text:
|Publication number
|Publication type
|Application number
|Publication date
|29 Nov 2007
|Filing date
|9 May 2006
|Priority date
|9 May 2006
|Also published as
|Publication number
|Murray Solsberg, Donald Schomer, Timothy Reeves, Bryce Way
|Original Assignee
|X-Sten, Inc.
|Export Citation
|BiBTeX, EndNote, RefMan
|Referenced by (41), Classifications (19), Legal Events (8)
|External Links: USPTO, USPTO Assignment, Espacenet
Not Applicable.
Not Applicable.
1. Field of the Invention
The present invention relates to minimally invasive methods, devices and systems for treating spinal disorders using imaging guidance. This invention also relates to devices used to reduce stenosis and increase the cross-sectional area of the spinal canal available for the spinal cord. This invention also relates to methods, devices, therapies and medications used to treat disorders that involve the epidural space within the spinal canal.
2. Background of the Invention
The vertebral column (spine, spinal column, backbone) forms the main part of the axial skeleton, provides a strong yet flexible support for the head and body, and protects the spinal cord disposed in the vertebral canal, which is formed within the vertebral column The vertebral column comprises a stack of vertebrae with an intervertebral disc between adjacent vertebrae. The vertebrae are stabilized by muscles and ligaments that hold the vertebrae in place and limit the movements of the vertebrae.
As illustrated in
Vertebral arch 14 is formed by two pedicles 24 which project posteriorly to meet two laminae 16. The two laminae 16 meet posteriomedially to form the spinous process 18. At the junction of pedicles 24 and laminae 16, six processes arise. Two transverse processes 20 project posterolaterally, two superior articular processes 22 project generally superiorly and are positioned superior to two inferior articular processes 25 that generally project inferiorly.
The vertebral foramen 15 is generally an oval shaped space that contains and protects the spinal cord 28 Spinal cord 28 comprises a plurality of nerves 34 surrounded by cerebrospinal fluid (CSF) and an outermost sheath/membrane called the dural sac 32. The CSF filled dural sac 32 containing nerves 34 is relatively compressible. Posterior to the spinal cord 28 within vertebral foramen 15 is the ligamentum flavum 26. Laminae 16 of adjacent vertebral arches 14 in the vertebral column are joined by the relatively broad, elastic ligamentum flavum 26.
In degenerative conditions of the spine, narrowing of the spinal canal (stenosis) can occur. Lumbar spinal stenosis is often defined as a dural sac cross-sectional area less than 100 mm2 or an anterior-posterior (AP) dimension of the canal of less than 10-12 mm for an average male.
The source of many cases of lumbar spinal stenosis is thickening of the ligamentum flavum. Spinal stenosis may also be caused by subluxation, facet joint hypertrophy, osteophyte formation, underdevelopment of spinal canal, spondylosis deformans, degenerative intervertebral discs, degenerative spondylolisthesis, degenerative arthritis, ossification of the vertebral accessory ligaments and the like. A less common cause of spinal stenosis, which usually affects patients with morbid obesity or patients on oral corticosteroids, is excess fat in the epidural space. The excessive epidural fat compresses the dural sac, nerve roots and blood vessels contained therein and resulting in back, leg pain and weakness and numbness of the legs. Spinal stenosis may also affect the cervical and, less commonly, the thoracic spine.
Patients suffering from spinal stenosis are typically first treated with exercise therapy, analgesics, and anti-inflammatory medications. These conservative treatment options frequently fail. If symptoms are severe, surgery is required to decompress the spinal cord and nerve roots.
In some conventional approaches to correct stenosis in the lumbar region, an incision is made in the back and the muscles and supporting structures are stripped away from the spine, exposing the posterior aspect of the vertebral column. The thickened ligamentum flavum is then exposed by removal of a portion of the vertebral arch, often at the laminae, covering the back of the spinal canal (laminectomy). The thickened ligamentum flavum ligament can then be excised by sharp dissection with a scalpel or punching instruments such as a Kerison punch that is used to remove small chips of tissue. The procedure is performed under general anesthesia. Patients are usually admitted to the hospital for approximately five to seven days depending on the age and overall condition of the patient. Patients usually require between six weeks and three months to recover from the procedure. Further, many patients need extended therapy at a rehabilitation facility to regain enough mobility to live independently.
Much of the pain and disability after an open laminectomy results from the tearing and cutting of the back muscles, blood vessels, supporting ligaments, and nerves that occurs during the exposure of the spinal column. Also, because the spine stabilizing back muscles and ligaments are stripped and detached from the spine during the laminectomy, these patients frequently develop spinal instability post-operatively.
Minimally invasive techniques offer the potential for less post-operative pain and faster recovery compared to traditional open surgery. Percutaneous interventional spinal procedures can be performed with local anesthesia, thereby sparing the patient the risks and recovery time required with general anesthesia. In addition, there is less damage to the paraspinal muscles and ligaments with minimally invasive techniques, thereby reducing pain and preserving these important stabilizing structures.
Various techniques for minimally invasive treatment of the spine are known. Microdiscectomy is performed by making a small incision in the skin and deep tissues to create a portal to the spine. A microscope is then used to aid in the dissection of the adjacent structures prior to discectomy. The recovery for this procedure is much shorter than traditional open discectomies. Percutaneous discectomy devices with fluoroscopic guidance have been used successfully to treat disorders of the disc but not to treat spinal stenosis or the ligamentum flavum directly. Arthroscopy or direct visualization of the spinal structures using a catheter or optical system have also been proposed to treat disorders of the spine including spinal stenosis, however these devices still use miniaturized standard surgical instruments and direct visualization of the spine similar to open surgical procedures. These devices and techniques are limited by the small size of the canal and these operations are difficult to perform and master. In addition, these procedures are painful and often require general anesthesia. Further, the arthroscopy procedures are time consuming and the fiber optic systems are expensive to purchase and maintain.
Still further, because the nerves of the spinal cord pass through the spinal canal directly adjacent to and anterior to the ligamentum flavum, any surgery, regardless of whether open or percutaneous, includes a risk of damage to the nerves of the spinal cord.
Hence, it remains desirable to provide simple methods, techniques, and devices for treating spinal stenosis and other spinal disorders without requiring open surgery. It is further desired to provide a system whereby the risk of damage to the dural sac containing the spinal nerves may be reduced.
The present invention provides methods, devices and systems for treating spinal stenosis or other spinal disorders using image guidance in combination with percutaneous techniques. Embodiments of the present approach are referred to as an ipsilateral approach minimally invasive ligament decompression procedure (ILAMP). In some embodiments, the present invention provides a means for compressing the thecal sac within the epidural space so as to provide a safety zone in which further surgical procedures may be performed without risk of damaging nearby tissues or the thecal sac itself.
In another embodiment, the present invention provides a method for treating stenosis in a spine of a patient. In an embodiment, the method comprises the steps of a) generating at least one view of a portion of the spinal canal in the region of interest; b) percutaneously accessing the epidural space in the region of interest; c) compressing the dural sac in the region of interest by injecting a fluid to form a safety zone and establish a working zone, the safety zone lying between the working zone and the dural sac; d) inserting a tissue removal tool into tissue in the working zone; e) using the tool to percutaneously reduce the stenosis by removing at least a portion of the ligamentum flavum by inserting an excision tool into the ligamentum flavum in the region of interest, wherein the portion of the ligamentum flavum removed is on the same side of the ligamentum flavum where the excision tool is inserted into the ligamentum flavum; and f) utilizing the at least one view to position the tool during at least a part of step d) and at least part of step e).
The foregoing has outlined rather broadly the features and technical advantages of embodiments of the present invention in order that the detailed description that follows may be better understood Additional features and advantages of embodiments of the present invention will be described hereinafter that form the subject of the claims. It should be appreciated by those skilled in the art that the conception and the specific embodiments disclosed may be readily utilized as a basis for modifying or designing other structures for carrying out the same purposes. It should also be realized by those skilled in the art that such equivalent constructions do not depart from and scope of the invention as set forth in the appended claims.
For a more complete understanding of the invention, reference is made to the accompanying drawings, wherein:
The following discussion is directed to various embodiments of the invention. Although one or more of these embodiments may be preferred, the embodiments disclosed should not be interpreted, or otherwise used, as limiting the scope of the disclosure, including the claims. In addition, one skilled in the art will understand that the following description has broad application, and the discussion of any embodiment is meant only to be exemplary of that embodiment, and not intended to intimate that the scope of the disclosure, including the claims, is limited to that embodiment
For purposes of this discussion, the x-, y-, and z-axis are shown in
It is to be understood that the median/midsagittal plane passes from the top to the bottom of the body and separates the left and the right sides of the body, and the spine, into substantially equal halves (e.g., two substantially equal lateral sides). Further, it is to be understood that the frontal/coronal plane essentially separates the body into the forward (anterior) half and the back (posterior) half and is perpendicular to the median plane. Still further, it is to be understood that the transverse plane is perpendicular to both the median plane and coronal plane and is the plane which divides the body into an upper and a lower half.
The Spinal Canal and Spinal Stenosis
Referring again to
Compression of spinal cord 28, particularly in the lumbar region, may result in low back pain as well as pain or abnormal sensations in the legs. Further, compression of the blood vessels in the epidural space 27 that houses the nerves of the cauda equina may result in ischemic pain termed spinal claudication.
In order to relieve the symptoms associated with a thickened or enlarged ligamentum flavum 26, methods, techniques, and devices described herein may be employed to reduce the compressive forces exerted by the thickened ligamentum flavum on spinal cord 28 and the blood vessels in epidural space 27 (e.g., decompress spinal cord 28 and blood vessels in epidural space 27). In particular, compressive forces exerted by the thickened/enlarged ligamentum flavum 26 may be reduced by embodiments of a minimally invasive ligament decompression (MILD) procedure described herein. In some embodiments, the MILD procedure may be performed percutaneously to reduce the size of ligamentum flavum 26 by excising portions of ligamentum flavum 26. In particular, in some embodiments of the MILD procedure, the ligamentum flavum 26 is accessed, cut and removed ipsilaterally (i.e., on the same side of vertebral arch 14) by a percutaneous cranial-caudal approach. Such an embodiment of the MILD procedure may be described hereinafter as Ipsilateral Approach MILD Procedure (ILAMP).
Creation of a Safety Zone
As shown in
As previously described, spinal cord 28 comprises nerves 34 surrounded by CSF and is contained within dural sac 32. Since more than 90% of the volume of dural sac 32 in the lumbar, region is filled by CSF, dural sac 32 is highly compressible. Thus, even when stenosis is causing compression of spinal cord 28, in most cases it is possible to temporarily compress spinal cord 28 further. Thus, according to preferred embodiments, dural sac 32 is further compressed in the region of interest by injecting a fluid into epidural space 27 to create safety zone 40. The presence of the injected fluid comprising safety zone 40 gently applies an additional compressive force to the outer surface of dural sac 32 so that at least a portion of the CSF within dural sac 32 is forced out of dural sac 32 in the region of interest, resulting in safety zone 40 between dural sac 32 and ligamentum flavum 26.
According to some embodiments, dural sac 32 is compressed by injecting a standard radio-opaque non-ionic myelographic contrast medium or other imagable or non-imagable medium into epidural space 27 in the region of interest. This is preferably accomplished with a percutaneous injection. Sufficient injectable fluid is preferably injected to displace the CSF out of the region of interest and compress dural sac 32 to at least a desired degree. The injected medium is preferably substantially contained within the confines of epidural space 27 extending to the margins of the dural sac 32. The epidural space is substantially watertight and the fatty tissues and vascularization in epidural space 27, combined with the viscous properties of the preferred fluids, serve to substantially maintain the injected medium in the desired region of interest. This novel method for protecting spinal cord 28 column may be referred to hereinafter as "contrast-guided dural protection."
Once a safety zone 40 has been created, a tool 100 may be inserted into the ligamentum flavum 26, as will be described in more detail below. Tool 100 may comprise any suitable device, tool or instrument for relieving stenosis caused by the thickened/enlarged ligamentum flavum 26 including without limitation, embodiments of tissue excision devices and tissue retraction devices described in more detail below. Further, as best illustrated in
While it is preferred that the tip of tool 100 remain within ligamentum flavum 26 as shown, the presence of safety zone 40 reduces the likelihood that dural sac 32 will be damaged, even if the tool breaks through the anterior surface of ligamentum flavum 26.
Because the present techniques are preferably performed percutaneously, certain aspects of the present invention may be facilitated by imaging. Imaging windows (e.g., a fluoroscopic window of access—FWA) may be employed to aid in performance of all or, part of the procedures described herein. For instance, an imaging window may be employed to aid in insertion of tool 100 into ligamentum flavum 26 as shown in
In this context, the spine can be imaged using any suitable technology, including without limitation, 2D fluoroscopy, 3D fluoroscopy, CT, MRI, ultrasound or with direct visualization with fiber optic or microsurgical techniques. Stereotactic or computerized image fusion techniques are also suitable. Fluoroscopy is currently particularly well-suited to the techniques disclosed herein. Flouroscopic equipment is safe and easy to use, readily available in most medical facilities, relatively inexpensive. In a typical procedure, using direct biplane fluoroscopic guidance and local anesthesia, epidural space 27 is accessed for injection of contrast media adjacent to the surgical site.
If the injected medium is radio-opaque, as are for example myelographic contrast media, the margins of expanded epidural space 27 will be readily visible using fluoroscopy or CT imaging. Thus, safety zone 40 created by the present contrast-guided dural compression techniques can reduce the risk of damage to dural sac 32 and spinal cord 28 during MILD procedures to remove or displace portions of ligamentum flavum 26 and/or laminae 16 in order to treat spinal stenosis.
Injectable Medium
If desired, the injected medium can be provided as a re-absorbable water-soluble gel, so as to better localize safety zone 40 at the site of surgery and reduce leakage of this protective layer from the vertebral/spinal canal. An injectable gel is a significant improvement on prior epidural injection techniques. The gel is preferably substantially more viscid than conventional contrast media and the relatively viscid and/or viscous gel preferably tends to remain localized at the desired site of treatment as it does not spread as much as standard liquid contrast media that are used in epidurography. This may result in more uniform compression of dural sac 32 and less leakage of contrast out of the vertebral/spinal canal. In addition, preferred embodiments of the gel are re-absorbed more slowly than conventional contrast media, allowing for better visualization during the course of the surgical procedure.
In some embodiments, a contrast agent can be included in the gel itself, so that the entire gel mass is imagable. In other embodiments, an amount of contrast can be injected first, followed by the desired amount of gel, or an amount of gel can be injected first, followed by the desired amount of contrast. In this case, the contrast agent is captured on the surface of the expanding gel mass, so that the periphery of the mass is imagable.
Any standard hydrophilic-lipophilic block copolymer (Pluronic) gel such as are known in the art would be suitable and other gels may be used as the injectable medium. The gel preferably has an inert base. In certain embodiments, the gel material is liquid at ambient temperatures and can be injected through a small bore, such as a 27 gauge needle. The gel then preferably becomes viscous when warmed to body temperature after being injected. The viscosity of the gel can be adjusted through the specifics of the preparation. The gel or other fluid is preferably sufficiently viscid or viscous at body temperature to compress and protect dural sac 32 in the manner described above and to remain sufficiently present in the region of interest for at least about 30 minutes. Thus, in some embodiments, the injected gel attains a viscosity that is two, three, six or even ten times that of the fluids that are typically used for epidurograms.
In certain embodiments, the injected medium undergoes a reversible change in viscosity when warmed to body temperature so that it can be injected as a low-viscosity fluid, thicken upon injection into the patient, and be returned to its low-viscosity state by cooling. In these embodiments, the injected medium is injected as desired and thickens upon warming, but can be removed by contacting it with a heat removal device, such as an aspirator that has been provided with a cooled tip. As a result of localized cooling, the gel reverts to its initial non viscous liquid state and can be easily suctioned up the cooled needle or catheter.
An example of a suitable contrast medium having the desired properties is Omnipaque� 240 available from Nycomed, New York, which is a commercially available non-ionic iodinated myelographic contrast medium. Other suitable injectable media will be known to those skilled in the art. Because of the proximity to spinal cord 28 and spinal nerves 34, it is preferred not to use ionic media in the injectable medium The preferred compositions are reabsorbed relatively rapidly after the procedure. Thus any residual gel compression on dural sac 32 after the MILD procedure dissipates relatively quickly. For example, in preferred embodiments, the gel would have sufficient viscosity to compress dural sac 32 for thirty minutes, and sufficient degradability to be substantially reabsorbed within approximately two hours.
The injected contrast medium further may further include one or more bioactive agents. For example, medications such as those used in epidural steroid injection (e.g. Depo medrol, Celestone Soluspan) may be added to the epidural gel to speed healing and reduce inflammation, scarring and adhesions. The gel preferably releases the steroid medication slowly and prolongs the anti-inflammatory effect, which can be extremely advantageous. Local anesthetic agents may also be added to the gel. This prolongs the duration of action of local anesthetic agents in the epidural space to prolong pain relief during epidural anesthesia. In this embodiment the gel may be formulated to slow the reabsorption of the gel.
The present gels may also be used for epidural steroid injection and perineural blocks for management of acute and chronic spinal pain. Thrombin or other haemostatic agents can be added if desired, so as to reduce the risk of bleeding.
In some embodiments, the gel may also be used as a substitute for a blood patch if a CSF leak occurs. The gel may also be used as an alternative method to treat lumbar puncture complications such as post-lumbar puncture CSF leak or other causes of intracranial hypotension. Similarly, the gel may be used to patch postoperative CSF leaks or dural tears. If the dural sac were inadvertently torn or cut, then gel could immediately serve to seal the site and prevent leakage of the cerebral spinal fluid.
Ipsilateral Approach for MILD Procedure (ILAMP)
Once safety zone 40 has been created, the margins of epidural space 27 are clearly demarcated by the injected medium and may be visualized radiographically if an imageable medium has been used. As mentioned above, percutaneous procedures can then more safely be performed on ligamentum flavum 26 and/or surrounding tissues with reduced potential for injuring dural sac 32 and spinal cord 28.
A variety of suitable techniques may be employed to reduce the size of the thickened/enlarged ligamentum flavum 26, thereby decompressing spinal cord 28 as well as blood vessels contained within the epidural space 27. Examples of suitable decompression techniques include without limitation, removal of tissue from ligamentum flavum 26, laminectomy, laminotomy, and retraction and anchoring of ligamentum flavum 26. In some embodiments, all or a portion of ligamentum flavum 26 is excised using a tissue excision tool (e.g., tool 100). Embodiments of tissue excision tools are described in more detail below.
Accessing ligamentum flavum 26 with a tool 100 to remove portions of ligamentum flavum 26 can present significant challenges For instance, in some conventional approaches to correct stenosis caused by an enlarged ligamentum flavum, an incision is made in the back of the patient and then the muscles and supporting structures of the vertebral column (spine) are stripped away, exposing the posterior aspect of the vertebral column. Subsequently, the thickened ligamentum flavum is exposed by removal of a portion of vertebral arch 14, often at lamina 16, which encloses the anterior portion of the spinal canal (laminectomy). The thickened ligamentum flavum ligament can then be excised by sharp dissection with a scalpel or punching instruments. However, this approach is usually performed under general anesthesia and typically requires an extended hospital stay, lengthy recovery time and significant rehabilitation. Referring briefly to
As previously described, each vertebral arch 14 a, 14 b, 14 c includes two pedicles 24 a, 24 b, 24 c, which project posteriorly to meet two lamina 16 a, 16 b, 16 c, respectively It is to be understood that in this view, one pedicle has been removed from each vertebra 10 a, 10 b, 10 c and only the cross-section of one lamina 16 a, 16 b, 16 c is visible The two lamina 16 a, 16 b, 16 c meet posteriomedially to form the spinous process 18 a, 18 b, 18 c, respectively.
Lamina 16 a, 16 b, 16 c of adjacent vertebra 10 a, 10 b, 10 c are connected by ligamentum flavum 26 (shown in cross-section). The relatively elastic ligamentum flavum 26 extends almost vertically from superior lamina to inferior lamina of adjacent vertebrae In particular, ligamentum flavum 26 originates on the inferior surface of the laminae of the superior vertebrae and connects to the superior surface of the laminae of the inferior vertebrae. For instance, ligamentum flavum 26 originates on the inferior surface of lamina 16 a of superior vertebra 10 a and connects to the superior surface of lamina 16 b of the inferior vertebra 10 b. Thus, ligamentum flavum 26 spans an interlaminar space 82 (i.e., space between laminae of adjacent vertebrae). Interlaminar space 82 is generally the space between laminae of adjacent vertebrae in spinal column 80.
Still referring to
As previously discussed, to relieve compressive forces on the spinal cord and hence relieve the associated symptoms of spinal stenosis, portions of ligamentum flavum 26 may be excised. However, to percutaneously excise portions of ligamentum flavum 26 via minimally invasive techniques, the innate structure of vertebral column 80 and each vertebra may present significant imaging challenges. For instance, lateral imaging windows/views of ligamentum flavum 26 substantially in the direction of the z-axis may be obscured by the various processes of the vertebrae (e.g., transverse processes, superior articular processes, inferior articular processes), the laminae of each vertebra, etc. Further, some anterior-posterior (A-P) imaging windows/views of ligamentum flavum 26 substantially in the direction of the x-axis may also be obscured by the laminae. In particular, in the A-P radiographic imaging planes substantially in the direction of the x-axis, the posterior edges of parallel laminae overlap and obscure ligamentum flavum 26 and interlaminar space 82, particularly the anterior portions of ligamentum flavum 26 and interlaminar space 82 closest to spinal canal 81. However, with an imaging window/view in a plane substantially parallel to the X-Y plane, at an angle θ generally in the direction of arrow 83, and slightly lateral to the spinous process, interlaminar space 82 and ligamentum flavum 26 may be viewed without significant obstruction from neighboring laminae. In other words, imaging windows/views generally aligned with arrow 83 (
Typically, the long axis of the substantially parallel laminae (e.g., laminae 16 a, 16,b, 16 c) and interlaminar spaces (e.g, interlaminar spaces 82) are generally oriented between 60 and 75 degrees relative to posterior back surface 85. Thus, preferably the imaging means (e.g., x-ray beam, fluoroscopy tube, etc.) is positioned generally in the direction represented by arrow 83, where θ is substantially between 60 and 75 degrees relative to the anterior back surface 85. In other words, the imaging means is positioned substantially parallel to the surface of the laminae. The resulting imaging window/view, termed "caudal-cranial posterior view" hereinafter, permits a clearer, more direct, less obstructed view of interlaminar space 82 and ligamentum flavum 26 from the general posterior back surface 85. The caudal-cranial posterior view permits a relatively clear view of interlaminar space 82 and ligamentum flavum 26 in directions generally along the y-axis and z-axis. However, the caudal-cranial posterior view by itself may not provide a clear imaging window/view of interlaminar space 82 and ligamentum flavum 26 in directions generally along the x-axis In other words, the caudal-cranial posterior view by itself may not provide a clear imaging window/view that can be used to accurately determine the posterior-anterior depth, measured generally along the x-axis, of a device across the ligamentum flavum 26.
Thus, in preferred embodiments, an additional imaging window/view, termed "caudal-cranial posterior-lateral view" hereinafter, is employed to provide a clearer, unobstructed view of interlaminar space 82 and ligamentum flavum 26 in directions generally along the y-axis and z-axis. The caudal-cranial posterior-lateral view is generated by orienting an imaging means generally at an angle θ relative to outer surface of the patient and also angling such imaging means laterally in an oblique orientation, revealing a partial lateral view of interlaminar space 82 occupied by ligamentum flavum 26 on the anterior side of the lamina and posterior to the underlying dural sac (not shown) and spinal cord (not shown).
By employing at least one of the caudal-cranial posterior view and the caudal-cranial posterior-lateral views, relatively clear imaging windows/views of the interlaminar space 82 and ligamentum flavum 26 in directions along the x-, y-, and z-axis may be achieved.
More specifically, using images of the interlaminar space 82 and ligamentum flavum 26 obtained from the desired direction(s), (e.g., caudal-cranial posterior view and the caudal-cranial posterior-lateral view), instrument 101 can be employed to penetrate the skin and soft tissue in the posterior back surface 85 of the patient. In preferred embodiments, the skin entry point for instrument 101 is between 5 and 10 cm inferior (caudal to) the posterior surface of the interlaminar space 82 of interest. For instance, if the portion of ligamentum flavum 26 between lamina 16 a and lamina 16 b is the area of interest, then instrument 101 may be inserted into the patient's back about 5 to 10 cm inferior to posterior surface 84 of interlaminar space 82.
Referring now to
Once inserted into the posterior tissue and musculature of the patient, instrument 101 can be positioned to provide a pathway across interlaminar space 82 in the area of interest, generally towards the anterior surface of the lamina superior to the area of interest. For example, if interlaminar space 82 between lamina 16 a and lamina 16 b is the area of interest, instrument 101 is positioned to provide a trajectory that will allow a cutting instrument to be inserted across interlaminar space 82 between lamina 16 a and lamina 16 b towards the anterior surface of lamina 16 a (superior lamina).
By switching between the caudal-cranial posterior view and the caudal-cranial posterior-lateral view, or by viewing both the caudal-cranial posterior view and the caudal-cranial posterior-lateral view at the same time, instrument 101, or an excision tool passing through instrument 101 (e.g., tool 100), can be advanced and inserted into ligamentum flavum 26 in the area of interest with more certainty than has heretofore been present. Once instrument 101, or an excision tool passing therethrough, is inserted into ligamentum flavum 26, portions of ligamentum flavum 26 may be excised so as to relieve pressure on the spinal nerves In some embodiments, resection can be performed generally from posterior to anterior across interlaminar space 82 and then laterally along the anterior portion of ligamentum flavum 26 if desired. The actual depth of the instrument tip in the general direction of the x-axis may be adjusted with guidance from the caudal-cranial posterior-lateral view and appropriate retraction/advancement of instrument 101 and appropriate adjustment of instrument 101 between 5 and 90 degrees relative to the posterior back surface 85.
In the manner described, portions of the ligamentum flavum can be excised by a percutaneous MILD procedure. In particular, with the approach described and as best illustrated in
Percutaneous Tissue Excision
Referring to
Embodiments of the present tissue excision devices and techniques can take several forms. In the discussion below, the distal ends of the tools are described in detail. The construction of the proximal ends of the tools, and the means by which the various components disclosed herein are assembled and actuated, will be known and understood by those skilled in the art.
By way of example, in the embodiment illustrated in
Tissue-engaging means 56 may be a needle, hook, blade, tooth or the like, and preferably has at least one flexible barb or hook 58 attached to its shaft. The barb 58 or barbs may extend around approximately 120 degrees of the circumference of the shaft. Barbs 58 are preferably directed towards the proximal end of the tool. When needle 56 is retracted slightly, barbs 58 allow it to engage a segment of tissue. Depending on the configuration of barbs 58, the tissue sample engaged by needle 56 may be generally cylindrical or approximately hemispherical. Once needle 56 has engaged the desired tissue, inner occluding means 54, which is preferably provided with a sharpened distal edge, is advanced so that it cuts the engaged tissue section or sample loose from the surrounding tissue. Hence occluding means 54 also functions as a cutting means in this embodiment. In alternative embodiments, such as
Referring still to
Referring briefly to
In still other embodiments, the tissue-engaging means may comprise a hook or tooth or the like that engages tissue via aperture 52 by being rotated about the tool axis. In such embodiments (not shown) and by way of example only, the tissue-engaging means could comprise a partial cylinder that is received in outer cannula 51 and has a serrated side edge. Such a device can be rotated via a connection with the tool handle or other proximal device. As the serrated edge traverses aperture 52 tissue protruding into the tool via the aperture is engaged by the edge, whereupon it can be resected and retrieved in the maimer disclosed herein.
In preferred embodiments, the working tip of tool 100 remains within the ligamentum flavum and does not penetrate the safety zone 40. Nonetheless, safety zone 40 is provided so that even an inadvertent penetration of the tool into the epidural space will not result in damage to the dural sac. Regardless of the means by which the tissue is engaged and cut, it is preferably retrieved from the distal end of the tool so that additional tissue segments can be excised without requiring that the working tip of the tool be repositioned. A tissue-removal device such as that described below is preferably used to remove the tissue from the retrieval device between each excision.
Tissue Removal
Each piece of tissue may be removed from barbs 58 by pushing tissue-engaging means 56 through an opening that is large enough to allow passage of the flexible barbs and supporting needle but smaller than the diameter of the excised tissue mass. This pushes the tissue up onto the shaft, where it can be removed with a slicing blade or the like or by sliding the tissue over the proximal end of the needle. Alternatively, needle 56 can be removed and re-inserted into the tool for external, manual tissue removal.
It is expected that in some embodiments, approximately 8-10 cores or segments of tissue will be excised and pushed up the shaft towards the hub during the course of the procedure. Alternatively, a small blade can be used to split the tissue segment and thereby ease removal of the segment from the device. If desired, a blade for this purpose can be placed on the shaft of needle 56 proximal to the barbs.
In an exemplary embodiment, shown in
In an alternative embodiment shown in
In another alternative embodiment (not shown) an alternative mechanism for removing the tissue segment from needle 56 includes an adjustable aperture in a disc. After the tissue-bearing needle is pulled back through the aperture, the aperture is partially closed. Needle 56 and flexible hooks 58 then can pass through the partially closed aperture but the larger cylinder of tissue cannot. Thus the tissue segment is pushed back onto the shaft. The tissue segment can either be pulled off the proximal end of the shaft or cut off of it. A small blade may be placed just proximal to the barbs to help cut the tissue segment off the shaft. The variable aperture can formed by any suitable construction, including a pair of metal plates with matching edges that each define one half of a central opening. The two pieces may be held apart by springs. The aperture may be closed by pushing the two edges together. In other embodiments, this process can be mechanically automated by using a disc or plate with an opening that is adjustable by a variety of known techniques, including a slit screw assembly or flexible gaskets,
Other cutting and/or grasping devices can be used in place of the system described above. For example, embodiments of the grasping mechanism include but are not limited to: needles with flexible barbs, needles with rigid barbs, corkscrew-shaped needles, and/or retaining wires. The corkscrew-shaped needle shown in
In other embodiments, shown in
Advancing one end of sleeve 74 toward the other end of sleeve 74 causes each strip 77 to buckle or bend. If strips 77 are prevented from buckling inward or if they are predisposed to bend in the desired direction, they will bend outward, thereby forming arcuate arms 72, which extend through aperture 52 of cannulated scalpel 51, as shown in
Closable arms 72 may include on their opposing edges 78 ridges, teeth, or other means to facilitate grasping of the tissue. In other embodiments, edges 78 may be sharpened, so as to excise a segment of tissue as they close. In these embodiments, closable arms 72 may also be used in conjunction with a hook, barbed needle, pincers or the like, which can in turn he used to retrieve the excised segment from the device.
Once aims 72 have closed on the tissue, if arms 72 have not cut the tissue themselves, the tissue can be excised using a blade such as cutting element 60 above. The excised tissue can be removed from the inside of needle 51 using a tissue-engaging hook 64 or other suitable means. The process of extending and closing arms 72, excising the tissue, and removing it from the device can be repeated until a desired amount of tissue has been removed.
If desired, this cycle can be repeated without repositioning the device in the tissue. Alternatively, the tool can be rotated or repositioned as desired between excisions It is possible to rotate or reposition the tool during an excision, but it is expected that this will not generally be preferred. Furthermore, it is expected that the steps of tissue excision and removal can be accomplished without breaching the surface of the ligament, i.e. without any part of the device entering the safety zone created by the injected fluid. Nonetheless, should the tool leave the working zone, the safety zone will reduce the risk of injury to the dural sac.
Ligament Retraction
In some embodiments, the spinal canal may also be enlarged by retracting the ligamentum flavum, either with or without concurrent resection. Retraction is preferably but not necessarily performed after dural compression has been used to provide a safety zone. In addition, the dural compression techniques described above have the effect of pressing the ligamentum flavum back out of the spinal canal and thereby making it easier to apply a restraining means thereto.
Thus, in preferred embodiments, after a safety zone is created by epidural injection of contrast medium or gel, a retraction device 90 as shown in
The distal end of the device is preferably positioned in the ligamentum flavum under fluoroscopic guidance. If desired, an accessway through the lamina may be provided using an anchored cannula or the like. The device is held in position by support shaft 112. Distal barbs 91 are unsheathed and optionally expanded by pulling back guide housing 102, as shown in
In an alternative embodiment, the proximal end of ligament anchor 90 may be adapted to engage the lamina. This may be accomplished by having the arm posterior to the lamina or by using the laminotomy and suturing the device to the lamina there. A knotted or knotless system or a suture plate can be used.
A second embodiment of the present method uses a plurality of retraction devices 90. In this embodiment, the retraction device is inserted through one lamina in an oblique fashion, paralleling the opposite lamina. After the distal anchor is deployed, the retraction device is pulled back and across the ligamentum flavum, thereby decompressing the opposite lateral recess of the spinal canal. This is repeated on the opposite side. This same device can also be deployed with a direct approach to the lateral recess with a curved guide housing.
While retraction device 90 is describe above as a double-headed anchor, it will be understood that other devices can be used. For example sutures, barbed sutures, staples or the like can be used to fasten the ligament in a retracted position that reduces stenosis.
Using the percutaneous methods and devices described herein, significant reductions of stenosis can be achieved. For example, a dural sac cross-sectional area less than 100 mm2 or an anteroposterior (A-P) dimension of the canal of less than 10-12 mm in an average male is typically considered relative spinal stenosis. A dural sac cross-sectional area less than 85 mm2 in an average male is considered severe spinal stenosis. The present devices and techniques are anticipated to cause an increase in canal area of 25 mm2 per anchor or 50 mm2 total. With resection and/or retraction of the ligamentum flavum, the cross-sectional area of the dural sac can be increased by 10 mm2, and in some instances by as much as 20 mm2 or even 30 mm2 Likewise, the present invention can result in an increase of the anteroposterior dimension of the canal by 1 to 2 mm and in some instances by as much as 4 or 6 mm. The actual amount by which the cross-sectional area of the dural sac and/or the anteroposterior dimension of the canal are increased will depend on the size and age of the patient and the degree of stenosis and can be adjusted by the degree of retraction of the ligament.
Dural Shield
In some embodiments (not shown), a mechanical device such as a balloon or mechanical shield can also be used to create a protective guard or barrier between the borders of the epidural space and the adjacent structures. In one embodiment a durable expandable device is attached to the outside of the percutaneous laminectomy device, preferably on the side opposite the cutting aperture. The cutting device is inserted into the ligamentum flavum with the expandable device deflated. With the aperture directed away from the spinal canal, the expandable device is gently expanded via mechanical means or inflated with air or another sterile fluid, such as saline solution, via a lumen that may be within of, adjacent to the body of the device. This pushes the adjacent vital structures clear from the cutting aperture of the device and simultaneously presses the cutting aperture into the ligament. As above, the grasping and cutting needles can then be deployed and operated as desired. The balloon does not interfere with tissue excision because it is located on the side opposite the cutting aperture. The cutting needle may be hemispherical (semi-tubular) in shape with either a straight cutting or a sawing/reciprocating blade or may be sized to be placed within the outer housing that separates the balloon from the cutting aperture.
In another embodiment, a self-expanding metal mesh is positioned percutaneously in the epidural spaces. First the epidural space is accessed in the usual fashion. Then a guide catheter is placed in the epidural space at the site of the intended surgical procedure. The mesh is preferably compressed within a guide catheter. When the outer cover of the guide catheter is retracted, the mesh expands in the epidural space, protecting and displacing the adjacent dural sheath The mesh may be configured to have an expanded shape that generally corresponds to the shape of the desired safety zone within the spinal canal. At the conclusion of the surgical procedure, the mesh is pulled back into the guide sheath and the assembly removed. The mesh is deformable and compresses as it is pulled back into the guide catheter, in a manner similar to a self-expanding mesh stent. While there are commercially available self-expanding stents approved and in use in other applications, using a self-expandable mesh configured to expand within the epidural space so as to protect and displace the dural sac is novel.
The ILAMP methods, techniques, and devices described herein allow spinal decompression to be performed percutaneously, avoiding the pain, lengthy recovery time, and risk associated with open surgery. In addition, the ILAMP methods, techniques, and devices described herein permit clearer, less obstructed imaging views of the interlaminar spaces and ligamentum flavum between the laminae in the areas of interest. Such improved imaging views offer the potential for enhanced accuracy and safety in the placement of tools within the ligamentum flavum proximal the epidural space and spinal cord. Further, the ILAMP methods, techniques, and devices described herein permit the excision of portions of the ligaments flavum on the same lateral side of the median plane as that into which instruments and tools for the procedure are inserted.
Through the provision of a safety zone and improved imaging, the present devices and techniques offer reduced risk of spinal cord damage. In addition to improving nerve function, it is expected that decompression of the spinal canal in the manner described herein will result in improved blood flow to the neural elements by reducing the extrinsic pressure on the spinal vasculature. For these reasons, it is believed that spinal decompression performed according to the present invention will be preferable to decompression operations performed using currently known techniques.
While preferred embodiments of this invention have been shown and described, modifications thereof can be made by one skilled in the art without departing from the scope or teaching of this invention. For example, the means by which the safety zone is formed may be varied, the shape and configuration of the tissue excision devices may be varied, and the steps used in carrying out the technique may be modified. Accordingly, the invention is not limited to the embodiments described herein, but is only limited by the claims that follow, the scope of which shall include all equivalents of the subject matter of the claims Likewise, the sequential recitation of steps in a claim, unless explicitly so stated, is not intended to require that the steps be performed in any particular order or that a particular step be completed before commencement of another step.
|Citing Patent
|Filing date
|Publication date
|29 Aug 2006
|28 Dec 2010
|Baxano, Inc.
|Tissue access guidewire system and method
|29 Jul 2005
|1 Mar 2011
|Vertos Medical, Inc.
|Spinal ligament modification
|9 May 2006
|17 May 2011
|Vertos Medical, Inc.
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|14 Jun 2011
|Baxano, Inc.
|Method, system, and apparatus for neural localization
|16 Mar 2007
|22 Nov 2011
|Baxano, Inc.
|Flexible tissue removal devices and methods
|16 Mar 2007
|22 Nov 2011
|Baxano, Inc.
|Tissue removal with at least partially flexible devices
|13 Jan 2009
|10 Jan 2012
|Baxano, Inc.
|Multiple pathways for spinal nerve root decompression from a single access point
|26 Nov 2008
|5 Jun 2012
|Baxano, Inc.
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|27 May 2008
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|Guidewire exchange systems to treat spinal stenosis
|20 Apr 2011
|6 Nov 2012
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|Method, system and apparatus for neural localization
|6 Dec 2011
|5 Feb 2013
|Baxano, Inc.
|Multiple pathways for spinal nerve root decompression from a single access point
|25 Jun 2010
|12 Mar 2013
|Baxano, Inc.
|Surgical tools for treatment of spinal stenosis
|27 Dec 2011
|19 Mar 2013
|Baxano, Inc.
|Tissue modification devices and methods
|4 May 2010
|2 Apr 2013
|Baxano, Inc.
|Tissue modification devices and methods
|16 Jul 2009
|16 Apr 2013
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|Spinal access and neural localization
|1 Nov 2010
|8 Oct 2013
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|Tissue access guidewire system and method
|17 Aug 2012
|29 Oct 2013
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|26 Mar 2012
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|Devices and methods for tissue modification
|6 Oct 2011
|19 Nov 2013
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|Flexible tissue removal devices and methods
|8 Aug 2008
|17 Dec 2013
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|20 May 2011
|24 Dec 2013
|Baxano Surgical, Inc.
|Methods, systems and devices for carpal tunnel release
|20 May 2011
|31 Dec 2013
|Baxano Surgical, Inc.
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|31 May 2012
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|23 Sep 2011
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|Flexible tissue rasp
|14 Sep 2011
|4 Mar 2014
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|31 Jul 2006
|15 Apr 2014
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|29 Dec 2011
|12 Aug 2014
|Baxano Surgical, Inc.
|Flexible neural localization devices and methods
|11 Sep 2013
|30 Sep 2014
|Baxano Surgical, Inc.
|Tissue access guidewire system and method
|14 Jan 2011
|30 Sep 2014
|Baxano Surgical, Inc.
|Tissue modification devices
|25 Oct 2010
|11 Aug 2015
|Amendia, Inc.
|Devices and methods for treating tissue
|1 Feb 2013
|8 Sep 2015
|Amendia, Inc.
|Multiple pathways for spinal nerve root decompression from a single access point
|2 Mar 2009
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|K2M, Inc.
|Minimally Invasive Retractor Screw and Methods of Use
|27 Apr 2009
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|Mayo Foundation For Medical Education And Research
|Biopsy Devices
|28 Jan 2011
|2 Aug 2012
|Laser Spine Surgical Center, LLC
|Foraminoplasty Device
|23 Oct 2008
|16 Feb 2010
|Vertos Medical, Inc.
|Tissue modification device
|23 Oct 2008
|2 Mar 2010
|Vertos Medical, Inc.
|Tissue modification device
|23 Oct 2008
|6 Jul 2010
|Vertos Medical, Inc.
|Tissue modification device
|23 Oct 2008
|6 Jul 2010
|Vertos Medical, Inc.
|Tissue modification device
|23 Oct 2008
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|Vertos Medical, Inc.
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|Vertos Medical, Inc.
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|U.S. Classification
|International Classification
|Cooperative Classification
|European Classification
|15 Jun 2006
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Peavey 03011990
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The Peavey Marvel Captain America Half Size Acoustic Guitar is a fun and easy to play starter instrument that stays in tune and perfect for your little Super Hero. Each half size guitar is made of real wood with steel strings and a removable headstock cover with a matching Captain America graphic that protects little fingers from string ends. The Marvel super hero guitar arrives with Peavey picks and a Marvel guitar strap. Peavey Electronics proudly announces this line of officially licensed musical instruments featuring the legendary comic Captain America of Marvel Universe. Musicians of every skill level can become real guitar heroes with this Captain America acoustic guitar exclusively from Peavey, which immortalize Marvel Super Heroes in highly detailed artwork on each body.
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text:
Bowling Green, Ky. – Runs were traded in the early going, but the Dayton Dragon (Class-A/Cincinnati Reds) pulled away with three runs in the top of the eighth to defeat the Bowling Green Hot Rods (Tampa Bay Rays) on Sunday afternoon, 8-3. The loss spoiled Johnny Field's three-hit day which raised his batting average to .282.
Dayton raced out to an early lead in the top of the second. Despite a highlight-worthy catch by Field, the Dragons plated two when Jon Matthews doubled and Jose Ortiz followed with a home run to left field.
Bowling Green cut the lead in half in the bottom half of the second. Ty Young drew a one-out walk, and proceeded to steal second base. The bases were later loaded thanks to another Dan Langfield walk, and a wild pitch strikeout, but Juniel Querecuto walked to force home Young and put the Hot Rods on the board.
Carlton Daal homered with two outs in the third inning to stretch the lead back to two, but the Hot Rods continued the back-and-forth contest by scoring a run of their own in the third. Field walked, and then stole both second and third base. Young would drive him home with a single to left field, slicing the Dayton advantage to 3-2.
The Dragons would not relent however, and a groundout by Jonathon Reynoso drove home Jon Matthews in the fourth inning, and Daniel Pigott grounded into a force out to plate Jamodrick McGruder. The single-run frames brought the lead to 5-2.
Field led off with fifth inning with a triple, and would score when Oscar Hernandez grounded out to the shortstop Daal. Unfortunately that would be the final run from the Hot Rods, and Dayton pushed across three insurance runs in the eighth. With Ortiz and Reynoso aboard on the corners, a wild pitch sent Ortiz home, and McGruder would later add a triple into right-center field to cement the game for Dayton.
The runs proved to be the game's final scoring in Dayton's 8-3 triumph.
Langfield was only able to toss four innings in his start for Dayton, but Tony Amezcua (2-2) earned the win out of the bullpen by throwing three innings and conceding just one run.
German Marquez (2-5) made his first start since June 19 after being activated off the disabled list, he allowed two runs before being removed on a strict pitch count in the third inning.
The Hot Rods will not play Monday in a Midwest League-wide day of rest, but their homestand continues at Bowling Green Ballpark on Tuesday night against West Michigan (Detroit Tigers). First pitch on Tuesday night is set for 7:05 p.m. CT on an All About You Urgent Clinic T-Shirt Tuesday. For tickets and more information, fans can visit BGHotRods.com, call 270-901-2121, or visit the Bowling Green Ballpark box office.


text:
Friday, March 7, 2008
9:30 a.m., ACR
PRESENT: Margie Huerta, Anna Chieffo, Andy Burke, Ike Ledesma, John Walker, Carmen Aguilera-Goerner, Lydia Bagwell, Jerry Welch, Sylvia Nickerson, J.B. Carrica, Susan Roberts, Bill Glenn, Meg Haines, Fred Owensby, Susana Rodriguez, Mozella Garcia, Fred Lillibridge, John Paulman, Lori Allen, Kelly Brooks, Doris Gleason, Kathy Reddington, Brad Mazdra, Becky Orduñez, Larry Sharp, David Twitty, and Irene Montoya (recorder)
ABSENT: David Pearse, Molly Morris, Ben Altamirano, Gladys Chairez, and Ken Tellez
GUESTS: Tammy Welch for Molly Morris, from the Budget Committee: Kim Seifert, Vicky Gonzalez, Viola Silva, Annja Cox, Jon Juarez, Lora Ross, Dean Thompson
Agenda Item
Meeting Start Time
9:32 a.m.
Dr. Huerta noted a good morning to the group. The first item on the agenda is the budget recommendations to this group from the Budget Committee.
Informational Item
1 – Final Budget Recommendations – Budget Committee
Mr. Seifert thanked Dr. Huerta and Mr. Burke for their support and guidance the last four years he has served as the Budget Committee chair. He also acknowledged Mr. Burke's knowledge. Mr. Seifert noted the Committee was tasked with looking at requests and chopping them down to a reasonable amount. This year the Committee did not chop anything and instead prioritized the requests. The Committee's final list was achieved by consensus. The priorities were divided into high, medium, and low. The recommendations are not dollar based. Mr. Burke continued with Item 2.
Informational Item
2 – Budget Decision Draft – Mr. Burke
Mr. Burke noted he took the Budget Committee recommendations and put into an internal worksheet used. Positions in the high and medium priority were added along with dollar amounts. The low priority items were taken out. Mr. Burke asked that he be allowed to go through document and ask questions when that particular item you have a question on comes up. Mr. Burke noted the college was further ahead than the past. He also noted that the number could potentially change due to adjustments that will need to be made. Mr. Burke provided a handout of his presentation. This is not the budget, but will be used to make initial budget decisions. There is $2.5 million available, which is mostly tuition and state. Adjustments include compensation increase, compensation adjustments, previous commitments, and other adjustments. After adjustments, $1.2 million is available to allocate. The total requests were over by $158,000. We need to cut $158,000; please keep this in mind. The compensation increase is 2%. It is possible the Union could initiate negotiations. Money will be set aside for faculty equity study which could lead to potential equity adjustments for faculty. Human Resources will be looking at an exempt staff equity study. The Union will handle non-exempt staff. Other compensation adjustments include faculty promotions, faculty equity, student pay increases, and other minor adjustments. Mr. Burke noted base expenditures included positions that we will bring into the budget: full-time manufacturing faculty at Gadsden, GED testing position at NMSU, Mesquite exempt position, non-exempt position at Hatch, tutorial salaries, and benefits. Mr. Burke noted other base expenditures include interpreting costs which was budgeted for $50,000 and the college has currently used $200,000. Main campus overhead has also increased. Main campus would like to increase it by 31%: from about $750,000 to $985,000. There will also be utility increases and increases to internal services operation. Mr. Burke noted the college will have future commitments to keep in mind for next year: faculty in manufacturing, aerospace, dental hygiene (clinical), physical therapy, nursing (clinical) and electronics. Mr. Burke noted for the new requested expenditures the number to the far left were the Budget Committee priorities. Please note number 39 is the last priority on the Budget Committee list that was added to the budget worksheet. Department budgets were not increased.
Business & Information Systems Division:
Full-time Faculty – Library (#5)
Non-exempt Technician – Computer Technology (#24)
Technical Studies Division:
FT Faculty – Automotive (#29)
FT Faculty – Construction (#7)
FT Faculty – Drafting (#16)
Health & Public Services Division:
FT Faculty – Dental Assistant (#22)
FT Faculty – Criminal Justice (#12)
FT Faculty – Sonography (#9)
FT Faculty – Emergency (#17)
FT Faculty – Education (#26)
FT Faculty – Health Care Assistant (#34)
Two positions will change:
Radiologic – from 12 month to 9 month
Public Health – from 12 month to 9 month
FT Faculty – Nursing (clinical)
Ms. Cox asked about the Fire faculty position. Dr. Huerta noted she had a conversation with Mr. Larry Perez and it was decided that the request could wait. Part-time faculty from the community will be available to teach.
General Studies:
FT Faculty – Math (#6)
FT Faculty Sociology (#15)
Mr. Burke noted General Studies was 50% of our enrollment.
Academic Administration:
Exempt – Dual Credit (#1)
Exempt Position (#3)
Continuing Education:
Exempt Position (.25 FTE) (#10)
Mr. Burke noted we need to look at this as this is not supported by revenue.
Division Administration:
Non Exempt – General Studies (#37)
Ms. Haines asked about Continuing Education and the request for marketing funds. Mr. Burke noted he had put in 1% as a gift.
Non Exempt – White Sands (#8)
Exempt Position (#4)
Student Services:
Non Exempt – Financial (#30)
Non Exempt – Admissions (#11)
Exempt – Admissions (#21)
Exempt – Counseling (#28)
Mr. Burke noted a position will need to be deleted.
Executive Office:
No requests
Finance Office:
Exempt – Accountant/Fiscal Specialist (#2)
Exempt – Network Admin (#13)
Physical Plant:
Non Exempt – Maintenance (#27)
Non Exempt – Custodian (#31)
Mr. Burke noted the total requested is $1.4 million which is over by $158,000. Dr. Lillibridge asked if the position freeze was still on. Mr. Burke noted the college can make exception requests now. Dr. Lillibridge asked how much of an impact did the planning document have on the budget decisions. Mr. Seifert noted none. Dr. Huerta noted it was required to determine requests.
Informational Items
3 – East Mesa Phase 5 – Mr. Burke
Mr. Burke showed the group a video of East Mesa phase 5. Dr. Huerta noted it was shown to our Advisory Board last night. Mr. Burke noted phase 5 would include an auditorium for 400 people, a staging area, and a lab. A site plan was also shown to the group. Dr. Huerta noted it would be on Monday's NMSU Regents agenda for approval. The multi-purpose facility will not be owned by any one division. Convocation and college wide meetings will be held there. Mr. Burke noted Mr. Jason Clark is the architect. This will be a one story building with a small stage and a sloped room. It will be used for events, board meetings, and workshops. A foyer inside and a covered outdoor foyer will be included. Mr. Burke added that due to the Governor's Executive Order, this building will be under the Green Building Initiative. It will need to be a day lighted building, be energy efficient and meet certification. Dr. Lillibridge asked when the building will be done. Mr. Burke answered that phase 3 and 4 would be available Fall 2009. This building 2010.
Dr. Huerta thanked the Budget Committee for their hard work. She knows it takes a lot of time. Dr. Huerta also thanked Administrative Council for their input.
Informational Items
4 – Approval of the Minutes of January 16, 2008, and February 1, 2008 – Dr. Huerta
Dr. Huerta asked for a motion to approve the minutes of January 16, 2008, and February 1, 2008. Ms. Haines noted in the cell phone policy section (January 16) it should read Mr. Ledesma and not Ms. Ledesma. Dr. Glenn noted on page 4 (February 1) it needs to state that the City Manager (Deming) did attend the meeting. Dr. Huerta asked for a motion. Dr. Sharp motioned to approve the minutes of January 16, 2008, and February 1, 2008, with corrections. Dr. Walker seconded the motion. All were in favor, the motion carried. Irene will post on the web.
The minutes for January 16, 2008, and February 1, 2008, were approved. Irene will post on the web.
5 – Performance Appraisals – Ms. Gleason
Dr. Huerta noted performance appraisals are due March 14, 2008. Ms. Gleason asked if anyone had any questions. She also reminded everyone the conflict of interest forms would need to be done on-line. Ms. Brooks asked about a deadline for these forms. Ms. Gleason answered that by the end of the month. She also noted that only 25 of 250 evaluations had been received. Dr. Huerta added that Ms. Gleason has offered to help please let her know.
Informational Item
6 – Higher Learning Commission – Dr. Huerta
Dr. Huerta noted she has been working on memorizing the vision, mission and value statements. Dr. Huerta read the vision statement to the group (by memory). The college will be planning an Accreditation Rally to prepare the college for the visit. It will be held on Thursday April 10, 2008, at 3:00 p.m. in the Commons Area. There will be prizes and questions will be asked about the self study which can be found on-line. There is a link on DACC's front page. There will be an email sent about 3rd party comments which will be sent directly to HLC. This is part of the process. It will also be in the newspaper. Dr. Chieffo noted the self study had been received by the site team members and Dr. John Taylor. Ms. Nickerson asked if there would be a schedule. Dr Huerta answered yes. The team will dictate to us who they would like to meet with. It will include meetings with faculty, staff, and students. A lunch meeting with NMSU Regents and a lunch/dinner with our Advisory Board will also be included. Once the schedule is finalized, we will get it out to everyone and made public. Please be flexible from April 28-30.
Informational Item
7 – Stars of Excellence & Service Awards Ceremony – Dr. Huerta
Dr. Huerta asked Dr. Walker to work with Faculty Affairs to send out nomination forms for the Stars of Excellence Awards. The ceremony will include employees who are up for a service award. It's scheduled on May 8, 2008, at 3:00 p.m.
Informational Item
8 – Announcements / Other
Ms. Haines noted the Customized Training Program would hold trainings at Sunland Park.
Informational Item
Mr. Owensby noted there would be a Symposium scheduled for June 26-27, 2008, at Hotel Encanto. He has assembled a community group to work on the program. It will be for business owners and entrepreneurs and will include general and breakout sessions.
Informational Item
Dr. Lillibridge noted the ACR would no longer be available. Dr. Huerta noted it would become the resource room for the HLC visit. Ms. Gleason asked where the April Admin Council meeting would be held. Irene will notify everyone. Mr. Mazdra asked if documents would be asked for to include in the room. Dr. Chieffo noted yes, we will work on that and get in touch with people. Dr. Huerta added that she and Dr. Chieffo were having a conference call at noon with the site team chair. Please remember to update your resumes. The deadline was February 1. Thank you to those who responded.
Next Meeting
Friday, April 4, 2008, 10:00 a.m., ACR
Meeting End Time
10:45 a.m.


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John BankstonAmerican (Benton Harbor, Michigan, 1963)
Bronze Cowboy
2003painting | oil on linen
Not on view at this time; find out where you can see works from our collection at locations around the Bay Area while our building is closed for expansion
72 in. x 60 in. x 1 3/4 in. (182.88 cm x 152.4 cm x 4.45 cm)
Acquired 2004
Collection SFMOMA
Accessions Committee Fund purchase
© John Bankston


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"Rudolph the Red-Nosed Reindeer: The Musical" is flying into the Majestic Theatre and subscribers can save up to 50% on tickets.
With this exclusive deal, Orchestra Center Rows A-N -- the best seats in the house -- are $32.50 (reg. $65). These premium tickets include a commemorative poster signed by the cast.
Mezzanine, Side and Rear Orchestra tickets are also $25 (reg. $35-$50).
The following seven performances are available:
Based on the beloved stop-motion television classic, the musical follows Rudolph on his journey to the Island of Misfit Toys to help Santa save Christmas.
Note: Premium ticket holders claim their commemorative poster in the Christmastown Shoppe in the Majestic Theatre.
Please go to your email and confirm your subscription.


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How JGI Helps Save Endangered Species
Friday, May 16, 2014, is Endangered Species Day in the United States. While the Jane Goodall Institute (JGI) has always been committed to protecting Africa's endangered wild chimpanzee populations, chimpanzees are not the only endangered species that benefit from JGI's many projects.
One of the biggest threats facing all endangered species is habitat loss. Shrinking habitats mean fewer resources for these dwindling animal populations, and contribute to harmful human/animal conflict as human settlements, logging and mining companies encroach on what was once pristine wilderness. Nowhere is this more easily seen than in the forests that chimpanzees and many other endangered species call home.
This is why JGI's project to protect Africa's forests from the effects of deforestation are so important. Projects like JGI's tree-planting initiative and our sustainable livelihoods programs not only help chimpanzees, they also aid in the preservation of forests that other endangered species such as mandrills, gorillas, and forest elephants must rely on for survival.
Below are photos and stories of several endangered or vulnerable species other than chimpanzees that benefit from JGI's protection of chimpanzees and their habitat.
Due to their striking appearance, mandrills are often captured by poachers and sold illegally as exotic pets. At JGI's Tchimpounga sanctuary in the Republic of the Congo, JGI has rescued and rehabilitated several mandrills who were taken from the forest by poachers. In fact, JGI is in the process of releasing many of these rehabilitated mandrills back into the wild. This will not only give these rescued mandrills the freedom that they deserve, we hope that it will also bolster the areas' threatened mandrill population.
Read more about JGI's Mandrill Release Program.
African elephants are listed as a vulnerable species by the IUCN, and due to habitat loss and poachers who hunt them for their ivory tusks, their numbers are falling drastically. One day, while participating in our Mandrill Release Project in the Conkouati National Park in the Congo, alert JGI staff members aided authorities in locating a notorious elephant poacher … even helping catch him when he escaped! The presence of JGI staff in that forest likely saved the lives of many of the Congo's forest elephants.
Like chimpanzees, gorillas are highly intelligent, highly social great apes. Unfortunately, also like chimpanzees, gorillas have been pushed to the brink of extinction. JGI has teamed up with the Diane Fossey Gorilla Fund International and several other organizations to fight for the survival of gorillas living in the forests of the Democratic Republic of the Congo. JGI is contributing to this effort by using cutting-edge technology to assist in monitoring gorilla populations and changes to their forest habitat.
Sandhill Cranes
Sandhill Cranes are large, migratory birds that live in freshwater wetlands. Though numerous, some populations of Sandhill cranes have become endangered due to the destruction and degradation of their habitat. The yearly migration of Sandhill Cranes is a sight so spectacular that Dr. Jane Goodall regularly travels to witness it. If you would like to join JGI on a trip to view the Sandhill cranes migration, click here.
You can participate in Endangered Species Day with JGI!


text: Photo by Andrew Burton/Getty Images [ Pipeline Fire In Milford Leads To Evacuations By Associated Press November 15, 2013 MILFORD, Texas (AP) — Hundreds of residents evacuated from a North Texas town after a Chevron pipeline explosion await returning home as the fire burns itself out. Read More|Comment Category: News Tags: gas pipeline, milford Send to a friend! Share on Facebook Share on Twitter Pin it! Reddit This! Share on Tumblr!


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Introduction of the Paper2
The Field Study Student3
Statement of the Purpose4
Cooperating School5
Momentous Experience and Insights
Entries and Evidences
Copy of Basic EducationinUBD Curriculum12
Interview on Grade 7 Teachers13
My Own Curriculum "Realistic Educational Curriculum"18
Reflection on Observation28
Articles about Field Study 4
Teaching Resources: Exploring the Curriculum 29
Let's Play! Using Play-Based Curriculum to Support Children's Learning Throughout 30 Domains
Exploring Teacher's Experiences in Implementation of Curriculum in China 38
Curriculum Review: Exploring Creation 39
Personal Reflection on the Paper40
This field study shows the dynamic ability of a curriculum to different changes.Field study 4 is all about different curriculum and assessment being utilized to promote students' progress. Field study 4 is a way on how to have a deep understanding in different curriculum being tested. Having a first year in K-12 program this field study open up the positive outcomes in getting this curriculum to be globally competitive.
The Field Study Student
Ednalyn Guinto Caguimbal was born on April 18, 1993 with my parents Edgardo Austria Caguimbal and Celina Guinto Caguimbal. I'm second eldest from five siblings. I graduated my in Tagkawayan Central Elementary School and I finished my secondary years at Novaliches High School. I had my first year college at Southern Luzon State University- Judge Guillermo Eleazar with Bachelor in Secondary Education Major in English. Due to unexpected events of my life I transferred here at Westmead International School and shifted in Science major. I believe in the quote "Who dares to teach must never cease to learn." -- John Cotton...


text: Leah C. Gardiner | IBDB: The official source for Broadway Information IBDB: The official source for Broadway Information Official Broadway League sites: - sites - broadway.org broadwayleague.com broadwayfanclub.com kidsnightonbroadway.com stagespecs.org tonyawards.com Quick Search For: In This Category: All Show People/Org. Theatre Season Leah C. Gardiner Director Female Productions ProductionsDate of ProductionsThe Goat, or Who Is Sylvia?[Play, Drama, Original]Assistant Directed by Leah C. Gardiner Mar 10, 2002 - Dec 15, 2002On the Town[Musical, Comedy, Revival]Assistant Directed by Leah C. Gardiner Nov 19, 1998 - Jan 17, 1999 Find out where Leah C. Gardiner and are credited together © 2001-2015, The Broadway League, All Rights Reserved. (Copyright and Disclaimer)


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Your Erie DUI & Criminal Defense Team
Your community is our community
"Erie and Northwestern Pennsylvania is our home and has been the community where our families have worked for more than a century," says Tim George about his wife, Kathy Scibetta, also a lawyer, and their three children. Tim's great-grandfather was a longshoreman in Erie. His maternal grandfather taught Math for decades at Gannon College (now Gannon University) and Cathedral Prep High School. In 1944, his paternal grandfather founded WESPEN Audio Visual Company, now owned by his father and brother. And, for 20 years his mother worked at Mercyhurst College (now Mercyhurst University).
Solid training & unique experience
After graduating from St. Bonaventure University and receiving a law degree from The Dickinson School of Law (now Penn State Dickinson), Tim returned home in 1992 to practice law. He founded J. Timothy George, P.C. in 1996. He credits the training provided by more experienced lawyers with whom he has worked, his time as a prosecutor, and his experience as an Army lawyer with shaping his practice. He was called to active duty in support of Operation Iraqi Freedom in January 2009 and served for 11 months as trial counsel for the 28th CAB where he handled military justice cases. Tim continues to serve as an Army lawyer, now a Major in the U.S. Army Reserve.
Fewer cases means more time for you
Our clients are supported by four full-time administrative support personnel, including two paralegals. We embrace the efficiencies of technology and, in particular, the many ways such advancements can improve the quantity, quality and timeliness of the services provided to our clients. Tim is careful to limit the number of cases he handles because real communication requires time, especially with clients who face a DUI or criminal allegations for the first time. Fewer cases means more time for clients. Fewer clients allows more time to meet, listen and explain, and doing so with enough frequency to ensure that clients truly understand the process, their options and the best way ahead. Check our what others say about our team here.
Convenient location
In 2004, Tim moved his practice to 2525 West 26th Street in Erie after overseeing extensive renovations made there. The location is central and easily accessible, just one block west of I-79. The location is convenient for clients throughout Northwestern Pennsylvania and offers free parking. You can receive directions elsewhere on our website.
Helping you & your family
Tim says, "Our singular objective is to defend freedom and, in the end, help people and their families." All meetings are confidential, and the first office consultation is free. Call toll free (888) 748-0090 or In Erie (814) 636-1618.


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Monthly Archives: June, 2012
Written by Megan Cowan on June 15, 2012 — Leave a Comment
The Role of Stillness in Mindfulness Below is a Q&A with one of our Curriculum Graduates about stillness. Hi Megan- I know in the first lesson, stillness is taught to be a trait of a mindful body. In one of my most recent classes of teaching mindfulness, we really focused on the aspect of stillness […]
Posted in Uncategorized


text: Photo courtesy of the DNR [ Exotic Carp Species Found in Mississippi North of Sartell Dam By Lee Voss May 14, 2013 An exotic species of carp not found in this part of Minnesota was caught in the Mississippi River by a bow-fisherman. Read More|Comment Category: St. Cloud News Tags: asian carp, DNR, exotic species, grass carp Send to a friend! Share on Facebook Share on Twitter Pin it! Reddit This! Share on Tumblr!


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Stephen Hawking Boycotts Israel 'On the Advice of Palestinian Academics'
May 8, 2013 - 4:46 pm
Extremely sad and disappointing news from Cambridge University.
JERUSALEM: Stephen Hawking has pulled out of a high-profile conference to be held in Jerusalem in June to support an academic boycott of Israel, conference organisers and the university said on Wednesday.
The academic and cultural boycott, organised by international activists to protest against Israel's policies toward the Palestinians, is a heated and contentious issue; having the renowned physicist and cosmologist join it is likely to help the anti-Israel campaigners significantly.
"Never has a scientist of this stature boycotted Israel," said Yigal Palmor, the spokesman for Israel's Foreign Ministry.
Organisers of the fifth annual Israeli Presidential Conference, held under the auspices of President Shimon Peres, said they had received a letter over the weekend from Professor Hawking announcing his decision.
Cambridge University issued a statement indicating that Professor Hawking had told the Israelis he would not be attending "based on advice from Palestinian academics that he should respect the boycott", Associated Press reported.
Looks like Hawking can't sort good advice from bad. The boycott is aimed, ultimately, at killing academic freedom.


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Boise Police are spearheading a campaign, asking people to register their valuables to an app that will revolutionize returning lost items.
Track mole lets users input the serial number of any item into their system. If the item is lost, whoever finds it simply enters the serial number into the app and a notification is sent to the owner.
Each year, police are unable to return tens of thousands of dollars worth of stolen items. Using this app will cut those losses and help prosecute burglars.
"Every property crime detective in the valley said 'wow, this is what we've been looking for. This is great.' So Meridian, Eagle, Ada County, Garden City, Star, they're all coming on board and they're going to get behind this as well," said Boise Police detective Jeff Dustin.
The app is already being used in Seattle, Portland and cities across the Northwest.
- Latest


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Syracuse Mayor Stephanie Miner said Saturday night that Superstorm Sandy's devastation in New York helped illustrate the need to elect Democrats who, unlike many of their Republican counterparts, believe in climate change.
"This is an incredibly important election year," said Ms. Miner, the co-chairwoman of the state Democratic Committee in remarks before the Jefferson County Democratic Committee in Watertown. "[W]e have a great slate of candidates. This really hit home this week, when we had the hurricane down in New York."
She continued: "We all believe in science, because we're Democrats. Republicans don't always believe in science. I happen to be represented by a member of Congress, one of the Flat Earth Five."
Rep. Ann Marie Buerkle, R-Onondaga Hill, received the moniker from the League of Conservation Voters. Ms. Buerkle is facing Democrat Dan Maffei on Tuesday.
Ms. Miner said that Democratic positions — like arguing that climate change exists — are more difficult to argue than Mitt Romney's belief that the Federal Emergency Management Agency should be sent back to the states.
"It is very difficult to argue against that in the abstract," she said. "What we had last week is that it no longer was abstract. It was real. You saw Republicans run away from that."
The north country escaped Sandy's brunt, but it has had political ramifications. For example, first-responders who were sent from the north country to New York City may not be able to vote on Tuesday. Election officials the past two days preparing to send them absentee ballots via FedEx so that they could vote in time.
"Keep them in your thoughts and prayers," Ms. Miner said of the Sandy victims. "It is a very difficult time down there."
Rep. Bill Owens, D-Plattsburgh, also weighed in on the storm in his speech. He gave props to New Jersey Gov. Chris Christie for recognizing what Mr. Owens sees as President Obama's leadership on the matter.
On climate change, Mr. Owens said that rigorous scientific study is appropriate, and also said he would have supported a "cap and trade" bill. His predecessor, former Rep. John McHugh, also supported cap and trade. Mr. Owens said he supported cap and trade in the interest of the Adirondacks.
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The sister Crossroads organizations have been relatively quiet in the lead-up to this year's midterm elections, and now we know why.
The pro-Republican super PAC and nonprofit groups, co-founded by strategist Karl Rove, experienced plummeting donations in 2013. After raking in $325 million in the 2012 cycle -- and failing to dislodge President Obama from the White House -- American Crossroads and Crossroads GPS together raised a little more than $6 million last year, according to a report in Politico, which got an early look at the numbers.
The super PAC has not yet filed its year-end fundraising report, which is due by midnight to the Federal Election Commission. Spokesman Jonathan Collegio did not immediately respond to a request for comment, but told Politico, "Our pledges are on track with previous cycles and we are increasingly enthusiastic about prospects for winning a majority in the Senate and holding the majority in the House."
After largely staying out for the 2014 fray, there are signs that Crossroads is beginning to engage. This week, the super PAC announced it was spending $500,000 on ads and mailers in support of GOP congressional candidate David Jolly, who is running in a special election to fill the Florida seat of the late Republican Rep. Bill Young. The funds are part of a $1.2 million effort by independent pro-GOP groups, including the advocacy group American Action Network, which is also putting in $500,000.
AAN does not report its donors, but its sister super PAC, the Congressional Leadership Fund, raised nearly $1.1 million in 2013, according to a spokesman.
Democratic super PAC are having more luck attracting large early donations this cycle, a sharp contrast to the dynamic four years ago. House Majority PAC raised nearly $7.5 million last year, while Senate Majority PAC pulled in $7.46 million – including $2.5 million from former New York mayor Michael Bloomberg, $500,000 from attorneys David and Mary Boies and $200,000 from producer Jeffrey Katzenberg.


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After the thrill of learning to fly has worn off, most experienced pilots turn the controls over to the autopilot, especially for frequently travelled routes. If you're repeating the same query over time, you can both improve your results and take the drudgework out of searching by taking advantage of search engines that offer autopilot.
Known as "search alerts," these services are different from many alerting services, because they give you a great deal of control over your queries. Most alerting services rely on simple keyword queries or recognizing physical changes to web pages. Alerting services from Northern Light and Profusion, on the other hand, let you create more powerful, customized alerts.
Northern Light Search Alerts send you email whenever Northern Light's database has been updated with new documents that match your search terms. There are two ways to create an alert. The easiest is simply to save any search you run on Northern Light as an Alert, using the link provided at the top of every result page.
You'll likely get better results, however, and sharply cut down on the amount of false drops if you sign on to the Search Alerts service. This gives you more control over your query, allowing you to create an alert that runs a simple search, a power search, business search, investext search or news search. Your search fields are slightly different for each type of search, so it's important to choose a search type before entering your keywords.
For all types of search other than simple search, you can also limit your search to specific categories, and have results sorted either by relevance or by date and time. You can also limit your query to words in a document title, publication name or URL. These limits can be extremely useful for creating very narrow, targeted searches, assuring highly relevant results.
Once you've created your search, you can preview the results. If they aren't satisfactory, you can fiddle with your settings until you get exactly what you want. That's all there is to it.
When Northern Light's database has been updated with Web sites or Special Collection articles that match your search terms, you will be sent an email containing a URL. To view your updated results, click this link. Northern Light stresses that it's necessary to click on the URL that is sent in the email to see all sites that have been added since you last clicked on the search alert update.
For tracking new Web sites, news, or other current events, Northern Light Search Alerts are definitely worth a look. You need to have an account with Northern Light, but registering is free.
The metasearch engine Profusion lets you create a single search alert that is run every day on up to ten search engines. Although Profusion doesn't give you the full range of limiting options that Northern Light does, you can nonetheless narrow your search by using the advanced search form.
This form allows you to apply limited Boolean operators, specify the overall number of results and number per source, and uniquely, perform a link check on the results to assure none of the links are broken. It also lets you choose which engines to search, including an option to use only those that Profusion determines to be the "best three" or "fastest three" for your query.
Once you run the search, you have two options for saving alerts. You can save the entire query, by clicking the "set search alert" link at the top of the result page. Alternately, you can monitor individual pages displayed in your result list by clicking the "set page alert" link next to the title of the page.
Profusion offers an Internet Explorer browser bar add-on that lets you easily create search alerts from any page that you're currently viewing. Installing the "Alert Me!" button is as simple as dragging a link to your browser's link bar. It's a handy feature if you find yourself creating and managing lots of search alerts.
Both Northern Light and Profusion provide controls to edit or delete search alerts, so you can fine-tune or get rid of them altogether as your needs change over time.
The next time you're slogging through a repetitive search, save yourself some time and effort by turning on the autopilot with search alerts from Northern Light or Profusion.
Northern Light Search Alerts
Profusion Search Alerts
Search Headlines
NOTE: Article links often change. In case of a bad link, use the publication's search facility, which most have, and search for the headline.


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The African Twin Towers
2005–09. Germany. Christoph Schlingensief. 70 min.
Introduced by Aino Laberenz. A conversation between Laberenz and Klaus Biesenbach, Director, MoMA PS1, and Chief Curator at Large, The Museum of Modern Art, will follow the screening.
Saturday, March 15, 2014, 7:00 p.m.
Theater 3 (The Celeste Bartos Theater), mezzanine, The Lewis B. and Dorothy Cullman Education and Research Building
The African Twin Towers
2005–09. Germany. Directed by Christoph Schlingensief. With Christoph Schlingensief, Aino Laberenz, Patti Smith, Irm Hermann, Klaus Beyer, the Lüderitz theater troupe. Originally conceived as a film about 9/11, Richard Wagner, and the warrior Hagen von Tronje, to be shot in the German southwest African colony of Lüderitz, Namibia, The African Twin Towers instead turned into an unusually personal and absorbing documentary about an incomplete film and Schlingensief's art in general. 70 min.
In the Film exhibition Christoph Schlingensief
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