fig1 - 5 show one embodiment of a dynamic spine prosthesis according to this invention . in this embodiment , the dynamic spine prosthesis is an artificial facet joint prosthesis 100 providing left and right cephalad facet joint bearing elements 102 and 104 and left and right caudal facet joint bearing elements 106 and 108 , respectively . when the cephalad facet joint bearing elements are attached to a superior vertebra and the caudal facet joint bearing elements are attached to an inferior vertebra , the corresponding left and right bearing elements move with respect to each other and bear against each other as the patient moves his or her back , which is often a combination of one of more of the following motions : flexion , extension , rotation and / or lateral bending . the cephalad facet joint bearing elements attach to a superior vertebra via fixation elements , such as screws 110 and 112 having threaded bone entry portions . a left arm 114 extends generally downward from fixation element 110 to a support bar 116 to which left cephalad bearing element 102 is attached . likewise , a right arm 118 extends generally downward from fixation element 112 to a support bar 120 to which right cephalad bearing element 104 is attached . a crossbar 122 extends between the right and left cephalad bearing elements . because of differences in patient anatomy , the cephalad portion of the dynamic spine prosthesis has adjustment mechanisms for adjusting the spatial relationship between the fixation elements and the other prosthesis components . first , the angle between the left cephalad fixation element 110 and the left support arm 114 may be adjusted and fixed in the adjusted position by rotating two angled washers 124 and 126 mounted on a proximal extension of fixation element 110 between the proximal face 127 of a fixation region 128 on the top end of arm 114 and a compression nut 130 or other tightening element . because each washer 124 and 126 has a contact surface not perpendicular to the axis of fixation element 110 , each washer 124 and 126 may be rotated about fixation element 110 to change the angle between arm 114 ( and , therefore , cephalad bearing element 102 ) and fixation element 110 . when the proper orientation has been set , tightening element 130 is tightened along a threaded proximal extension of fixation element 110 to keep the components in place . in this embodiment , a partially spherical washer 132 is disposed between the distal face 129 of the left cephalad support arm &# 39 ; s fixation region 128 rests in an annular channel 134 on fixation element 110 to provide firm contact between the distal face of the arm fixation region and the fixation element . alternatively , a second pair of angled washers may be used in place of the partially spherical washer . similarly , the angle between the right cephalad fixation element 112 and the right support arm 118 may be adjusted and fixed in the adjusted position by rotating two angled washers 136 and 138 mounted on a proximal extension of fixation element 112 between the proximal face 140 of a fixation region 142 on the top end of arm 114 and a compression nut 144 or other tightening element . as on the left side , because each washer 136 and 138 has a contact surface not perpendicular to the axis of fixation element 112 , each washer 136 and 138 may be rotated about fixation element 112 to change the angle between arm 118 ( and , therefore , cephalad bearing element 104 ) and fixation element 112 . when the proper orientation has been set , tightening element 144 is tightened along a threaded proximal extension of fixation element 112 to keep the components in place . as on the left side , in this embodiment a partially spherical washer 146 disposed between the distal face 148 of the right cephalad support arm &# 39 ; s fixation region 142 rests in an annular channel 150 on fixation element 112 to provide firm contact between the distal face of the arm fixation region and the fixation element . once again , a second pair of angled washers may be used in place of the partially spherical washer . an additional adjustment mechanism is provided by the oval shaped openings 152 and 154 of the fixation regions 128 and 142 of left and right cephalad support arms 114 and 118 , respectively . the support arms 114 and 118 may be moved up or down with respect to fixation elements 110 and 112 , respectively , before tightening compression screws 130 or 144 to further adjust the spatial relationships between cephalad facet bearing elements 102 and 104 and fixation elements 110 and 112 . the cephalad support arms 114 and 118 may also be rotated about their respective fixation elements 110 and 112 before tightening . the caudal facet joint prosthesis components may be adjusted with respect to their fixation elements as well . the caudal facet prosthesis bearing elements attach via screws or other fixation elements 160 and 162 to a vertebra inferior to the vertebra to which the cephalad components have been attached . looking first on the left side , a clamp 164 mounted on fixation element 160 holds a left caudal support bar 166 extending from left caudal bearing surface 106 . likewise , a clamp 168 mounted on fixation element 162 holds a right caudal support bar 170 extending from right caudal bearing surface 108 . a crossbar 172 extends between the left and right caudal bearing surfaces . in this embodiment , the angle between the left caudal fixation element 160 and the left caudal clamp 164 may be adjusted by rotating a first partially spherical washer 174 ( disposed proximal to clamp 464 ) with respect to a cap 179 beneath a compression screw 180 and / or by rotating a second partially spherical washer 176 ( disposed distal to clamp 164 ) with respect to an annular channel 178 formed in fixation element 160 . when the proper orientation has been achieved , compression screw 180 or other tightening element is tightened along a threaded proximal extension of fixation element 160 to fix these components in place . alternatively , a pair of angled washers may be used in place of the partially spherical washers , as in the cephalad component . likewise on the right side , the angle between the right caudal fixation element 162 and the right caudal clamp 168 may be adjusted by rotating a first partially spherical washer 182 ( disposed proximal to clamp 168 ) with respect to a cap 189 beneath a compression screw 188 and / or by rotating a second partially spherical washer 184 ( disposed distal to clamp 168 ) with respect to an annular channel 186 formed in fixation element 162 . when the proper orientation has been achieved , compression screw 188 or other tightening element is tightened along a threaded proximal extension of fixation element 162 to fix these components in place . alternatively , a pair of angled washers may be used in place of the partially spherical washers , as in the cephalad component , as before . because the various components of the present invention allows for significant adjustment and / or modular variability between the dynamic elements and the fixation elements , the device is particularly well suited for use in virtually all levels of the spine , and for virtually all anatomical variations , including adult males or females or even children . if desired , the fixation elements can incorporate bony in - growth and / or osteo - integration surfaces and / or materials , or the various fixation elements could be utilizes in conjunction with auxiliary fixation materials such as ceramic , crystalline , organic , polymeric or other types of bone cement or adhesives . where the device fails for some reason , or revision is necessitated ( such as , for example , where a young patient “ grows out of ” the device ), a physician could access the device and disassemble those pieces necessary to be replaced , and then reassemble the same or a different size or configuration of the device , or assemble a fusion construct utilizing one or more of the original fixation elements already integrated within and / or attached to the patient &# 39 ; s bones . if desired , the devices of the present invention could be utilized with virtually any dynamic system , including those used in combination with an artificial spinal disc replacement device . virtually all of the various embodiments disclosed here could be utilized , in various ways , in combination with artificial disc replacement devices , as well as nucleus repair systems and replacement devices , interbody spacers , dynamic stabilization devices , articulating rod and screw systems , posterior ligament or annular repair and / or augmentation devices , interspinous spacers , facet replacement and / or resurfacing devices , and the like . use of the present devices in a dynamic system , in combination with an artificial disc replacement or repair , provides a solution for the total disc replacement contraindication of facet degeneration . moreover , implantation of a total disc replacement device after removal of some or all of one or more of the facets and / or other intervening tissues ( hard or soft ), but prior to implantation of the dynamic device , provides a large , safe and repeatable access to the disc space , as well as aiding in any decompression of the joint that may be necessary . such access facilitates passage of one or more components of the artificial disc replacement ( or nucleus replacement , or annular repair material , and their respective tools ) through the removed facet tissues via a lateral , posterior - lateral and / or posterior approach . the functions of the removed tissues can then be replaced by implanting the dynamic device as described herein . of course , the dynamic devices disclosed herein ( and the surgical removal of tissues to create one or more access paths ) may be used unilaterally or bilaterally , depending on the nature of and stage of disease , and can be used at multiple levels of the spine of facet and / or other intervening tissues . in various embodiments , a series of artificial dynamic components of differing shapes , sizes and / or orientations and / or lengths can be provided to accommodate different objectives , including alteration of dynamic element height / orientation relative to the fixation element , to accommodate different loading conditions due to other surgical treatments ( i . e ., artificial disc replacement of the same or other spinal level , annular repair , nucleus replacement , dynamic stabilization , interspinous spacer and / or adjacent level fusion and / or facet replacement devices ). moreover , to accommodate differing designs ( i . e ., constrained discs versus unconstrained discs ) and / or arrangement / positioning of artificial disc replacement devices used on the same or different spinal levels , the dynamic elements could be of differing shapes , sizes , orientations and / or lengths to accommodate the different loading profiles induced or desired by the artificial disc replacement devices . in one alternate embodiment , once the components of the device have been secured to the targeted vertebral bodies , one or more elastic compression devices or “ bands ” could be secured about the dynamic elements ( or to the vertebral bodies themselves , or between other parts of the device , or any combination thereof ). properly positioned and / or tensioned , these “ bands ” would tend to keep the dynamic elements in contact and / or close proximity , even under extreme and / or unusual loading conditions , and thus reduce and / or eliminate the opportunity for the device to dislocate . moreover , in the event that dislocation of the device did occur , the bands could prevent and / or limit motion of the dislocated joint ( by holding the dynamic elements together ), and thus reduce or eliminate damage to other tissues ( such as the spinal cord , various other nerves and / or circulatory / connective tissues ) resulting from the dislocation . in fact , the compression of the bands might make it possible to eventually “ reduce ” the dislocation and / or repair the dislocated device through external manipulation and / or minimally - invasive surgery . if desired , one or more “ bands ” could be secured between the dynamic elements of the device , or between the various surfaces , arms , cups , stems and / or cross - arms of the device components , with varying results . in another alternative embodiment , the compression device could comprise an elastic or pliable material surrounded by a non - elastic housing , whereby the elastic material allows various movement of the dynamic elements ( with resistance commensurate to the flexibility of the material ), but the non - elastic housing acts as an ultimate “ stop ” to movement of the dynamic elements beyond a certain pre - determined limit . similarly , the “ band ” could comprise an elastic , non - elastic or rigid material , such as stainless steel cable , which desirably prevents relative motion of the elements of the device beyond a certain pre - defined maximum extension / flexion . advantageously and in contrast to conventional techniques where fusion and dynamic implants are implanted via an open procedure , a majority of the components of the present dynamic devices can be surgically implanted using minimally - invasive techniques alone or in combination with conventional open techniques . for example , all or most of the components of the device may be delivered through a cannula inserted through a small incision in the skin . to implant the device components , the physician can first create an access path through the skin and soft tissue ( with a spinal needle and / or k - wire ) to the targeted vertebral body . desirably , non - invasive visualization , such as fluoroscopic or real - time mri , is used to monitor the advancement of the needle and avoid damage to tissue structures such as muscles , tendons , ligaments , nerves , veins and / or the spinal cord itself . once the access path has been created , a suitable cannula can be advanced through the tissues to the targeted bone . if necessary , progressively larger dilation catheters ( such as the access ™ dilation port commercially available from spinal concepts of austin , tex .) can be used to introduce a cannula having a lumen large enough to accommodate passage of the components . depending upon the patient &# 39 ; s condition and the desired surgical outcome , as well as the surgeon &# 39 ; s preference , the present embodiment can facilitate the repair and replacement / augmentation of the facet joints in a minimally - invasive , limited - open ( or modified - open ) and / or fully - open surgical procedure . for example , where facet joint replacement is deemed necessary , but removal of soft and / or hard tissues in and / or adjacent the spinal canal is not warranted or desired ( such as where spinal stenosis and nerve impingement is not a significant concern ), the repair and / or replacement of one or more facet joints can be accomplished in a least - invasive fashion , using one or more cannulae to implant the prosthesis and associated distal hardware . alternatively , where removal of the facet joints and / or lamina is necessitated , such a procedure can be accomplished through a combination of open , semi - open and / or minimally invasive procedures ( which will be referred to herein as a modified - open or mini - open procedure ) to minimize damage and / or disruption to surrounding soft - tissue structures . in such a procedure , one or more of the facet joint capsules can be exposed through an open incision ( to allow easy resection and removal of the facet joint and / or surrounding anatomical structures ), and the components of the dynamic device can be delivered through a cannula or other minimally - invasive delivery method . various alternative embodiments of the present invention could incorporate laminar , spinous process , pedicle - based and / or vertebral body fixation elements , or any combinations thereof , ultimately desirous for replacing and / or augmenting the natural facets and other intervertebral tissues . of course , the systems disclosed herein may be anchored to the vertebral bodies in various ways , including the use of screw threads or stems , with or without using cement and / or bony ingrowth surfaces to augment fixation . while preferred embodiments of the present invention have been shown and described herein , it will be obvious to those skilled in the art that such embodiments are provided by way of example only . numerous variations , changes , and substitutions will now occur to those skilled in the art without departing from the invention . it should be understood that various alternatives to the embodiments of the invention described herein may be employed in practicing the invention . it is intended that the following claims define the scope of the invention and that methods and structures within the scope of these claims and their equivalents be covered thereby .
a dynamic spine prosthesis that has a fixation element with an elongated bone entry portion defining a longitudinal axis and a dynamic spine prosthesis component connected to the fixation element at a connection location by an adjustable connection . the adjustable connection has first and second washers each rotatably supported by the fixation element and each having an angled contact surface in a plane not perpendicular to the longitudinal axis of the fixation element , with the connection location being between the bone entry portion and the first and second washers .