incorporate neural information. Neural information can also be used to more specifically localize the actual location and orientation of neural structures. For example, a wide range of electrical stimuli can be applied when the instrument is in motion. If no nerve response is measured, this widespread electrical stimulation continues. However, when the nervous response is measured, pinpointing electrostimulation can be applied repeatedly while localizing the stimulated neurostructure location, reducing coverage.

In another embodiment, referring to FIG. 15, prior electrical stimulation may be used to signal a surgeon that the instrument is approaching a nerve or nervous structure. The signal may be in the form of a visual identifier on a graphical user interface or an audible warning broadcast through the audio system described herein. In this regard, in step 280 the integrated system determines the instantaneous position of the instrument. Then at step 282 the system compares the position of the instrument with information about the patient's anatomical makeup to determine the proximity of the tool to the neurostructure that may not appear readable in the anatomical visualization. If the instrument is not adjacent to the neural structure at steps 282 and 284, the process loop returns to step 280. If the instrument is in or adjacent to an already identified neurostructure at steps 282, 286, the neurostructure is identified or classified from the patient's anatomical framework and / or neural response of the structure. Once the neural structure is identified in step 288, an appropriate signal is output in step 290 to signal that the instrument is adjacent to the neural structure. It is contemplated that the strength and discernment of the signal may be based on the type of neurostructure found to be in proximity to the instrument. For example, the size and pattern of audible alarms may vary depending on the type of neurostructure. Also in embodiments of audible proximity indicators, the magnitude and / or pattern of audible beeps may change as the instrument approaches or moves away from the neurostructure. Thus, audible signals provide the surgeon with real-time feedback of the position of the instrument relative to the neurostructure. After the appropriate signal is output, the process returns to determining the position of the instrument at step 280.

As mentioned above, the integrated system may perform measurements between trajectories or between instrument positions. Thus, for example, bone measurements can determine whether enough bone has been removed at a particular surgery. For example, the instrument may be tracked via a profile of the bone portion to be removed. Then the trajectory through the profile can be stored as one trajectory. After one or more bone removal procedures, the instrument may be tracked back through the bone from which portions have been removed. The system can then calculate the difference between these trajectories and provide quantitative figures to the surgeon, for example, via a graphical user interface to help the surgeon determine if enough bone has been removed at a particular surgery.

In addition, the characteristics of the electrical stimulation can be automatically adjusted based on the momentary position of the tracked instrument. That is, through a real-time tracking of the instrument and an overall understanding of the patient's anatomical layout from images, atlas models, etc., an integrated system allows the anatomical structure to be in close proximity to the instrument when the surgeon indicates the application of electrical stimulation. The strength, range, and type of electrical stimulation can be set automatically based on. Without automatically setting the electrical stimulation characteristics, the system may similarly display the electrical stimulation values induced by the system in a graphical user interface for consideration by the surgeon. In this regard, the surgeon may apply, through appropriate inputs to the graphical user interface, or define a different value than those suggested by the system. In addition, because the instrument is used for bone milling or removal and electrical stimulation, neural responses can be measured during active milling or bone removal.

Although surgical navigation and neurosurgery integration systems have been described, stand-alone systems can be communicatively coupled to one another in a handshake manner. Thus, through software modules such as those described herein, the neural information provided by the independent neurosurgical probe and system is provided to an independent surgical navigation system to provide an integrated visualization of the navigation information and the neurosurgical information.

As described above, the integrated system may provide the surgeon with on-demand access to technical resources. The integrated system is also designed to provide a list of on-demand resources based on instrument location, neural structure location or neural structure response. As shown in FIG. 16, in step 292 the integrated system receives user input from a surgeon or other user requesting the disclosure of technical resources. In step 294, in response to the input, the integrated system determines the instantaneous position of the instrument when requested. In step 296, an anatomical structure close to the instrument is determined based on the instrument position. From the location of the instrument, the identified close anatomy, and possibly the neural response of the adjacent neural structure, in step 298 the system accesses the corresponding portion of the technical resource database to obtain a list of relevant technical resources that can be released to the surgeon in step 299. Induce and mark. Preferably the list is in the form of selectable computer data links displayed in a graphical user interface for the surgeon to select, and can be linked to, for example, posts, publications, instructions, maps, presentations, videos, instructions and manuals. . In response to the user selection in the graphical user interface at step 302, the technical resource selected at step 304 is uploaded from the database and disclosed to the surgeon or other user. The integrated system can upload technical resources from a local or remote database.

Another process that can be performed by the integrated system described herein is shown in FIG. 17. 17 discloses steps in which a prediction process that provides feedback to a surgeon or others evaluates neuronal integrity. The process commences at step 306 and determines the location of the electrical stimulation mechanism when the electrical stimulation is applied. In step 308 the location of the stimulated neural structure is also determined. Based on the location of the neural structure, the neural structure is identified in step 310. Identification of the neural structure can be determined by comparing the patient's anatomical information to previous neural maps, graphical models, anatomical maps, and the like. Based on the identification of neural constructs, such as classes, in step 312 the neural response of the neural constructs to electrical stimulation is predicted. Then in step 314 the predicted neural response is compared with the actual, measured neural response. In step 316, the results of the comparison are communicated by the graphical user interface to the surgeon or other user to assist in determining the integrity of the stimulated neurostructure. In addition, the visualization of the stimulated and measured neurostructure is automatically updated based on the comparison, indicating that the neural response, for example color coded or annotated, does not match what was expected.

7-14 illustrate various embodiments of surgical instruments in accordance with the present invention. 18 shows another surgical instrument according to the present invention. In particular, FIG. 18 illustrates a NIM probe 318 that can be used to apply electrical stimulation to the neurostructure. The NIM probe can be used to form pilot holes in the pedicle so that neurosurgery can be performed during the formation of the pilot holes.

The illustrated NIM probe is generally similar to the configuration described in US 2006/0173521, the entire contents of which are incorporated herein by reference. NIM probe 318 includes a needle assembly 320 and a handle assembly 322. The needle assembly 320 is electrically connected to the neurosurveillance system 324 by a lead 326. Conductor 326 extends through handle assembly 322 and is electrically connected to a stylet 328. The stylet 328 is disposed inside an insulating cannular 330. In this regard, stylet 328 protrudes distal from cannula 330. The proximal protrusion of stylet 328 includes a tip portion 332 that can be used to penetrate skin, soft or hard tissue, form a pedicle pilot hole, and apply electrical stimulation to the neurostructure. NIM probe 318 optionally includes a sheath 334 surrounding a portion of cannula 330 and / or stylet 328. Preferably, cannula 330 and sheath 334 are made of a non-electrically conductive material. In this regard, the unexposed portion of the stylet is electrically insulated from tissue adjacent to the NIM probe when current is applied to the tip 332.

The NIM probe also includes navigational sensors 335 located at various points in the cannula, sheath and handle assembly 322. In one embodiment, the sensors are passive devices, such as reflectors. In another embodiment, the sensors are active devices, such as emitters or transmitters. In another embodiment, passive and active devices may be used in combination. Active devices may be activated by energy supplied from neural monitoring system 324 to the NIM probe. Alternatively, the active devices may be powered independently, for example by batteries. Navigation sensors 326 communicate with a surgical navigation system as described herein to determine the location and / or orientation of the instrument in real time. As described above, the user interface may then be updated to include visualization of the instrument (or portion thereof, such as a stylet tip) on the patient's anatomy to help the surgeon diagnose the patient and manipulate the instrument.

Although probes, retractors, drivers and tabs have been shown and described, other surgical instruments in accordance with the present invention can also be used to perform surgical functions as well as to apply electrical stimuli, e.g. blunt dilators, awls. Pedicle access needles, biopsy needles, drug delivery needles, ball tip probes, inner body dilators, spinal disc removal tools disc removal tools, inner body spacer tools, soft tissue retractors, gloves, finger covers, tool guides, and the like. In addition, implants such as pedicle screws, discs or nucleus replacements may also be conductive when connected to the conducting portion of the surgical instrument and thus may be used to apply electrical stimulation while the implant is implanted. For example, bone screws may also be used to apply electrical stimulation when engaged with the driving end and the conductive end of the driver. In addition, while surgical instruments having reflectors for optically determining the position and orientation of the instrument are shown by way of example, the surgical instruments may electromagnetically determine the position and orientation of the instrument, as described with respect to FIG. Circuitry for inductively powering the electrical stimulation and transmitter circuitry. In addition, surgical instruments may be adapted to control the parameters of surgical navigation and neurosurgery systems. It is also contemplated that surgical instruments can communicate with surgical navigation and neurosurveillance systems via a wireless or wired connection. It is also contemplated that the magnitude of the electrical stimulation may be pre-defined or automatically determined based on the relative position and orientation of the instrument. Thus, the electrical stimulation intensity and pattern can be automatically determined based on the position of the instrument.

The surgical instruments described herein show various embodiments in which the present invention may be implemented. It will be appreciated that other instruments may be used in addition to those described. In addition, the tool is preferably formed of a biocompatible material, for example stainless steel. However, it will be appreciated that other biocompatible materials may be used. It will also be appreciated that non-tips of the instrument can be used to apply electrical stimulation. For example, a dilator or retractor blade can be configured such that multiple electrodes are formed along the length of the instrument. Thus, electrical stimulation can be selectively applied along the length of the device.

Although only a few example implementations have been described in detail above, those skilled in the art will readily appreciate that many modifications may be made within the example implementations without departing from the novel teachings and advantages herein. I will understand. Accordingly, all changes and alternatives are intended to be included within the scope of the invention as defined in the following claims. Those skilled in the art will also appreciate that such changes and equivalent constructions or methods do not depart from the spirit and scope of the invention, and that those skilled in the art will appreciate that various changes herein, without departing from the spirit and scope of the invention, It should be understood that alternatives and alternatives may be made. "Horizontal", "vertical", "top", "top", "bottom", "bottom", "left", "right", "cephalad", "caudal", It is to be understood that all spatial representations such as “upper” and “lower” are for illustrative purposes and may vary within the scope of the present invention. Moreover, embodiments of the present invention are directed to multiple spinal levels and spinal motion segments. In addition, although embodiments have been described with respect to the spine, and more particularly spinal motor segments, the invention applies similarly to other motor segments and sites of the body. In the claims, means-plus-function phrases are intended to include equivalent elements as well as structural equivalents, as described herein, to perform the aforementioned function. .

1 is a diagram of a surgical navigation and neurosurgery integrated system.

FIG. 2 is a view of an operating room having the surgical navigation and neurosurveillance integrated system of FIG. 1.

3 is a block diagram of the surgical navigation and neurosurgery integrated system of FIG.

4 is a front view of a graphical user interface displayed by the surgical navigation and neurosurveillance integration system of FIGS. 1-3.

FIG. 5 is a partial front view of the graphical user interface shown in FIG. 4.

6 is a block diagram of a wireless instrument tracking system for use with the surgical navigation and neurosurgery integration systems of FIGS. 1-3.

7 is a side view of a surgical probe according to one aspect of the present invention.

8 is a side view of a wireless retractor capable of applying electric stimulation according to one aspect of the present invention.

9 is a side view of a wired retractor capable of applying electric stimulation according to one aspect of the present invention.

10 is a side view of a wireless bone driver capable of applying electrical stimulation in accordance with an aspect of the present invention.

11 is a side view of a surgical tab capable of applying electric stimulation according to another aspect of the present invention.

12 is a side view of a surgical probe according to another aspect of the present invention.

FIG. 13 is a cross-sectional view taken along line 13-13 of the surgical probe of FIG. 12.

14 is an end view of the surgical probe shown in FIGS. 12-13.

15 is a flow chart of the steps of signaling an instrument proximity to an anatomical structure in accordance with an aspect of the present invention.

16 is a flowchart of steps for accessing and publishing a technical resource in accordance with an aspect of the present invention.

17 is a flowchart of steps for determining neural structure integrity in accordance with an aspect of the present invention.

18 illustrates a neurosurveillance probe according to another aspect of the present invention.

Claims (32)

A mechanism having a handle portion and a body member extending from the handle portion, wherein the body member has an electrically conductive portion connected to an energy source and is connected to the energy source. A mechanism capable of applying electrostimulation energy supplied by the apparatus; And A surgical tool capable of applying electrostimulation, comprising a tracking system associated with the instrument and operative to provide information related to the position of the instrument, wherein the surgical tool is capable of applying electrostimulation. An energy source includes one or more battery packs disposed within the handle portion, wherein the energy source is positioned away from the instrument. The surgical instrument of claim 1, wherein the handle portion comprises an electrical lead connected to the energy source. delete The electrical stimulation of claim 1, wherein the body member includes an electrically insulated outer surface area, wherein the electrically conductive portion extends from the handle portion and is present within the insulated outer surface. Surgical instruments that can be added. The apparatus of claim 1, wherein the tracking system includes a set of reflectors coupled to the instrument and operative to reflect the energy detected and analyzed by a navigation system to determine the real time position of the instrument. , Surgical instruments that can apply electrical stimulation. 6. The surgical instrument of claim 5, wherein the set of reflectors is connected to an outer surface of the handle portion. The electrical stimulation of claim 1, wherein the tracking system includes a set of emitters coupled to the instrument and operable to provide detectable energy analyzed by the navigation system to determine the real time position of the instrument. Applicable Surgical Instruments. 8. The surgical tool of claim 7, wherein the set of emitters is actuated by electrical energy provided to the instrument by the energy source. The surgical instrument of claim 1, wherein the instrument is capable of applying bi-polar electrostimulation. The surgical instrument of claim 1, wherein the instrument is a surgical probe. The surgical instrument of claim 1, wherein the instrument is a surgical tab. The surgical instrument of claim 1, wherein the instrument is a screwdriver. The surgical instrument of claim 1, wherein the instrument is a retractor. The surgical instrument of claim 1, wherein the instrument is capable of applying uni-polar electrostimulation. The surgical tool of claim 1, wherein the electrically conductive portion has a distal end configured to be detachably coupled to an electrically conductive implant. 16. The surgical tool of claim 15, wherein the electrically conductive implant comprises a pedicle screw. The surgical tool of claim 15, wherein the electrically conductive implant comprises an artificial disc. The surgical instrument of claim 15, wherein the electrically conductive implant comprises a nuclearus replacement. A mechanism having a handle, an insulating sheath and a conductive member connected to the handle and residing within the insulating sheath, wherein a portion of the conductive member protrudes distal from the insulating sheath; Operable by an instrument, designed to provide electrical energy to the conductive member to apply electrical stimulation to the neural structure when a neural structure is in contact with a portion of the conductive member and electrical energy is provided to the conductive member Energy source; And And a tracking system associated with the instrument and operative to provide information related to the position of the instrument. 20. The surgical instrument assembly of claim 19, wherein said energy source is a battery. The surgical tool assembly of claim 20, wherein the battery is housed inside the handle. 20. The surgical instrument assembly of claim 19, wherein the insulating sheath comprises a non-conductive coating on the conductive member. 20. The surgical tool assembly of claim 19, wherein the instrument is one of a probe, retractor, driver, and tab. 20. The surgical instrument assembly of claim 19, wherein the instrument is capable of applying bipolar or unipolar electrical stimulation to the neural structure. 20. The surgical tool assembly of claim 19, wherein the tracking system comprises an active tracking element, a passive tracking element, or a combination of active and passive tracking elements. A neuromonitoring instrument capable of applying electrical stimulation to a neural structure, the instrument comprising: A stylet extending from the handle and the distal end of the handle; And A navigation sensor associated with at least one of the handle and stylet, wherein the navigation sensor includes a navigation sensor operative to provide feedback regarding the position of the instrument. Neural Surveillance Device Applicable. 27. The cannula of claim 26, wherein the neuromonitoring mechanism further comprises a cannular of insulating material extending from the distal end of the handle, wherein the stylet is a lumen of the cannula. Neural monitoring device that is disposed inside, which can apply electrical stimulation to the nerve structure. 28. The neuromonitoring device according to claim 27, wherein the navigation sensor is fixed to an outer surface of the cannula. 29. The neuromonitoring apparatus according to claim 28 wherein said navigation sensor is a reflector. 27. The neurosurgery device of claim 26 wherein the handle receives an energy source for providing energy to the stylet for applying electrical stimulation to the neural structure. 31. The neuromonitoring apparatus according to claim 30, wherein said energy source is a battery. 27. The neurosurgery device of claim 26 wherein the stylet includes a sharp distal end capable of forming a hole in the pedicle.

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