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    Streamline MIS Op Tech

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    Streamline MIS Op Tech

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    Streamline MIS Op Tech

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    surgical Streamline® MIS fe Spinal Fixation System Surgical Technique PS Ue TABLE OF CONTENTS INTRODUCTION System Overview nu SURGICAL TECHNIQUE ‘Step 1 - Patient Positioning n- . ‘Step 2 - Pedicle Targeting and Guidewire Placement ‘Stop 8 - Tissue Dilation ‘Stop 4 - Pedicle Preparation .. Stop § - Pedicle Screw Placement Step 6 - Rod Measurement Step 7 ~ Rod Contouring Step 8~ Rod Insertion ennnnnn a Step &- Set Screw Insertion 18 Step 10 - Rod Reduction. NB ‘Step 11 - Compression and Distraction 19 ‘Step 12 Final Set Screw Locking a Step 13 ~ Screw Extension Removal con 22 Removal if Necessary) ae a) ORDERING GUIDE Instrument Guide = 24 Tray Layout 28 Implant and instrument Lists Cleaning and Steriization nn ss 24 “Torque and Driver Information . INDICATIONS & WARNINGS Indications, Warnings, Precautions, Contrancications. - 36 ‘SYSTEM OVERVIEW INTRODUCTION The Streamline MS Spinal Fixation System allows a rigid construct to be creatad in the thoracolumbar spine via a percutaneous or mintopen approach using cannulated pedicle screws, set screws and rods. The system offers abroad range of implants and instruments proving the ability to tal treatment to a specitc patient for a more efcient, sreamined, implant experience. CANNULATED PEDICLE SCREWS * integrated, disposable and easily detached ‘exension sleeves * Double lead thread design for faster implantation + 60° conical screw angulation previceos intraoperative tlexbiity + Extensive size offering of polvenial sorews + Standard diameters: 55, 65 and 75mm * Oplonel diametars: 46 and 8.5mm + Sorow lengths: 20-85mn, depending on sorow diameter * Composed of THAALAV ‘SETSCREWS * Designed to reciuoe incidence of crassthreading + Use a standard 725 drive mechanism » Fitall screw sizes * Composed of THAN MIs RODS * Slandardi 5.5m pre-bent rods from 85 - 160mm * Optional staight rod set for tharacic procedures * Optional long rod set for long constructs + Composed of THAN INTRODUCTION ROD INSERTION OPTIONS. + Fixed rod holder for standard constructs * Curved red holder for long constructs REDUCTION OPTIONS. * Standard reduction threads (1mm) intagrated into extension sleeve * Optional reduction (up to 30mm) available withthe rad reducer or threaded rod reducer SURGICAL TECHNIQUE By parent posmonine lace the patient in the prone postion ying flat on a radiolucent table, Ensure that unobstructed fluoroscopic Images of tne operatwe levels can be takan in ot the AYP and lateral view, Clean and drape the operative st Flue t BBB Pepicie tancerine and GUIDEWIRE PLACEMENT Obtain an A/P Image of he targeted vertebral body. Ensure thet the endplates are patalel and thatthe spinous processes are centered on the image. Prepare for screw placement by algning the fst guidewire in a cephalad caudal oriertation along the lateral borders of he pedicles. Tanslerthe guidewire outine using a skin marker Next, align a transverse guidewire along the center of both pedicles. Transfer the outline of he second gutdewhe Using the skin marker: Intersect his line wih the cephalad caudal ine. Rapeat for each pedicle, progressing in a cephalad direction, For placement of each percutaneous soree, make a longitudinal skin incision through the fascia approximately 2omlong, located 1 to 2em Ieteralto the vertical ne thet ‘marks the lateral border ofthe pedicle lateral Note: Heavier patents require incsons witha gr tistance for he pete, Insert the pedicle targeting neecle (gure 1) trough the incision, Using AVF fluoroscopy, confi the needle positon atthe lateral border ofthe pedicia, Using a mall, advance tne needle slightly to dock Wino the bone and slabilze, Reference a lateral fuerascapic image to confirm that the cophatad/caucal trajectory matches the pedicular anatomy, Continue advancing the needle under A/P fluoroscopy. AS the tip ofthe needle approaches the riddle ol the padicle Cyndy t should be approximately one tid nto tho verlebal body when viewsd on @ lateral image. Acwance the needs to the desired depth, but no futher than hat ‘the doptn of ha vertsbxal body SURGICAL TECHNIQUE ‘Adpth aauge (Fiqure 2)is available for measuting the dopth of the pede targeting needle Sie the podiole targeting needle through the depth aauge (Figure 3} rior to insertion into the pedicle. Once the assembly is plagedino the pedicle, skde the demth gauge down unt i contacts the bone, Lines ave etched on the pedicle farang nese at 10mm one ins}, 20mm (two es) 0mm (tee nas) and damm (four lines). Faque 4 shows the depth gauge and pedicle targeting needle indicating a depth of Som. Ramove the inner tocar of the pedicle targeting needle by tuming the top hance 90° tothe cannula handle (Figures 5 and 6), Carell advance the quidewie east the tp ot ‘he targeting needle and fim inte cancellous bone. Kal placement ofthe quidewire tis is approximately two-thirds ofthe depth ofthe vertebral body, Remove the pelle targeting needle while maintaining the postion ofthe uci. Repeat these stops for all pedicles that are intended for serew placement Mote: Do ct bend the quidewie Bending he guidewire coud Powe? 8S aes -q Fue Fours SURGICAL TECHNIQUE BB tissue piarion sores end ced ns ear oan Downed wen ota see on gue Sdene re tmortied el err be yoni Te lela bak ans rows ecanchg Sonn be cule rl Reoracs he bone Fue 10) Push eo-—— ti cna iomr aa ee i Cito, leaving the tap sleeve/screw sleeve assembly ana) juidowire in place [Figure 11), Foweo Note: The screw sieeve hes a tin wal Do ot grip ning =o es SURGICAL TECHNIQUE [By revicte preparation Ifthe paint has sclortts bone, the cannulated dil or ‘cannulated bone ae can be used to penetrate the cortex in order to gain acces tothe vertobral boc. Altech the desited tap to handle and sie over the ‘Guide, thyough the tap slacva/ecrew elaeve assembly tone bone (Fiquie 12). Advance tne tap by turning the handle clockwise while applying fim dowrmard pressure, cutting threads into tna pede Mote: Tp are rue lo in" (not udertiead) and are aniable in standard sles of 4.5, $.5 and 6.5mm. Optional sizes of £0 an 7.5m ate avaiabeby epee cequast Mote: Do not advance ie ap pas the tp of te guidewire Powe 12 ure 14 ‘Conti position using lator fuoreecony andl stop atthe appropriate depth, Sams rtance ey eaenngtn pia es ottotep coon ged sph rateonbeg it The eh so 0 tS a dered nen nen Gis oa a ent of om, Tho tp up dee ust be cota See bres mesa t Tre ono pion vie rr tusotoony a0 osinanap Spt Th et at the od ofp rads whch coor Om, The € 2 © raul © t cocoa ret dap goose tt ccous 4m 4 Frater ohn San Fe i vf Figure 15 Figure 16 Figure 17 Mote: Trove dOmm notched depth groove on the 4.0 and Remove the tap wil keeping the quidawie in place (Figwe 15) Push the screw sleeve down towards the bona to separa the tap slave fom the scrow sleeve (Figure 16). Remove tne tap sleeve, leaving he screw sleove and guide in place (Figure 17) SURGICAL TECHNIQUE BB Pepicie sonew pLacemenT Two siylos of screw insertors are avaiable for padiale sora placement the simple driver (Figure 18} anc! the threaced soraw inserter (Figure 19) Figure 18 tation fe oten extend in length verse otf! oes ees age oo. Erceat ore SS serew pik Fique 10 Note: Select noper screw size based on anatomy Undersized ‘Simple Drivor W ‘tach the simple river toa handle and insert the assembly ‘through the screw extension and down int the head ofthe pedicle scren. needed, push and twist he simple arver ntl i uly seas into the sorew head (Figure 20) ote: The soe dover sy seare iia the pode sero uvor trgure 23. Aiter loading a screw onto the simple driver, place it over A the guidewire and side it down through the screw sleeve to Fore 20 ‘the bone, Rotato the handle of the simple civar clockwise Figure at Figure 22 {a implant the screw into the pedicle [Figure 22). Continue rotating the handle ofthe simple driver until the screw & at the approprats depth. Keep the screw and simple driver in line with he quidewie during insation. Use fucroscopy to confirm the trajectory and depth of the screw. Note: Remove the guidewire ater advancing the sorew past he CAUTION: To maintain the potyaal characteristic of the ecto screw, avoid bottoming anor innging te twinned crew and serew extension when leverage forces To disengage the screw ftom the simple driver, pull upon ‘the atachod handla and aide the simple drvar aut of the Note: Do not deform extensions when hatin sores SURGICAL TECHNIQUE Thanded Serw inert rer he theaied eso near satis both Serine slave Pg 29).tach he ita SS + Sse aan andar ese rough he sr btenson nd dom noth ead ore ce Fg ree 24) oto th tend eae inst lone GU 28) into the tulip ofthe screw head until ts frmlyin place and comes to a stop (Figure 26), ‘Aer loading @ screw onto the threaded screw inserter plage it ovr the guidewire and sd it dow through tho serow sleeve tothe bone, Rota the handle ofthe ‘tended screw inserter clockwise to implant the screw into tha pedicle (Figure 27). Continue rotating the handle ofthe threadod screw inserter untl the screw fs imolanted tothe appropriate clepin. Koap the screw and threadod Figure 25 ‘Serews inserter inline with the guidewire during insertion, Use luerascopy to canfim the tajactory andl depth of the Mote: Do not ose the veae0 serew sorter sleeve whe inserting the sera. Thi wil cause the tnbaded screw ineerter assembvy 0 aatach tom tne sero. Fiowe 24 Figure 26 CAUTION: Ts sini ne east saractnsies o 0 pete scien, rd eostoning and/or wpangirg ie tuip head sgsinst oy larnts. Lites maken may moras stoest toe sro and screw enesion whan Inverape ( To disengage the threaded screw inserter fom the scren, hol the screw extension while rotating the threaded screw inserter seave sounterclackwlsa unt disangages from ‘he screw: Pull up on the altachsd handle and slide the ‘treaced screw inserter out ofthe screw. Repost Stop 6 untl all of the scrous aro implanted Mote: Aer guidenire removal, aestonal screw acfustmants ‘may 60 made mth ether the simple chive athe Soa tee f ? b Figue27 SURGICAL TECHNIQUE ROD OVERVIEW Proper rod orientation is important when banding the rod or inserting the rod into any rod holder. The tod is property oriented for insertion into the rod halders when the circle and notch are both facing upward in relation to the eval slct. For proper orientation ofthe rod during rod bending, please refer to Figure 31 for lordtic bends and Figure 32 for kyphotc bends on page 10. CIRCLE] NOTCH | OVAL SLOT rop measunement ‘The Streamline MIS instrument Setinchides a rod caliper 1 provide guidance prior to rec length selection, Insart ‘he posts af the 1od caliper into he most cephalad and caudal screw extensions. Sle the posts down the screw ‘extensions untl the shelvas ofthe posts are flush with and resting ontop af the xconsions (Figure 28). Road the value on either side ofthe scale at the top ofthe rod caliper (Figure 29) The value shown on the rod caliper represents te functional pro-bent rod langtn as dpicte in Figure 30, Ary intended cstrction or compression ‘must also ba considered as part of rod langth selection. An appropriately sized rad extends slighty bayond tho Ccaphalacl and caudal onds of the screw head so that sel screw locking cecurs on the functional length ofthe rod. Determination of appropriate od length is italy vortied following red insertion (Step 8) using AYP and letra uoroscopy. Figure 29 Functional Lonath of Pre-Bent Rod Note:The serow ext eunetnacnioeen S—_— Figure 30 SURGICAL TECHNIQUE [Do 200 measurement (conTINUED) eee ‘sn tte: Sami MS sap ended be son et prior fnserton Tosi te rig oct he ne rneeromer echt on ho cals th poonnte unclean atte ote nara 95 eh ‘em a. The erence Slnee tech ean nde ow ctu sagt eaten eng inrere jropotanly she ation peot ncmeetenih rea sicasa auaceck a pelea (earn end ee Forte fal lic “ 0m 2m Bae inn [By ro contourna ‘Tomeke changes tothe contour ofthe 10d, select an ‘appropriate bend radius onthe rod bender and place the ‘od between the rllre ofthe rod bender. There ae thee: bend radius settings on the center roller Compress the ‘od bender untl the desired contour is achieves. Lordatc LGAUTION: Conse croper ro erlontaton bolove Benalng Figwe st te rea Pope ea anentaten &impartat when placing the ‘into any ofthe tvee rod holders mentioned in Sto 8. linen apsiving a lores bend to the ro the ron shal be ‘bend tothe zo the rox should be postionad as shown in kyphotie 1 he rota tis my food to premature materi fave oF he implant. a not band the rn the revs ection, a thie may invoauce aera fractures that comeramise ts evongth ‘revarse rod bending oF excestie bending has occurred, the as shown in Figure 33. When ania a kyphatic ben rd must be discarded Pease contact AN Suga! at Figure 32 (288) 778.8771 wn any questions in regard t9 contouring rod CAUTION: Ensur0r09 contouring paces he rod segment in polvanial screw yoke. mpraper rod contouring may ‘suit n exceeding the 430" 6 60° conical range of meten oF the polar serew. Exceeding these lite may hit proper looking oF cause permanent damage othe paljena 2/6, SURGICAL TECHNIQUE ROD OVERVIEW Proper rod orlentation is important when bending the rod or inserting the rod into any rod holder. The tod is property fiantad for insertion into the rod holders when the circle and noich are both facing upward in relation to the oval slot. For proper orientation of the rod during rod bending, please refer to Figure 31 for lardatic bends and Figure 32 for kyphotic bends on page 10. CIRCLE} NOTCH | OVAL SLOT BB no insertion The Streamline MIS system provides two instrument = Fo options for tod insetion: the fod od holder and the curved od holier, 03 Note: sing 2 iesopen techniase, the muscle spitting wed can be une to create pane fr ro passage (Poe 99 2 Option 1: The Fixed Rod Holder To insert a rod withthe teed rod holder (Figure 84), place ‘the gold fied rad haldar locking serew (Figure 35} nto tho fiagd rod holder and advance slightly so thal the locking 619M isnot visible in the rod slot ofthe fixed rod holder \Wan tne rad propery orient, place the connection end ofthe rad into the fixed rod holder. Tighton the locking screw with the set screw inserter to secure the rod to the ——— fod rod holder (Faures 36 and 37} Note: Ony me v0 srew inerer sno Fique3s (6 usea to tighten ne Fue 36 Fire 37 SURGICAL TECHNIQUE (Orient the handle ofthe tod holder paraliel to the pationt’s ‘kin surface with tho tp ofthe rad facing downward Inert tne tip othe rod ino the incision of the seen ‘extension with the fed rod holder on the outside of tho serow aonsion (Figura 39), Advanos the tp of the ‘0d downward through the sorew extension toward the ‘serew untl touches the screw hoadl oF as far the tlssue wil allow (Figure 36). Enaure that th cstal ond ofthe "0d is below the fascia. Begin to rotate the handle ofthe ‘0d holdar up while Keeping the shatt ofthe rod holder ‘98 close tothe screw extension as possible Figure 40} Continue to rotate the handle up to a verti! postion while guiding the distal tip of the rod into the adjacent screw extension stot untl the top ofthe rod holder shat is ‘tush wth the top ofthe screw extension (Figures 41 ana 42). Very thatthe rod is in postion using A/P and lateral ‘luorassopy Erssure that the rod extends sightly beyond the cephalad ancl caudal ends ofthe screw head, Note: 0 net ease the 10d Kom tho rod holder unt a least crew has Been prewstonaly vontanea. Proceed 0 ‘Step 9 forinsuucton an set screw placement ‘Alora set screw has baen provisionally tightened, release ‘tho 04 tom the fixed rod holder by lecssning the goles locking screw wit the set screw inserter. Pul the fixed ro hold away from the roto separate the connection. Lit to instrument up to remove it rom the pation. owe a0 Foure at igure 42 SURGICAL TECHNIQUE ROD OVERVIEW Proper rod orientation is important when banding the rod or inserting the rod into any rod holder. The rod is propery oFiantod for insertion into the rod holders when the clrole and notch are both facing upward in rolation to the oval slet. For proper orientation of the rod during rod bending, please refer to Figure 31 for lordotic bends and Figure 932 for kyphotic bends on page 10. CIRCLE} NOTCH | OVAL SLOT Option 2: The Curved Rod Holder ° To inset a rod with the curved rod holder (Figure 43), . ‘open the thumb lever (Figure 44) located in the handle ofthe curved rod holder With the rod properly rientad, place the connection end ct the rod nko the ip of tha curved rod holder (Figures 46 and 47). Close the thus ions levar to secura tha rod tothe curved rod hokdor (Faue 45). ° Figure és Figuo 45 et aa Ca Figure 46 Figure a7 SURGICAL TECHNIQUE \When using the curved rod holder the rod entry point will be cephalad to the most superior screw inthe consiuct (Figure 48). This allows laminar shingling to serve a8 «a safely measure when inserting the rod, Estimate the ‘cd entry point depending on patent size and make a vertical incsion approximately 1¢m in length. ert the ‘2c through the incision and below the fascia (Figure 40), Using A/P and lateral luoroscopy, guid the rod through all extensions. Very that the rodis in postion using AVP and letra fluoroscopy (Figures 50 and 51). Ensure that the rod exlends slightly beyond the osplad and caudal tends ofthe screw head Mote: Da net cease the 100 fem he rod hold unt a lsat has Coen preilanalitiomaned. Proceed ta ‘Step 9 for nstucton on set screw placement Altera set screw has been provisionally tightened, release ‘he od from the curved rod had by opening the thumbs lover Pll and it the instrument to remove tram the pater }-~ SURGICAL TECHNIQUE DD serscrewinsention Pace the sot sorew inserter (Figure 62) ino a set screw a Fue 52 inthe set screw cad, retaining ito the tp of the inst 3 (Figure 53). Insert the loads! set screw gener into the screw extension and throad the set screw into the tulip ofthe screw by ctating clockwAse unt the set screw and rod are fully Seated inthe tu othe screw. ‘ign the proximal end of the gold band on the set screw Inserter with the top of the sctew extansion ta very thet the screw and rod are ful seated, When the set screw is {ull seated, pull up onthe set sew inserter to disengage Itfiom tho sot sora, nen the top ofthe gala Gana reachos the top otha extansion Four 53 sfoore the sot screws ful eeatd (Figure 86 and 97. Ropoat this stop to ingort sat screws into the remaining pedicle serous, Note: Do not erase tread the set screw Note: Te sot sraw inserter intended or povsional ooking only and should not be used fr Figure 54 Figue ss gure 58 Fue 57 SURGICAL TECHNIQUE [BD roo neouction ‘The Streamline MIS system features mutiple rod reduction ccapabities, Each screw extension has 1Smm of addtional treads locate! above the tulip ofthe screw that alow {or simple rod reduction with the set screw inserter. ‘greater rod reciuction is requited, the reducer (Figure 88) lr threaded red redhicer ean be used in cambination wath ‘ho reducing set screw inserter (Figure 59) to previde uP 10:30mm of reduction CAUTION: Rectuction instrumentation proved within the ‘Streamine 1 Spinal Fuaticn System intended 9 aid in the reduction of versal snondvolsthess, Steering MS ‘eduction mstumentaton should nc be used o focetuly Contour ara in stu toa tlip hea in a previous hse or otherwise mmotie spina levels) n such cases, ensure rod ontouurg places ie red segment whi re pea (> Ine 430° or 60° conica! ange oF metion of te paleo! screw, Whether o7 aot the maximum petyana rage of mation i exceeded foretul eduction of an improper contoured ro may mnina proper leckng er cause permanent damage the eotvawatsorow, such aF wip head eieassoctaton trom CAUTION: To factitate Mis peatoe serew implantation, Instrumentation olen aende in onan versus natura ion used fr opan techniques Actions length an aubject pions 10 meroased overage teres, Excessive lovorage forces may increase the ith for premature extension bre0k990.tulp head association, sorew Haru, pedioke tractue ancyorserew putt Four 58 gure 50 ‘SURGICAL TECHNIQUE The Reducer Pross the reducing set sorew inserter into a set screw Inthe set screw caddy retaning itn the tp of the instrument Push dawn on the tp of he inserter o get it to nap into tho set screw Insert the loaded reducing set Setaw inserter into the sore extension une it comes toa sop (Figure 63). White capturing the reducing et screw insertor within the preximal slot ofthe reducer (Figure 60), see the distal end ofthe reduser anto the prema collar ofthe extension sleeve [Figure 61). Final assemblyis picid in Figute 62. Squeeze the handle of the reducer Lntt cores toa siop, This wl dre tha reducing set screw inserter dowrwrard though the set scree, pushing the od ints the noad of tha podiole crow (Figure 64), lowing the set screw to reach tne reduction threads Rone ieee ofthe extension sleeve, While maintaining pressure on the reducer handle turn the reducing sat screw insartor ‘locks to advance the st scrow ito the reduction threads ofthe extension sloove (Figue 65), Advance ‘the set screw unl uly seated or untl the set screw can 4 advance no further ote: The reducing set srow inserter hanate (Figure 66) can be ute scstonalorque fe needed ta turn te rucng set Note: he gaia tan onthe reducing set exon iertar = ten load sed 9 indicate poston of he rod inthe serew extension non tne boston ofthe gold band reaches he top ofthe the rod is seated nthe screw Head and the set screw can be \ ‘uty advanced ure 65 SURGICAL TECHNIQUE ‘The Threaded Rod Reducer Press he reducing sal cra inserter into ast screw Tr ‘nthe 2 ore 04 tang on ho tpt Na instrument. Insert the lead! educing set screw inserter ino the sero extansion unt comes toa stp, Assembla ‘ho threaded re reducer by inserting the threaded reducer ina te threaded fecucerhanale (Figure 67). Slice the ascerbied tveaded rod reducer over tho reducing set sew inserter ancinto We praxis eduction owes threads located nthe colar of he extension sleeve (Fue 68). Peale he hance ofthe assembled teal reducer locke unt comes a hard lop Figure 69) « Wh the assembled threaded reducerin place, turn he reducing set screw inserter clockwise f advance he set < sore io the reduction threads ofthe extension sleve ‘Achare the set stew unt fly sated runt the sat screw can ackance no farther (Figo 7}. sel Tacit cnt aha a bia rere, ¥ mK mS YD mK Fue 68 Figure oo Figure 70 BD compression ano vistraction CAUTION: To acttate HS pecctascrew implaiatin, Inctrmentation ute! fer open teonauss,Atational fenath can subject implonts fo increased leverage forces Excessive Compression To apply compression to one of more levels ulizing the compressor, fist provisionally lock one of the set screws of the level being compressed Assemble the final ver withthe torque tmiting handle nd inser this essembly into the extension cf the uniockect scrom. Engage the final diver inthe set Seren and loosen one-quarter to one-half tun. Insert the post ofthe ‘compressor into the extension sleeve ofthe provisional locked sorew. While inserting the post ofthe compressor, ‘sing the hook of the compeessor onto the narrow Portin ofthe final driver (Figures 71 and 72},then side ‘the compressor down unt the pest ofthe compressor bottoms our an the locked sat serew (Figure 73) Wl applying downward pressure onthe fina dive, squesz= the compressor hancles together to compress the level (Figure 74) (Once adequate compression fs achieved, tum the final vor clockwise unl the et sere is tight on the rod. Do rot attempt to apply ful lacking torque tothe set screw withthe compxessor in place, Remove the compressor and final driver, then proceed to final get sorew locking (Step 12). caurior screw locking Adana feces and fet cccur between the J: The compressor must be removed pra to fal st wn me compressor pice. Reter 0 Step 12 or ore at i ] SURGICAL TECHNIQUE 1 I Figure 74 SURGICAL TECHNIQUE Distraction To apply distraction tone or mare lavas tizing the lstrsotr fist provisionally look one ofthe set sorews of ‘ho level being dstractoc, ‘Assemble the fina driver withthe torque-Imiting han ‘and insert this assembly into the extension ofthe unlocked sore. Engage the final drvor in the set screw ‘and loosen one-quarter to one-half tum, Insert the post of ‘he clstractor nto the extension sleewe o the prwsionally locked som. While inserting the post ofthe distractor, ‘swing the hook ofthe dlstactorento the narrow poxtion Fie 75 Figure 76 ofthe final driver {Faures 75 and 76}, then side the dlstactor down unt the posto the distractr bottoms ut on the locked set screw (Figure 77). While applying lowmardl pressure on the final civ, squeeze the distractor handles ogether to distract he level (Figure 78). Onee adtaquate distraction is achievad, tum the fal iver clockwise untl the sat screw is ight on the rod. Do not atte: to apply ful ooking torque tothe eat sorew with ne distractor in place, Remove te ostractor and tal tives then proceed final set sorew locking (Step 12). ote: Disaster clear ident sab by te gakd haat Mote: Do FoweT™ Figure 78 ‘cauTION: screw locking Adon! forces an hetton occur between This may rsut in insult fore for false screw locking with the ostactorim place Retro Ste 12 or erp fa A [BB am serscrew Lockina CAUTION: To facitate WS pode screw moana, Instrumentation is oten extended in ongth versus ean subject molents fo mereated leverage forces. Excessive lovarage forces may increase the risk for premature extension luyp head atssoc.aven, screw rctue, peaiele fracture sne/orserew pul To inal lock the set screw attach the final diver to the ‘orquo ting handle, Seat the tip of the cauntar toque ‘ue over a sarew an ait it down und reals an top ofthe red, The od is heldin the grooves ofthe counter {orque tube whan the top o he extension stave i us vith the oponing othe courterorque tube. Inger the assembled final oriver trough the screw exonsion and engage the set sore. Holaing the handle of the countertorque tube in place, rotate the torquedimiing handle clockwise until emits an audible and/or tangible ‘click’ (Figure 79). Apply no more torque. Carefully remove the instruments and repeat tis step for al sorews. Note: The ina! diver {05 EMALDRWVER) must be vod > ombination wit he torque inning hands (O2-TLHANDLE) to complet alse screw locking SURGICAL TECHNIQUE SURGICAL TECHNIQUE [BD screw extension Removat. CAUTION: To aotate is pea sorew inpisration, (nateaantation i often extend in engin versus instumntation used fr open techniques. Adctiona length can subject mplants to increased overage fares, Excessho leverage force may increas the isk for premature extension Figure 60 (Mote: Encur a set sree have been ra foe or 0 ‘removing the screw extensions (Orit the extansion removal pliers (Figure 80} so that ‘he cephalad/caudal markings are facing the cephalad’ | ‘caucal direction and the handle ofthe insrument s perpencicular tothe rad lace the extonsion removal plier over the top ofthe sorew extension 80 thatthe post ofthe instrument fs down ito the collar of the screw ‘extension (Figure 81), Side the extension removal pliers CEPI On. CEPH: 05-6 down unl the top ofthe screw extension i fush with the etched line onthe instrument. This inicates thatthe ‘extension removal pliers a fully seated, Paws Figure e2 ‘Squeeze the handle of the extension removal pliers to separate one tb ofthe extonsion sleeve fromthe collar (Figwe 82), Release the handle, Grieping the shalt of { ‘tho extension removal prs, rock the instrument and scrow extension back and forth perponcicuar tothe ‘0d, separating the screw extension from the screw head (Figure 83), Remove all pieces of the screw extension and ciscard (Figure 84), LGAUTION: Winn using th extension remove pers (05-EXTREM-PLIER} to break and remove the screw futanions, ensure hat he instrument uy seat over proxima colar ofthe screw extension belore anpvingfece. ono! attempt fo rows the serew extension rom the tuo rom the cot ‘Mote: When squeeting the extension remand pers the colar may become completely separated om the screw screw extension with a pa of forceps oy racking the iavigval extension tabe ack ana forth eereensicula othe roa Mote: Using A/° ace ia ‘SURGICAL TECHNIQUE REMOVAL (IF NECESSARY) To remove contruct, apply counterclockwise rotation to loosen is components and remove them in the opposite corer in which the construct was bull ORDERING GUIDE INSTRUMENT GUIDE Sd inset omen . 11¢Pedde Taping | Frcen plotted NE Noodle and guidewre plaoament 1G Pedicle Tageting Sa oxaoanes) ners NbconpoartcosPrAEEDLE | nase ano TEA forcing ltl pak cxwurrocans | Feds Ta Teor] Soom e OSPTNEEELE | mast ead GoavOANTT oi 4 | Fm re ap oe pee ance! eoumance | Rtmmunge — Fg caver cerndaostait Foriegn ramet ovum udeno bo Fotos ne guns @ecconnonnnEnnEES ; surtpNta Gussie | re gudng nen ag caus arenes 1.5m x5COmm pedicle somws into the pedis ORDERING GUIDE WnsTRUMENT GUE SEES = a ee ie srnatenionuinsrane ecommece | amsien Sornngemcs eter sets - “os cioccmosarstetiase Nat Comsacatoreént | snp cataloarae’ hopes pam LoANNORL assomcaruina | Fe neemng te dander eg romana FachtngTeerte | Fann upserocmninere — raw: gyri | resect =) eile i ; soaeae wee ae ‘Standard setineludes 45,55 and Paerenr - ORDERING GUIDE INSTRUMENT GUIDE Pat umber instant Deseripon SS SMPLECRNER Srp Der For esetng semi pvicies —= OSSCREWINSTHRD. Threaded Seow ncrtct | For nsering serwsirto pecicies SS See . eens csomenacoe | arsine Satter me [o

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