ACIS Anterior Cervical Interbody Spacer

Transcription

1 An enhanced system of implants and instruments for interbody fusion ACIS Anterior Cervical Interbody Spacer Surgical Technique

2 Image intensifier control This description alone does not provide sufficient background for direct use of DePuy Synthes products. Instruction by a surgeon experienced in handling these products is highly recommended. Reprocessing, Care and Maintenance For general guidelines, function control and dismantling of multi-part instruments, please contact your local sales representative or refer to: For general information about reprocessing, care and maintenance of Synthes reusable devices, instrument trays and cases, please consult the Important Information leaflet (SE_023827) or refer to:

3 Table of Contents Introduction ACIS Anterior Cervical Interbody Spacer 2 AO Spine Principles 4 Indications and Contraindications 5 Surgical Technique Preparation 6 Patient Positioning 7 Exposure and Discectomy 8 Segment Distraction 9 Endplate Preparation 10 Implant Size and Shape Determination 11 Implant Size and Shape Determination 12 Implant Insertion 14 Implant Insertion 16 Supplemental Fixation 22 Implant Removal 23 Product Information Implants 24 Instruments 28 Sets 31 Additionally available 32 Also Available from Synthes: chronos Putty Spine 33 Bibliography 35 ACIS Anterior Cervical Interbody Spacer Surgical Technique DePuy Synthes 1

4 ACIS Anterior Cervical Interbody Spacer. An enhanced system of implants and instruments for interbody fusion. The ACIS implant is designed to meet the specific demands of anterior cervical interbody fusion procedures (1 6). The implant features a large central canal and is available in three footprints, multiple heights and three sagittal profiles to accommodate various patient anatomies. Pyramidal teeth Provide resistance to implant migration Implant-Instrument interface Stable interface for fast and effective connection/release with the insertion device Large central canal Accommodates autogenous bone graft or bone graft substitute to allow fusion to occur through the implant Midline markers Facilitate implant positioning/alignment in multilevel procedures Anatomic shapes Multiple implant variations offered to suit individual anatomical conditions Lateral windows Windows on the lateral walls of the cage to allow for fusion Material Biocompatible radiolucent polymer (PEEK*) allows clear assessment of bony fusion *Polyetheretherketone 2 DePuy Synthes ACIS Anterior Cervical Interbody Spacer Surgical Technique

5 Trial Implants Preassembled trials for improved handling Double-sided trials for fast height comparison Color coded by sagittal profile Insertion Device Rigid interface for secure implant placement Slim implant interface for optimal visibility during insertion Multiple shaft options with and without depth stop to accommodate surgeon preference Implant Holder Alternative implant insertion option for enhanced precision control Quick implant engagement and disengagement with one click squeezelock mechanism Allows for excellent visibility ACIS Anterior Cervical Interbody Spacer Surgical Technique DePuy Synthes 3

6 AO Spine Principles The four principles to be considered as the foundation for proper spine patient management underpin the design and delivery of the Curriculum: Stability Alignment Biology Function. 7,8 Stability Stabilization to achieve a specific therapeutic outcome axial sagittal coronal Alignment Balancing the spine in three dimensions Biology Etiology, pathogenesis, neural protection, and tissue healing Function Preservations and restoration of function to prevent disability Copyright 2012 by AOSpine 7 Aebi et al (1998) 8 Aebi et al (2007) 4 DePuy Synthes ACIS Anterior Cervical Interbody Spacer Surgical Technique

7 Indications and Contraindications Intended Use The Synthes ACIS system is intended to replace cervical intervertebral discs and to fuse adjacent vertebral bodies at vertebral levels C2 C7 following anterior cervical discectomy for reduction and stabilization of the cervical spine. The use of autologous bone or bone graft substitute is recommended. Indications Cervical pathologies for which segmental arthrodesis is indicated: Degenerative disc diseases and instabilities Ruptured and herniated discs Pseudarthrosis or failed spondylodesis For multisegmental fusions with the ACIS system supplemental fixation is recommended. Contraindications Osteoporosis Severe instabilities Vertebral body fractures Spinal tumors Infections ACIS Anterior Cervical Interbody Spacer Surgical Technique DePuy Synthes 5

8 Preparation 1. Preparation Required set ACIS Standard Set in Vario Case Optional sets Cervical Retractors and Distractors Have all necessary imaging studies readily available to plan implant placement and visualize individual patient anatomy. Have all necessary sets readily available prior to surgery. 2. Assemble insertion device Instrument ACIS Insertion Device 1 Assemble the insertion device prior to use according to the assembling instruction shown here or refer to DePuy Synthes ACIS Anterior Cervical Interbody Spacer Surgical Technique

9 Patient Positioning Position the patient in a supine position on a radiolucent operating table. Ensure that the neck of the patient is in a sagittally neutral position and supported by a cushion. When treating C6 C7 make sure that the shoulders do not limit the x-ray monitoring. For all cases, both vertebrae should be completely visible. ACIS Anterior Cervical Interbody Spacer Surgical Technique DePuy Synthes 7

10 Exposure and Discectomy 1. Access Optional set Cervical Retractors and Distractors Locate the correct operative level under radiographic control and incise. Expose the intervertebral disc and the adjacent vertebral bodies through a standard anterior approach to the cervical spine. Warning: Careful positioning of the retractor is required to avoid soft tissue damage. 2. Discectomy Prepare the fusion site following the appropriate technique for the given indication. 8 DePuy Synthes ACIS Anterior Cervical Interbody Spacer Surgical Technique

11 Segment Distraction Optional set Cervical Retractors and Distractors Perform segmental distraction. Note: Distraction of the segment is essential for restoring disc height and for providing good access to the intervertebral space. ACIS Anterior Cervical Interbody Spacer Surgical Technique DePuy Synthes 9

12 Endplate Preparation Optional instrument Endplate Rasp When the discectomy is complete, remove the superficial cartilaginous layers of the endplates to expose bleeding bone. Warning: Adequate cleaning of the endplates is important for vascular supply of the autologous bone graft or bone graft substitute. Excessive cleaning, however, may result in removal of bone underlying the cartilaginous layers and weaken the endplates. The removal of any osteophytes is crucial for achieving complete decompression of the neural structures and for avoiding the risk of partial compression after implant insertion. Note: The endplate rasp is double sided with a standard depth on one side and a large depth on the other side. These are indicated by one (standard) and two (large) white bands on the shaft as well as etchings on the rear side of the rasp. The depth is limited by a stop. Depths are 14 mm for the standard and 16 mm for the large. The width is 8 mm and the height is 4 mm. height 4 mm depth 14 mm: standard 16 mm: large width 8 mm 11 DePuy Synthes ACIS Anterior Cervical Interbody Spacer Surgical Technique

13 Implant Size and Shape Determination Instruments ACIS Trial Implant, standard, lordotic, heights 5 12 mm, double-sided, blue ACIS Trial Implant, standard, parallel, heights 5 12 mm, double-sided, purple ACIS Trial Implant, standard, convex, heights 5 12 mm, double-sided, yellow ACIS Trial Implant, large, lordotic, heights 5 12 mm, double-sided, blue ACIS Trial Implant, large, parallel, heights 5 12 mm, double-sided, purple ACIS Trial Implant, large, convex, heights 5 12 mm, double-sided, yellow ACIS Trial Implant, small, lordotic, heights 5 12 mm, double-sided, blue ACIS Trial Implant, small, parallel, heights 5 12 mm, double-sided, purple ACIS Trial Implant, small, convex, heights 5 12 mm, double-sided, yellow Optional instrument Mallet For a complete overview of trial implants please refer to page 28. ACIS Anterior Cervical Interbody Spacer Surgical Technique DePuy Synthes 11

14 Implant Size and Shape Determination The selection of the trial implant depends on the height, width and depth of the intervertebral space, the preparation technique and the patient s anatomy. Choose a standard, large or small footprint trial implant with convex, lordotic or parallel sagittal shape of the appropriate height. yellow convex Notes: The trial implants are double sided with different heights on either side. Colored bands on the shaft indicate which side is of lesser (one band) or greater (two bands) height. In addition, heights are etched on the cranial and caudal surfaces of the trial implants. Trial implants are color coded by sagittal shape: yellow, blue and purple bands on the shaft indicate that a trial implant is convex, lordotic or parallel. Furthermore, the following etchings on the cranial and caudal surfaces indicate the sagittal shape: C for convex, L for lordotic, and P for parallel. The footprint is indicated by the etchings Small, Standard and Large on the cranial and caudal surfaces of the trial implants. blue lordotic purple parallel greater height lesser height lordotic convex parallel Before carefully inserting the trial implant, ensure that the orientation of the trial implant is correct. Each convex trial implant is etched with an arrow pointing cranially on the lateral walls to indicate the correct cranial/caudal alignment. The lordotic and parallel trial implants do not have a dedicated cranial or caudal surface. They can be inserted into the intervertebral disc space with either surface pointing cranially. Warning: Ensure that all disc material has been removed from the insertion path to avoid dislocation into the spinal canal. 11 DePuy Synthes ACIS Anterior Cervical Interbody Spacer Surgical Technique

15 If necessary, controlled and light hammering with the mallet can be used to help advance the trial implant into the intervertebral disc space. Precautions: Excessive impaction force during trial implant insertion must be avoided. The trial implants do not have a depth limiter; an image intensifier should be used to check the position during insertion. Use image intensifier to confirm the fit of the trial implant. If the trial implant appears too loose or too tight, try the next larger or smaller size height until the most secure fit is achieved. Warnings: The height of the trial implants is undersized by 0.5 mm compared to the implant, to ensure a tight fit for final implant insertion. With the segment fully distracted, the trial implant must fit tightly and accurately between the endplates. To minimize potential increased risk to the patient, it is recommended to first trial with smaller height trial implants before trialing with taller trial implants. Trial implants are not for implantation and must be removed before insertion of the ACIS implant. The mallet can be used for trial implant removal. While holding the trial implant slide the mallet over the upper part of the trial implant s shaft and apply an upward force. Repeat this process until the trial implant has been removed. ACIS Anterior Cervical Interbody Spacer Surgical Technique DePuy Synthes 11

16 Implant Insertion Option A. Insertion device 1. Attach implant to insertion device Instruments ACIS Insertion Device and Inner Shaft, small, with Stop, for No or Inner Shaft, standard/large, without Stop, for No or Inner Shaft, standard/large, with Stop, for No or Inner Shaft, small, without Stop, for No Optional instruments Impactor, flat Mallet Select the ACIS implant that corresponds to the footprint, shape and height determined using the trial implant. Refer to page 6 for ACIS insertion device assembly. If desired, the insertion device can be combined with an inner shaft with stop. It has a depth limiter that will contact the anterior edge of the vertebral body when the ACIS implant is inserted approximately 1 mm beyond the anterior edge of the vertebral body. Attach the implant to the ACIS insertion device by aligning the recessed grooves located on the side walls of the implant with the prolonged tabs of the instrument tip and engaging those. Turn the knob clockwise to secure the implant. Ensure that the implant is held flush against the insertion device and securely in the tabs. 11 DePuy Synthes ACIS Anterior Cervical Interbody Spacer Surgical Technique

17 2. Pack implant with autologous bone graft or bone graft substitute Optional instruments Cancellous Bone Impactor Packing Block It is recommended to pack the ACIS implant with autologous bone or bone graft substitute. Place the ACIS implant into the packing block. Small and standard footprint implants fit into the cavity marked Standard while large footprint implants fit into the cavity marked Large. The cancellous bone impactor can be used to firmly pack the autologous or bone graft substitute into the implant cavity. Precaution: Excessive impaction of the implant with the cancellous bone impactor should be avoided to prevent possible implant damage. Notes: To ensure optimal contact with the vertebral endplates, it is important to fill the implant until the autologous bone or bone graft substitute protrudes from the openings of the implant. A table on page 27 shows the approximate graft volume that the ACIS implants hold, depending on the footprint, height and sagittal profile. ACIS Anterior Cervical Interbody Spacer Surgical Technique DePuy Synthes 11

18 Implant Insertion 3. Insert implant Confirm the implant is securely attached. Carefully insert the implant into the distracted segment, ensuring that the orientation of the implant is correct. Each convex implant is etched with an arrow pointing cranially on the left lateral wall to indicate the correct cranial/caudal alignment. The lordotic and parallel implants have a symmetrical sagittal profile and therefore do not require specific orientation. If necessary, controlled and light hammering with the mallet can be used to help advance the implant into the intervertebral disc space. Turn the knob in a counterclockwise direction to release the implant from the insertion device. Remove the insertion device and if required use the flat impactor to seat the implant into its final position. 11 DePuy Synthes ACIS Anterior Cervical Interbody Spacer Surgical Technique

19 Use image intensifier to confirm the position of the implant. Precautions: If an inner shaft without stop is used then an image intensifier should be used to check the position during insertion. Excessive impaction must be avoided to prevent implant damage or too deep insertion. Excessive tilting of the insertion device must be avoided to prevent implant separation or damage. Warning: Verify final implant position relative to the vertebral bodies in the AP and lateral direction with the help of an intraoperative x-ray. The ACIS implant has three x-ray markers incorporated in the implant to enable accurate intraoperative radiographic assessment of the implant position. Notes: B 1.0 mm TAV pins as x-ray markers. The distance between pins and the anterior and posterior walls of the implant is approx. 1.0 mm. The posterior pin is centered. ACIS Anterior Cervical Interbody Spacer Surgical Technique DePuy Synthes 11

20 Implant Insertion Option B. Implant holder 1. Attach implant to implant holder Instrument ACIS Implant Holder Optional instruments Impactor, flat Mallet Select the ACIS implant that corresponds to the footprint, shape and height determined using the trial implant. Attach the implant to the ACIS implant holder by aligning the recessed grooves located on the side walls of the implant with the prolonged tabs of the instrument tip. Engage the squeeze-lock by applying slight pressure on the arms of the implant holder. 11 DePuy Synthes ACIS Anterior Cervical Interbody Spacer Surgical Technique

21 2. Pack implant with autologous bone graft or bone graft substitute Optional instruments Cancellous Bone Impactor Packing Block It is recommended to pack the ACIS implant with autologous bone or bone graft substitute. Place the ACIS implant into the packing block. Small and standard footprint implants fit into the cavity marked Standard while large footprint implants fit into the cavity marked Large. The cancellous bone impactor can be used to firmly pack the autologous or bone graft substitute into the implant cavity. Precaution: Excessive impaction of the implant with the cancellous bone impactor should be avoided to prevent possible implant damage. Notes: To ensure optimal contact with the vertebral endplates, it is important to fill the implant until the autologous bone or bone graft substitute protrudes from the openings of the implant. A table on page 27 shows the approximate graft volume that the ACIS implants hold, depending on the footprint, height and sagittal profile. ACIS Anterior Cervical Interbody Spacer Surgical Technique DePuy Synthes 11

22 Implant Insertion 3. Insert implant Confirm the implant is securely attached, carefully insert the implant into the distracted segment, ensuring that the orientation of the implant is correct. Each convex implant is etched with an arrow pointing cranially on the left lateral wall to indicate the correct cranial/caudal alignment. The lordotic and parallel implants have a symmetrical sagittal profile and therefore do not require specific orientation. Release the implant holder by applying slight pressure on the arms of the implant holder and disengaging the squeezelock. Remove the holder and if required use the flat impactor to seat the implant into its final position. Use image intensifier to confirm the position of the implant. Precautions: The implant holder does not feature a depth stop. Image intensifier control should be used to check the position during insertion. Excessive tilting of the implant holder must be avoided to prevent implant separation or damage. Warning: Excessive impaction must be avoided to prevent implant damage or too deep insertion. 22 DePuy Synthes ACIS Anterior Cervical Interbody Spacer Surgical Technique

23 Warning: Verify final implant position relative to the vertebral bodies in the AP and lateral direction with the help of an intraoperative x-ray. The ACIS implant has three x-ray markers incorporated into the implant to enable accurate intraoperative radiographic assessment of the implant position. Notes: B 1.0 mm TAV pins as x-ray markers. The distance between pins and the anterior and posterior walls of the implant is approx. 1.0 mm. The posterior pin is centered. ACIS Anterior Cervical Interbody Spacer Surgical Technique DePuy Synthes 22

24 Supplemental Fixation Optional Sets Cervical Spine Locking Plates with variable angle in Vario Case Cervical Spine Locking Plates 4.0/4.35 (Pure Titanium) in Vario Case Vectra in Vario Case For multi-segmental instrumentation, ACIS is intended to be used with Synthes supplemental fixation, e.g. CSLP or Vectra. Complete the procedure by following the steps indicated in the respective surgical technique. 22 DePuy Synthes ACIS Anterior Cervical Interbody Spacer Surgical Technique

25 Implant Removal Instrument ACIS Insertion Device Optional instrument Mallet Attach the ACIS insertion device to the implant in the disc space by aligning the pronged tabs of the instrument tip to the recessed grooves located on the side walls of the implant. Tighten the knob clockwise until the implant has a rigid connection. Ensure that the implant is held flush against the insertion device and securely in the tabs. Remove the implant from the disc space. Warning: Take care not to push the implant towards the posterior elements. Precautions: Excessive tilting of the insertion device must be avoided to prevent implant separation or damage. In case of visible damages on the implant it should not be reused. The mallet can be used for implant removal. While holding the insertion device, slide the mallet over the shaft of the insertion device and apply an upward force. Repeat this process until the implant has been removed. ACIS Anterior Cervical Interbody Spacer Surgical Technique DePuy Synthes 22

26 Implants ACIS implants Supplied sterile Implant material: PEEK with Titanium alloy (Ti-6Al-4V) radiographic marker pins Three radiographic marker pins Enable visualization of the implant position B 1.0 mm TAV pins Distance between pins and the anterior and posterior walls of the implant is approx. 1.0 mm Posterior pins are centered Distance between anterior pins and lateral walls of the implant varies between the different footprint sizes: Small 3.0 mm Standard 4.0 mm Large 5.0 mm 1 mm 1 mm 22 DePuy Synthes ACIS Anterior Cervical Interbody Spacer Surgical Technique

27 3 footprints: Small (11.5 mm 12.5 mm) Standard (13 mm 14 mm) Large (15 mm 16 mm) 11.5 mm Small Standard Large 13 mm 15 mm 12.5 mm 14 mm 16 mm 3 sagittal shapes: Lordotic Parallel Convex Lordotic Parallel Convex 8 heights ranging from 5 mm to 12 mm (in 1 mm increments) Height Height Height ACIS Anterior Cervical Interbody Spacer Surgical Technique DePuy Synthes 22

28 Implants Lordotic Parallel Convex Height Implant Footprint depth width Small S S S 5 mm 11.5 mm 12.5 mm S S S 6 mm 11.5 mm 12.5 mm S S S 7 mm 11.5 mm 12.5 mm S S S 8 mm 11.5 mm 12.5 mm S S S 9 mm 11.5 mm 12.5 mm S S S 10 mm 11.5 mm 12.5 mm S S S 11 mm 11.5 mm 12.5 mm S S S 12 mm 11.5 mm 12.5 mm Standard S S S 5 mm 13 mm 14 mm S S S 6 mm 13 mm 14 mm S S S 7 mm 13 mm 14 mm S S S 8 mm 13 mm 14 mm S S S 9 mm 13 mm 14 mm S S S 10 mm 13 mm 14 mm S S S 11 mm 13 mm 14 mm S S S 12 mm 13 mm 14 mm Large S S S 5 mm 15 mm 16 mm S S S 6 mm 15 mm 16 mm S S S 7 mm 15 mm 16 mm S S S 8 mm 15 mm 16 mm S S S 9 mm 15 mm 16 mm S S S 10 mm 15 mm 16 mm S S S 11 mm 15 mm 16 mm S S S 12 mm 15 mm 16 mm 22 DePuy Synthes ACIS Anterior Cervical Interbody Spacer Surgical Technique

29 Filling volume The table below shows the approximate graft volume (in cc) that ACIS implants will hold, depending on the footprints, heights and sagittal profiles. Convex Parallel Lordotic Height Height Height Small Standard Large Small Standard Large Small Standard Large ACIS Anterior Cervical Interbody Spacer Surgical Technique DePuy Synthes 22

30 Instruments Double-sided Trial Implants ACIS Trial Implant, standard, lordotic, heights 5/6 mm; 7/8 mm; 9/10 mm; /12 mm, double-sided, blue ACIS Trial Implant, standard, parallel, heights 5/6 mm; 7/8 mm; 9/10 mm; /12 mm, double-sided, purple ACIS Trial Implant, standard, convex, heights 5/6 mm; 7/8 mm; 9/10 mm; /12 mm, double-sided, yellow ACIS Trial Implant, large, lordotic, heights 5/6 mm; 7/8 mm; 9/10 mm; /12 mm, double-sided, blue ACIS Trial Implant, large, parallel, heights 5/6 mm; 7/8 mm; 9/10 mm; /12 mm, double-sided, purple ACIS Trial Implant, large, convex, heights 5/6 mm; 7/8 mm; 9/10 mm; /12 mm, double-sided, yellow ACIS Trial Implant, small, lordotic, heights 5/6 mm; 7/8 mm; 9/10 mm; /12 mm, double-sided, blue ACIS Trial Implant, small, parallel, heights 5/6 mm; 7/8 mm; 9/10 mm; /12 mm, double-sided, purple ACIS Trial Implant, small, convex, heights 5/6 mm; 7/8 mm; 9/10 mm; /12 mm, double-sided, yellow DePuy Synthes ACIS Anterior Cervical Interbody Spacer Surgical Technique

31 ACIS Insertion Device Turning Knob for ACIS Insertion Device ACIS Implant Holder Cancellous Bone Impactor Packing Block Inner Shaft, small, with Stop, for No Inner Shaft, standard/large, without Stop, for No Inner Shaft, standard/large, with Stop, for No ACIS Anterior Cervical Interbody Spacer Surgical Technique DePuy Synthes 22

32 Instruments Inner Shaft, small, without Stop, for No Endplate Rasp Impactor, flat Mallet 33 DePuy Synthes ACIS Anterior Cervical Interbody Spacer Surgical Technique

33 Sets ACIS Tray for Basic Instruments ACIS Tray for Additional Instruments ACIS Tray for Trial Implants Lid for Modular Tray, size 1/ Vario Case, Framing, size 1/2, height 88 mm Vario Case, Framing, size 1/2, height 126 mm Lid (Stainless Steel), size 1/2, for Vario Case ACIS Anterior Cervical Interbody Spacer Surgical Technique DePuy Synthes 33

34 Additionally available ACF Holder ACIS Trial Implant, standard, parallel, height 4 mm S ACIS, standard, parallel, height 4 mm, sterile 32 DePuy Synthes ACIS Anterior Cervical Interbody Spacer Surgical Technique

35 Also Available from Synthes: chronos Putty Spine Benefits of chronos Putty No wash-out X-ray visibility Added osteoinductivity Accelerated remodeling Indications* chronos Putty with autologous bone marrow and/or blood is intended for use in spine indications, such as: Intraoperative filling of IBF cages and the space around them Posterolateral fusion * For complete indications, contraindications, precautions and warning notices, please refer to the instructions for use. ACIS Anterior Cervical Interbody Spacer Surgical Technique DePuy Synthes 33

36 Also Available from Synthes: chronos Putty Spine Ordering information chronos Putty for Spine* S chronos Putty, 1 cc S chronos Putty, 2.5 cc S chronos Putty, 5 cc S chronos Putty, 10 cc Bone Marrow Aspiration System (BMAS) Art.No. Diameter Length Syringe S 11 ga 11 cm 20 ml S 11 ga 15 cm 20 ml *Manufactured by: Mathys AG Bettlach Güterstrasse 5 CH-2544 Bettlach Distributed by: Synthes GmbH Eimattstrasse 3 CH-4436 Oberdorf 33 DePuy Synthes ACIS Anterior Cervical Interbody Spacer Surgical Technique

37 Bibliography 1 Kaiser MG, RW Haid Jr., BR Suback, et al. Anterior cervical plating enhances arthrodesis after discectomy and fusion with cortical allograft. Neurosurgery 50 (2002): Barsa P, P Suchomel. Factors affecting sagittal malalign ment due to cage subsidence in standalone cage assisted anterior cervical fusion. Eur Spine J. 16 (2007): Caspar W, FH Geisler, T Pitzen, et al. Anterior Cervical plate stabilization in one and two level degenerative disease: overtreatment or benefit? J. Spinal Disord. 11 (1998): Fraser JF, R Hartl. Anterior approaches to fusion of the cervical spine: a meta analysis of fusion rates. J Neurosurg. Spine 6 (2007): Mobbs RJ, P Rao, NK Chandran. Anterior cervical discec tomy and fusion: analysis of surgical outcome with and without plating. J. Clin. Neurosci. 14 (2007): Moftakhar R, GR Trost. Anterior cervical plates: a historical perspective. Neurosurg. Focus. 16 (2004): E8. 7 Aebi M, JS Thalgott, JK Webb. AO ASIF Principles in Spine Surgery. Berlin: Springer-Verlag Aebi M, Arlet V, Webb JK (2007): AOSPINE Manual (2 vols), Stuttgart, New York: Thieme. ACIS Anterior Cervical Interbody Spacer Surgical Technique DePuy Synthes 33

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40 DSEM/SPN/1016/ /16 Synthes GmbH Eimattstrasse 3 Not all products are currently available in all markets Oberdorf Switzerland This publication is not intended for distribution in the USA. Tel: Fax: All surgical techniques are available as PDF files at DePuy Synthes Spine, a division of Synthes GmbH All rights reserved