the present invention provides apparatus and methods for surgical procedures in which an expandable implant is positioned and deployed in a patient by means of a driver and a flexible connector . the driver may be used to both position the implant in the desired location in relation to spinal vertebrae , and to expand the implant after it is positioned . the flexible connector transfers torque from the driver to thereby expand the implant , and is detachable from the driver or implant after the implant is expanded . fig1 schematically illustrates a tlif spinal procedure in which an expandable implant is initially inserted in one orientation , and then rotated into the desired position in relation to the spinal vertebrae . as shown in fig1 , a spinal vertebra 5 comprising a vertebral body 6 , transverse process 7 , spinous process 8 and spinal canal 9 is subject to a tlif implant procedure . an implant generally labeled as element 10 is initially inserted between the transverse process 7 and spinous process 8 , while substantially avoiding the spinal canal 9 . during an initial insertion stage , the implant 10 a is oriented as shown with its longitudinal or axial direction a corresponding to the initial direction of insertion i . subsequently , the implant is moved to its final desired position , labeled as 10 b , in which the axial direction a of the implant 10 b is aligned in a direction substantially transverse to the spinal vertebra 5 . the bottom face of the implant 10 b may contact the anterior one - third of the vertebral body 6 , while the top face of the implant 10 b contacts the vertebral end plates of an adjacent vertebra in the spine ( not shown ). as described above , the tlif procedure illustrated in fig1 advantageously orients the implant 10 b along a longer dimension of the vertebral body 6 , and in a direction that does not intersect the spinal canal 9 . fig2 is a partially schematic illustration showing the initial arrangement of an implant 10 a , driver 20 and flexible connector 30 during an implant procedure , such as a tlif spinal procedure , in accordance with an embodiment of the invention . fig2 also shows the arrangement of the implant 10 b , driver 20 and flexible connector 30 ( in phantom ) after the implant 10 b has been positioned in its final location where the implant may be expanded . as shown in fig2 , the implant 10 a is initially grasped by the driver 20 , which has a shaft 21 and a handle 22 . the driver 20 includes a stationary arm 23 and a pivoting arm 25 , as more fully described below . although not shown in fig2 , an axially movable sleeve may be provided around the shaft 21 to force the pivoting arm 25 into the closed position ( shown by the solid line ) when the sleeve is extended away from the handle 22 , and to allow the pivoting arm 25 to move to the open position ( shown in phantom ) when the sleeve is retracted toward the handle 22 . as further shown in fig2 , the flexible connector 30 releasably couples the driver 20 to the implant 10 a , 10 b . in the embodiment shown , the flexible connector 30 has a proximal end 31 connected to the driver 20 by means of a releasable engagement mechanism 27 . the flexible connector 30 also has a distal end 32 connected to the implant 10 a . as shown in phantom in fig2 , the implant may be moved to the position labeled as 10 b while the pivoting arm 25 has been rotated away from engagement with the implant 10 b , and the flexible connector 30 bends but remains connected to the driver 20 and insert 10 b . in certain embodiments , the flexible connector 30 comprises a helical spring having sufficient flexibility to bend laterally , but sufficient torsional stiffness to transfer torque from the driver 20 to the implant 10 during the expansion operation . for example , the flexible connector 30 may comprise a double helical spring or a double start spring with two elements , one wound clockwise and one wound counterclockwise . such a counterwound double helical arrangement may add torsional stability to prevent buckling or permanent deformation when the spring is tensioned with high forces . examples of flexible helical couplings that may be adapted for use in accordance with the present invention include commercially available helical springs sold under the designation heli - cal by helical products company , inc . the flexible connector 30 may have any suitable dimensions , for example , a length of from 3 to 50 mm , and an outer diameter of from 1 to 10 mm . fig3 - 5 schematically illustrate an arrangement of an expandable implant 10 and a driver 20 . as shown in the top view of fig3 , the shaft 21 of the driver 20 has a distal end including a stationary arm 23 and a pivoting arm 25 . the stationary arm 23 includes a grip tooth 24 comprising an extended ridge having a generally v - shaped cross section . the pivoting arm 25 includes a similar grip tooth 26 . as shown in fig3 , each of the grip teeth 24 and 26 engage a grip recess 18 in the implant 10 , comprising a generally v - shaped groove running vertically from the top to bottom of the insert 10 . fig4 and 5 are side views schematically illustrating expansion of the implant 10 . the implant 10 includes an upper plate 11 and a lower plate 12 that may be expanded away from each other from a contracted position as shown in fig4 to an expanded position as shown in fig5 . for purposes of illustration , the pivoting arm 25 is not shown in fig4 or 5 . as most clearly shown in fig5 , as well as in fig3 , when the upper and lower plates 11 and 12 expand away from each other , the grip tooth 24 on the stationary arm 23 may remain engaged with the respective grooves 18 in the upper and lower plates 11 and 12 . in this manner , the stationary arm 23 of the driver 20 may remain engaged with the implant 10 not only during placement of the implant 10 in the desired location within the spine , but also during subsequent expansion of the implant 10 . fig6 and 7 schematically illustrate an intermediate stage of a tlif spinal procedure in which the implant 10 has been inserted into the region of the anterior one - third of the vertebral body 6 , and is being rotated toward its final transverse position . the trajectory of the implant 10 starts approximately parallel to the direction of the two adjacent spinal pedicles on the ipsilateral side of the spine . as the spinal implant 10 is rotated it is turned by the implant driver 20 into a position such that the long axis of the implant is in the translateral or transverse axis . as shown most clearly in the enlarged view of fig7 , the stationary arm 23 and its grip tooth 24 may remain engaged in the respective grip recesses 18 of the implant . however , the pivoting arm 25 has been rotated to a position as shown in which its grip tooth 26 has disengaged from its corresponding grip recesses 18 in the insert 10 . although the grip tooth 26 of the pivoting arm 25 has been disengaged , contact may still be maintained between an inner surface of the pivoting arm 25 and an end corner of the implant 10 . as further shown in fig7 , at this stage of the procedure , the flexible connector 30 bends but is still secured to both the driver 20 and implant 10 . in certain embodiments , the flexible connector 30 may also expand or contract along its longitudinal axis , e . g ., the connector 30 may comprise a helical spring that extends and / or compresses during stages of the procedure . fig8 illustrates a subsequent stage of a tlif spinal procedure in which the implant 10 b is located at its desired transverse position in relation to the anterior one - third of the vertebral body 6 . the long axis of the implant 10 b is in the transverse orientation , i . e ., the line bisected by the anatomic transverse and coronal planes . in this position , the grip tooth 24 of the stationary arm 23 may still remain in contact with the corresponding grip recesses 18 of the implant 10 b , however , the pivoting arm 25 may no longer contact the implant 10 b . during the stages shown in fig6 - 8 , the stationary arm 23 may be used in various ways to push or otherwise force the implant into position . for example , instead of maintaining contact between the grip tooth 24 and the grip recesses 18 during the entire procedure , the arm 23 may be manipulated by the surgeon in any desired manner to contact various parts of the implant 10 with various parts of the arm 23 to move the implant into the desired position . after the implant 10 b has been moved into position as shown in fig8 , torque may be applied to the driver 20 to rotate the flexible connector 30 in order to expand the implant 10 b , as more fully described below . after the expansion step is completed , the driver 20 is disengaged from the implant 10 b . in one embodiment , the driver 20 is disengaged by releasing the flexible connector 30 from the driver 20 . in another embodiment , the driver 20 is disengaged by disengaging the flexible connector 30 from the implant 10 b . fig9 - 12 schematically illustrate embodiments of expandable implants 10 in accordance with the present invention . in the embodiment shown in fig9 , the implant 10 includes upper and lower plates 11 and 12 comprising angled expansion ramps 13 on their inwardly facing surfaces . a threaded expansion rod 14 extends along the longitudinal axis of the implant 10 in the region between the upper and lower plates 11 and 12 . internally threaded expansion wedges 15 are threaded onto the expansion rod 14 . the threaded expansion rod 14 may be rotated around its longitudinal axis by turning the flexible connector 30 . rotation of the flexible connector 30 , and the resultant rotation of the threaded expansion rod 14 , causes the internally threaded expansion wedges 15 to move axially along the rod 14 with their upper and lower exterior surfaces sliding along the expansion ramps 13 . when the wedges 15 move toward each other , the upper and lower plates 11 and 12 expand away from each other . while the expansion wedges 15 may be have cross - sectional shapes that are circular or otherwise rounded , in a preferred embodiment , the expansion wedges 15 have square or rectangular cross sections that prevent the wedges from rotating around their central longitudinal axes . in this embodiment , the expansion ramps 13 may comprise substantially flat surfaces contacting correspondingly flat surfaces of the expansion wedges 15 . in the embodiment shown in fig1 , the upper and lower plates 11 and 12 of the implant 10 have a similar configuration as shown in the embodiment of fig9 . however , the implant 10 has generally conical expansion wedges 17 that are externally threaded , and an expansion rod 16 is not threaded . in this embodiment , the expansion ramps 13 are preferably concave with conical surfaces that contact the threads of the conical externally threaded wedges 17 . in this embodiment , the cross - sectional shape of the expansion rod 16 may be non - circular , and the externally threaded wedges 17 may have correspondingly shaped holes extending axially therethrough with sufficient clearance for the wedges 17 to axially slide along the expansion rod 16 . in this manner , the externally threaded wedges 17 may be free to slide along the axial length of the expansion rod 16 , but are constrained to rotate with the expansion rod 16 when the expansion rod 16 is rotated around its longitudinal axis . rotation of the flexible connector 30 causes the expansion rod 16 and externally threaded wedges 17 to rotate around their longitudinal axes , while the wedges 17 are free to slide along the axial length of the expansion rod 16 . contact between the external threads of the wedges 17 and the conically shaped inner surfaces of the expansion ramps 13 causes the wedges 17 to move axially toward each other , which results in expansion of the upper and lower plates 11 and 12 away from each other . the embodiment shown in fig1 is similar to the embodiment shown in fig9 , except the expansion ramps 13 a of the upper and lower plates 11 and 12 are oriented in opposite directions , and the wedges 15 a are likewise oriented differently . in this embodiment , rotation of the flexible connector 30 causes the wedges 15 a to move away from each other along the longitudinal axis of the threaded expansion rod 14 . as the wedges 15 a move away from each other , their exterior surfaces slide against the interior surfaces of the expansion ramps 13 a , thereby forcing the upper and lower plates 11 and 12 away from each other . as shown in fig9 - 11 , the distal end 32 of the flexible connector 30 is attached to one end of the expansion rod 14 or 16 . it is noted that in the embodiments shown in fig9 - 11 , the flexible connector 30 is illustrated as bending in a downward direction , however , it is to be understood that the flexible connector 30 may also bend in other directions , for example , into the page and / or out of the page in fig9 - 11 . in the embodiments shown , the distal end 32 of the flexible connector 30 includes a hexagonal recess 34 configured to receive the head of a releasable engagement mechanism 27 of the driver 20 , as more fully described below . in the embodiment shown , the distal end 32 of the flexible connector 30 may be permanently secured to the end of the expansion rod 14 or 16 , while the proximal end 31 of the flexible connector 30 may be releasably engaged with the driver 20 . alternatively , the distal end 32 may be releasably engaged with the expansion rod 14 or 16 , while the proximal end 31 may remain engaged with the driver 20 . for example , the distal end 32 of the flexible connector 30 may have a hex - head projection or recess that matingly engages a corresponding hex - head recess or projection at the end of the expansion rod 14 or 16 . such a hex - head connection may be sufficiently tight such that the connection is maintained during the steps of inserting , positioning , and expanding the implant , but may be disengaged after the implant is expanded by pulling the driver back with sufficient force remove the hex - head projection from the recess . fig1 schematically illustrates another embodiment of an expandable implant 10 in which the upper and lower plates 11 and 12 are expanded away from each other by means of a distractor paddle 116 having an outer cam surface that contacts inner surfaces of the upper and lower plates 11 and 12 and forces them away from each other when the paddle 116 is rotated around its longitudinal axis . the upper and lower plates 11 and 12 include expansion ramps 113 having surfaces that engage expansion wedges 15 a and 15 b . during the expansion procedure , the distractor paddle 116 is rotated to spread the upper and lower plates 11 and 12 away from each other , then a pusher 118 is used to move the first expansion wedge 115 a into a desired axial location where contact between the outer surface of the expansion wedge 115 a and the expansion ramps 113 results in the desired amount of expansion of the upper and lower plates 11 and 12 . next , the distractor paddle 116 may be rotated by the paddle shaft 117 to a position in which there is sufficient clearance between the distractor paddle 116 and the inner surfaces of the upper and lower plates 11 and 12 to allow the distractor paddle 116 to be at least partially removed from the region between the upper and lower plates 11 and 12 . the paddle shaft 117 is thus used to rotate and axially move the distractor paddle 116 . upon removal of the distractor paddle 116 , the interior space between the upper and lower plates 11 and 12 may be packed with bone material or the like in order to facilitate fusion of the implant 10 into the spinal structure . after the interior space is packed with material , the second expansion wedge 115 b may be moved into a desired axial position by inserting it through the proximal end of the implant 10 . the wedge 115 b may be placed with a screwdriver or other tool ( not shown ) which rotates the wedge 115 b 90 degrees after it is inserted deep into the proximal end of the central cavity of the implant 10 . the proximal wedge 115 b may have an oblong or elliptical cross - sectional shape . the proximal wedge 115 b may be inserted past the proximal ramp steps or teeth , and then rotated 90 degrees such that its largest dimension of the ellipse is from cephalad to caudad . the proximal wedge 115 b may then be pulled toward the ipsilateral open end of the implant until the smallest ramp is engaged or tight . the proximal wedge 115 b may thus be pulled away from the other wedge 115 a , and then rotated around its longitudinal axis to contact the expansion ramps 113 of the upper and lower plates 11 and 12 . the expansion wedges 115 a and 115 b may have non - circular cross sections which facilitate placement of the wedges in their desired axial locations , and retention in those positions in contact with the expansion ramps 113 . the dimensions used for the various components of the expandable implants 10 may be selected as desired . for example , a typical implant 10 may expand 10 percent to 100 percent of its original compact height , e . g ., an implant may have a compact height of 8 mm and an expanded height of 12 mm . any suitable length of implant may be used , for example , from 10 to 80 mm , e . g ., 50 mm . in the embodiments shown in fig9 - 12 , the expansion ramps 13 , 13 a and 113 may be sized and arranged as desired . for example , each expansion ramp 13 , 13 a , 113 may have a dimension of 1 mm high and 1 mm in width , with a 10 to 15 degree ramp angle . in certain embodiments , the ramps may be used to incrementally raise the height of an implant , e . g ., from 8 mm to 9 mm to 10 mm to 11 mm to 12 mm in succession . the upper and lower plates 11 and 12 of the implants 10 may have openings of suitable sizes that allow bony ingrowth through the fusion cage , e . g ., approximately 5 mm by 20 mm in size . the wedges , rods and other components of the expansion mechanisms may be made of any suitable material such as titanium , while the upper and lower prosthetic endplates 11 and 12 may be made of poly - ether - ether - ketone ( peek ) or other suitable materials . the components of the driver 20 and flexible coupling 30 may be made of suitable materials such as stainless steel , titanium , and the like . in certain embodiments , the expandable implants may be manufactured of known radiolucent material to allow radiographic visualization of the bone graft healing and incorporation . the flexible driver allows the surgeon to reference the radiolucent implant orientation via a more constrained and predictable junction . a more secure linkage makes it easier to exchange preparation instruments , soft tissue protective cannulas , trochars , particularly while inserting implants over guidewires . fig1 schematically illustrates a release mechanism 27 for engaging and disengaging the driver 20 from the flexible connector 30 . it is noted that the various components are not drawn to scale in fig1 , but are provided for illustration purposes . in the embodiment shown , the release mechanism 27 comprises a hex - head connector including radially movable engagement members or jaws 28 . the outer surfaces of the jaws 28 are configured to engage respective inner surfaces of the hex head recess 34 of the flexible connector 30 . when the jaws 28 are inserted into the recess 34 and forced radially away from each other , they engage and are secured in the recess 34 . an axially movable rod plunger 29 is used to force the jaws 28 radially away from each other by insertion of its tapered head into opposing semi - circular channels in the interior surfaces of the jaws 28 . the rod plunger 29 is axially movable inside the cannulated driver shaft 21 . although not shown in fig1 , the jaws 28 may be biased radially towards each other , for example , through the use of tension springs ( not shown ). thus , when the rod plunger 29 is retracted along its longitudinal axis away from the jaws 28 , the jaws 28 collapse toward each other , thereby disengaging their outer surfaces from the recess 34 of the flexible connector 30 . although not shown in fig1 , the rod plunger 29 can also be threaded to create a smoother insertion without a need for hammering or impaction force . although a hex - head connection using two radially movable jaws is shown in fig1 , it is to be understood that any other suitable type of releasable coupling may be used in accordance with the present invention . for example , instead of two jaws 28 as shown in fig1 , three , four , five , six , or more radially expandable jaws or pivot arms may be used . furthermore , although a hexagonal recess 34 is shown in fig1 , any other suitable recess configuration could be used , such as square , rectangular , triangular , oval and the like . although the driver 20 is releasably attached to the flexible connector 30 in the embodiment shown in fig1 , the flexible connector 30 may alternatively be releasably attached to the implant , e . g ., by a coupling similar to that shown in fig1 with a flexible rod plunger extending through a cannulated central opening through the flexible connector 30 , a tight - fitting hex head connection that can be disengaged after the implant is expanded by pulling the driver and flexible connector away from the expanded implant with sufficient force , or the like . the instruments of the present invention allow an implant to be optimally positioned before it is expanded . for example , a tlif implant can be placed at an angle of up to 90 degrees from the posterior angle of insertion . such a procedure allows a minimally invasive approach , as the incision and exposure do not have to be extended to allow manipulating or turning the expandable implant . this allows moving a tlif implant into the preferred direct transverse orientation before opening . in certain embodiments , the invention allows for expansion of an expandable xlif implant with minimally invasive exposure . often with a deformity , or with multiple procedures performed through the same small incision , the orientation of the interbody fusion changes as the deformity is reduced . the angle of performance of the xlif and the disk space changes by the end of the case . this is common especially when dealing with l4 - l5 and especially when dealing with the reduction of a scoliotic deformity . the flexible driver of the present invention allows for fine tuning , readjustment , backing off , re - expansion and balancing the expansion between the multiple xlif implants at the end of the procedure . the flexible driver of the present invention may be used in other types of minimally invasive spine surgery . in such mis procedures , the approach is through a tube , narrow corridor , or confined space . this puts a premium on screwing , drilling , tapping , cutting screw threads , and performance of other maneuvers through a confined corridor without the ability to alter the angle of trajectory of the tool shaft . the flexible driver of the present invention helps solve this mechanical challenge by applying a rotational force at an angle from the insertion direction . in certain embodiments , anchorage of a stand alone anterior lumbar interbody fusion ( stalif ) type cages or interbody spacers is facilitated by an angled driver with a helical spring flexible component . this is particularly useful as the implant surgery becomes more minimally invasive . in certain types of procedures , two expandable implants may be positioned side by side in the intervertebral disk space . if the expandable implant that is anterior is expanded and the posterior expandable implant is collapsed then this would increase and adjust the amount of spinal lordosis . on the contrary , if the reverse occurs with the anterior implant collapsing and the posterior implant expanding then this would increase the amount of kyphosis . in certain other types of procedures , two expandable implants may be placed laterally end - to - end and individually adjusted . the expandable implants could adjust the amount of coronal balance , and scoliosis correction could be adjusted after implant insertion at multiple levels but before closing the skin . by adjusting and expanding the implants differentially , the spine can tilt left or right . thus , the functional spinal unit can be used to correct scoliosis apex toward the left or the right . the functional spinal units with expandable implants may be stacked one above another such as from t12 to l3 in order to correct a thoracolumbar scoliosis . whereas particular embodiments of this invention have been described above for purposes of illustration , it will be evident to those skilled in the art that numerous variations of the details of the present invention may be made without departing from the invention as defined in the appended claims .
expandable spinal implants and drivers connected by a bendable joint are disclosed . the flexible connector allows the implant and driver to move to different angular orientations with respect to each other , and to apply rotational force or torque from the driver to the implant and its expansion mechanism . during insertion of an implant into the desired position , the driver may be oriented in the same or different direction than the long axis of the implant . after the spinal implant is placed in the desired position , the driver is used to expand the implant in selected dimensions .