this invention includes instruments and methods for inserting spinal implants in the vertebral columns of patients and to spinal implants themselves . in one embodiment , instruments are provided for inserting a main body assembly between spinous processes of adjacent vertebrae . these instruments , termed herein “ main body insertion instruments ” generally comprise an elongated body portion having a handle at one end , an insertion shaft and an insertion tip . the insertion tip engages with the main body assembly and holds the assembly in fixed relation to the instrument . the surgeon prepares the site for implantation , and uses the instrument to urge the assembly between spinous processes of adjacent vertebrae . in other embodiments of this invention , different instruments can be used to insert universal wings on to the main body assembly of the spinal implant . these other instruments are termed herein “ wing insertion instruments .” a wing insertion instrument generally comprises a handle , an insertion shaft and an insertion tip . the insertion tip of a wing insertion instrument engages with the universal wing and holds it fixed relative to the instrument . the surgeon then grasps the handle portion of the instrument and uses it to urge the wing implant portion into proximity with a main body assembly which has been inserted between spinous processes of the spine . main body insertion instrument of this invention is illustrated , by way of example only , in fig1 - 3 . fig1 depicts an exterior view of a main body insertion instrument 100 of this invention having a handle 10 , an insertion shaft 20 and an insertion tip 30 . handle 10 can be made of any suitable material , such as by way of example only , gray ultem ™, a polyetherimide resin . insertion shaft 20 can be made of any suitable , strong material , such as 304 stainless steel . insertion shaft 20 has a central bore extending through its length . the proximal end of insertion shaft 20 is adapted to fit within the distal end of handle 10 , and can be held in place with a set screw , made of , by way of example only , 304 or 455 stainless steel . a main body insertion tip 30 is attached to the distal end of the insertion shaft . insertion tip 30 can be made of , by way of example only , 17 - 4 stainless steel . a bore extends longitudinally through the insertion tip 30 and is contiguous with the bore through the insertion shaft 20 . an insertion rod 40 , having a distal end with a spacer engagement pin and a locking pin , extends through the length of the bore in insertion shaft 20 . insertion rod 40 extends into the handle 10 of the main body insertion instrument 100 . on one side of handle 10 , insertion knob 110 , having a raised portion 112 , is for manipulation of a locking pin and spacer engagement pin in insertion tip 30 . the insertion knob 110 can be made of , by way of example only , 304 stainless steel . the stainless steel components of the instruments of this invention can desirably meet astm standard f899 - 95 : standard specifications for stainless steel billet , bar , and wire for surgical instruments . fig2 depicts a longitudinal cross - sectional view of a main body insertion instrument 100 as depicted in fig1 , and shows details of this embodiment of the invention . handle 10 has an insertion knob groove 105 on a lateral surface , within which insertion knob 110 is provided . insertion knob 110 and groove 105 are sized so that insertion knob 110 can move in a proximal / distal path along the handle 10 . insertion knob 110 has said raised portion 112 used for applying force to move insertion knob 110 proximally and distally along handle 10 . insertion knob 110 is attached to rod 111 , which is located within cavity 121 of the cavity 121 . when placed within cavity 121 , the rod 111 engages spring 125 , which is located within an interior space 124 of handle 10 . spring 125 is urged against insertion rod 40 . the spring 125 provides a force that urges rod 111 and also rod 40 toward the distal portion of the instrument 100 . spring 125 is compressed by manual movement of insertion knob 110 in a proximal direction , acting via rod 111 . because insertion rod 40 is engaged with rod 111 , insertion rod 40 is drawn proximally by proximal movement of insertion knob 110 . when manual force on insertion knob 110 is relaxed , as for example , after alignment of a main body implant in relation to insertion tip 30 , spring 125 urges rod 111 , insertion rod 40 and insertion knob 110 in a distal direction . as insertion rod 40 is urged distally , locking pin 155 and spacer engagement pin 157 are urged toward the distal end of insertion instrument 100 as well , where pins 155 , 157 can engage the main body assembly of the spinal implant . fig2 depicts insertion shaft 20 having a proximal end that is adapted to fit within the distal portion of handle 10 . when so placed , set screw 130 engages with insertion shaft 20 to keep insertion shaft 20 engaged in handle 10 . set screw 130 can be made of any convenient material , such as , by way of example only , stainless steel . it can be especially desirable for set screws 120 and 130 to be completely removable from handle 10 , to provide open access to the interior of handle 10 for cleaning and sterilization . insertion tip 30 is adapted to fit onto the distal end of insertion shaft 20 , by way of example only , with an interference fit . fig2 depicts such an interference fit engagement of insertion tip 30 with the distal end of insertion shaft 20 . however , other ways of attaching insertion tip 30 to insertion shaft 20 are contemplated and are considered to be part of this invention . fig2 depicts components of insertion tip 30 , which include a proximal portion 145 , which can act as a position stop for spacer engagement pin 157 . spacer engagement pin 157 protrudes laterally from the portion of the insertion rod 40 , and is adapted to engage a spacer engagement hole of a main body assembly . when so engaged , spacer engagement pin 157 can position a spacer relative to the remainder of the main body wing and tissue expander , making insertion of the implant between spinous processes convenient . at the distal end of insertion rod 40 , locking pin 155 is positioned to engage a hole in the main body assembly . thus , when so engaged , locking pin 155 and spacer engagement pin 157 can hold the main body , tissue expander and spacer in position relative to one another for convenient insertion . at the distal end of the insertion tip 30 , portion 147 , having a flat medial surface 165 , can support the main body . in some embodiments , one or more alignment pins 160 can be provided to engage with a main body to provide additional support during surgery . in general , the construction of main body insertion instrument 100 desirably is sufficiently robust to provide firm support of the main body assembly during surgery . for example , in certain situations , it can be desirable for the surgeon to exert relatively large forces on the main body assembly to urge the tissue expander between spinous processes . generally , the connective tissue , including ligaments , can be strong and tough , tending to resist stretching . however , during surgery using the spinal implants and insertion instruments of this invention , it may be desirable to deflect , distract and / or stretch the ligaments to permit passage and proper location of spinal implants . in these situations , the instruments are strong and rigid . it also can be desirable for the surfaces to be smooth and have relatively simple geometrical shape . simple shape and relatively open construction can provide for easy access to the interior of the parts of the instrument , and can permit easy and convenient cleaning and sterilization . fig3 a - 3 c depict the insertion tip 30 of main body implant insertion instrument 100 in additional detail . fig3 a depicts a side view of insertion tip 30 fitted into the distal end of insertion shaft 20 . bore 150 of insertion shaft 20 is shown in dashed lines . locking pin 155 of insertion rod 40 is shown in the distal - most extension , as urged by spring 125 of fig2 . portion 147 is shown having alignment pin 160 with an axis aligned substantially perpendicularly to the plane of portion 147 . spacer engagement pin or catch 157 is shown above locking pin 155 . at its distal - most extension , locking pin 155 crosses the axis of alignment pin 160 . when alignment pin 160 and spacer engagement pin 157 have engaged their respective portions of a main body assembly , the assembly can be firmly held by the insertion tip 30 . fig3 b depicts an insertion tip as shown in fig3 a in which the insertion rod 40 has been moved to a proximal position . in the embodiment depicted in fig3 b , locking pin 155 and spacer engagement pin 157 have been retracted sufficiently to be proximal to surface 156 of insertion tip 30 . when so positioned , the main body assembly can be disengaged from insertion tip 30 and the instrument can be withdrawn from the patient &# 39 ; s body , leaving the main body assembly in place . fig3 c depicts a top view of insertion tip 30 . insertion rod 40 is shown in the retracted position , with locking pin 155 and spacer engagement pin 157 being located proximally to surface 156 of insertion tip 30 . two alignment pins 160 are shown . when engaged with a main body assembly , flat surfaces 156 and 165 , alignment pins 160 , and locking pin 155 and spacer engagement pin 157 of the instrument 100 can hold the main body assembly firmly to the insertion instrument . fig4 a - 4 c depict the method of engagement of a main body insertion instrument of the invention with a main body assembly of the invention . fig4 a depicts a main body assembly 400 of the invention for use with the instrument 100 of this invention . main body assembly 400 has a main body wing 401 having a cephalad wing member 402 and a caudal wing member 402 a . cephalad wing member 402 , after insertion , is aligned toward the head of the subject along the right side of a dorsal spinous process . member 402 a is also positioned along the side of a spinous process . main body wing 401 also can have one or more holes 403 adapted to receive alignment pins 160 of main body insertion instrument 100 . main body wing 401 also has locking pin hole 404 adapted to receive locking pin 155 of main body insertion instrument 100 . main body wing 401 is attached to spacer 405 , which has spacer engagement hole 406 adapted to receive spacer engagement pin 157 of insertion instrument 100 . on the other end of spacer 405 , tissue expander 407 is shown , having a threaded hole 408 adapted to receive a bolt of a universal wing implant ( described below ). tissue expander 407 has a tapered left end to ease insertion of the main body assembly between spinous processes . fig4 b depicts a lateral view showing the points of engagement between a main body assembly and main body insertion instrument . insertion rod 40 of insertion instrument is shown in a retracted , or proximal position . locking pin 155 and spacer engagement pin 157 are shown aligned proximally to plane 156 of insertion tip 30 . spacer engagement pin 157 is adapted to engage with spacer engagement hole 406 , locking pin 155 is adapted to engage with locking pin hole 404 , and alignment pin 160 is adapted to engage with alignment hole 403 . fig4 c depicts main body insertion instrument engaged with main body assembly . while insertion rod 40 , locking pin 155 and spacer engagement pin 157 are in the retracted position , a main body assembly has been positioned with alignment pin 160 received into alignment pin hole 403 . thereafter , insertion rod 40 has been urged distally by the spring 125 of fig2 , thereby engaging locking pin 155 with locking pin hole 404 and spacer engagement pin 157 with spacer engagement hole 406 . the engagement of spacer engagement pin 157 with spacer 405 keeps spacer 405 from rotating about its axis , and thereby keeps the spacer 405 in position relative to the tissue expander 407 and to the main body implant insertion instrument 100 . a wing insertion instrument of this invention is depicted in fig5 - 7 . fig5 depicts an exterior , lateral view of a wing insertion instrument 500 , having a handle 10 , and insertion shaft 20 , an insertion tip 30 and a driver knob 50 . as with the main body insertion instrument 100 depicted in fig1 and 2 , on a lateral surface , insertion knob 110 , having raised portion 112 is provided to actuate a locking mechanism at the distal end of the instrument . fig5 depicts a cross - sectional longitudinal view through the wing insertion instrument 500 of this invention . handle 10 has an insertion knob groove 505 on a lateral surface , within which insertion knob 110 is provided . insertion knob 110 and groove 505 are sized so that insertion knob 110 can move in a proximal / distal path along the handle 10 . insertion knob 110 has a raised portion 112 used for applying force to move insertion knob 110 proximally and distally along handle 10 . insertion knob 110 is attached to rod 511 , which is located within interior space 521 of the handle 10 . rod 511 engages insertion rod 541 by way of set screw 520 which is accessible through hole 515 . hole 515 is desirably of sufficient size to permit complete removal of set screw 520 from the instrument , permitting insertion knob 110 to be removed from handle 10 and the instrument to be cleaned and sterilized . insertion shaft 540 has a proximal end that fits within the distal portion of the bore of handle 10 . set screw 530 is inserted through hole 535 , and engages insertion shaft 540 with handle 10 . it is desirable for hole 535 to be of sufficient size for set screw 530 to be completely removed , permitting cleaning and sterilization of the component parts of instrument 500 . insertion rod 541 extends through the full length of the bore of instrument 500 , and has a proximal portion sized to accommodate spring 525 . when installed in handle 10 , insertion rod 541 compresses spring 525 . the distal end of spring 525 is held in place by handle end cap 501 , which , along with handle 10 can be made of , by way of example , gray ultem ™. handle end cap 501 is engaged with handle 10 by means of threads . thus , for disassembly , handle end cap 501 can be disengaged from handle 10 , and spring 525 and insertion rod 541 can be removed from the proximal end of handle 10 . when assembled , rod 511 and insertion knob 110 are urged by spring 525 in a distal direction . the distal motion is stopped when insertion knob 110 or rod 511 reach the distal wall of space 521 . spring 525 is further compressed by manual movement of insertion knob 110 in a proximal direction , acting via insertion rod 511 . because insertion rod 541 is engaged with rod 511 , insertion rod 541 is drawn proximally by proximal movement of insertion knob 110 . when manual force on insertion knob 110 is relaxed , as for example , after alignment of a universal wing in relation to insertion tip 30 , spring 525 urges insertion rod 541 and insertion knob 110 in a distal direction . as insertion rod 541 is urged distally , driver 555 is urged toward the distal end of insertion instrument 500 as well . driver knob 502 is provided at the proximal end of instrument 500 . driver knob 502 can be made of , by way of example , gray ultem ™. driver knob 502 has a bore into which the proximal most extension of insertion rod 541 is placed . insertion rod 541 is held within driver knob 502 by means of set screw 504 within hole 503 . it can be desirable for hole 503 to be sufficiently large so that set screw 504 can be completely removed from driver knob 502 for cleaning and sterilization . insertion rod 541 desirably is free to rotate about its longitudinal axis , so that when driver knob 504 is rotated , driver 555 is rotated . in summary and referring to fig2 and 6 , set screws 120 , 130 of main body insertion instrument 100 , and set screws 520 , 530 , and 504 of universal wing insertion instrument 500 can be removed using a hex screw driver , having a hexagonal driver head made of , by way of example , 455 stainless steel . such removal can be used to disassemble the instruments 100 and 500 for cleaning . fig7 a - 7 c depict details of insertion tip 30 of wing insertion instrument 500 of this invention . fig7 a is an end - view of the distal end of insertion tip 30 , showing driver 555 , alignment pins 560 , and surfaces 547 and 565 . an edge of universal wing 800 can abut surface 547 to provide support during the insertion of universal wing 800 . a surface of universal wing 800 can abut surface 565 to provide additional support of universal wing 800 . fig7 b depicts a bottom view of insertion tip 30 of wing insertion instrument 500 . insertion rod 541 is depicted in a distal position , within insertion shaft 540 . driver 555 is shown extending into space 567 of insertion tip 30 . fig7 c depicts a bottom view of the insertion tip 30 as shown in fig7 b with the driver 555 and insertion rod 541 in a proximal position , with the distal - most end of driver 555 retracted from the space 567 . in this position , mounting ring 816 of fig8 ( below ) of a universal wing can be received in space 567 . fig8 a - 8 c depict a universal wing 800 of the invention for use with the wing insertion instrument 500 of the invention . fig8 a is a lateral view of universal wing 800 , having caudad portion 801 and cephalad portion 802 . alignment holes 806 are adapted to receive alignment pins 560 of wing insertion instrument 500 . although two alignment holes 806 are depicted , additional or fewer alignment holes can be provided . between caudad portion 801 and cephalad portion 802 , mounting ring 816 is provided having an oblong bore therethrough to receive shaft 814 of bolt 812 . bolt 812 has a proximal end with a recess 813 adapted to receive driver 555 of instrument 500 . the distal end of bolt 812 is threaded to engage with hole 408 of a tissue expander 407 depicted in fig4 a - 4 c . the oblong bore has partial threads that allow a bolt to be screwed through the bore with the smooth shaft of the bolt then trapped in the bore . fig8 b is a side view of universal wing 800 without bolt 812 , depicting mounting ring 816 with oblong bore 817 therethrough . alignment holes 806 are shown as dashed lines . fig8 c depicts a similar view of universal with 800 with bolt 812 provided . hex recess 813 , adapted to receive driver 555 of instrument 500 is shown . hole 817 is oblong to provide a choice of positions of bolt 812 within bore 817 . by providing a choice of bolt positions , the surgeon can install universal wing with a desired spacing between universal wing 800 and main body wing 401 . fig9 a - 9 c depict the relationships between wing insertion instrument 500 of this invention and the universal wing 800 of the invention . fig9 a depicts a lateral view of the insertion tip 30 , with driver 555 in space 567 and alignment pin 560 . insertion rod 541 is shown within insertion shaft 540 . also depicted is universal wing 800 , having bolt 812 with recess 813 , mounting ring 816 , alignment hole 806 , and caudad wing portion 801 . the axes of driver 555 and alignment pin 560 , which in this embodiment cross each other and can be substantially perpendicular if desired , are shown in relation to recess 813 and alignment hole 806 , respectively . fig9 b depicts a lateral view of insertion tip 30 engaged with universal wing 800 . driver 555 is received by recess 813 in bolt 812 and alignment pin 560 is received by alignment hole 806 . bolt 812 is received within recess 567 of insertion tip 30 , and when insertion shaft 541 is rotated , bolt 812 can rotate . fig9 c depicts a bottom view of insertion tip 30 and universal wing 800 , engaged as in fig9 b . cephalad portion 802 and caudad portion 801 of the universal wing are shown engaged by alignment pins 560 received through alignment holes 806 . edge 807 of wing 800 is shown abutted against surface 547 of insertion tip 30 . spinal implant surgery can be carried out by using specially designed instruments to determine the correct size of an implant to be used and to predistract the spinous process . the instruments incorporating trial implants comprise a handle , made of a convenient material , for example , gray lultem ™, fig1 a - 10 d depict four embodiments of trial implant instruments of the invention . fig1 a - 10 d depict instruments 1000 , 1001 , 1002 , and 1003 of this invention , each having handle 1006 and insertion shaft 1007 . the instruments differ in the size of the trial implant for each . trial implant 1010 is the smallest , implant 1011 , 1012 , and 1013 become progressively larger , corresponding to instruments 1000 , 1001 , 1002 and 1003 , respectively . these trial implants in the embodiment are cylindrical in shape with diameters of 6 mm , 8 mm , 10 mm , and 12 mm , respectively . the trial implants have a lead - in nose , guide , or tissue expander that is cone shaped . other shapes such as elliptical shapes , oval shapes , and egg - shapes are within the scope of the invention . further , the nose can be of other shapes such as pyramid shaped . in use , these trial implant instruments are used one after the other to size the implant location and to progressively distract the implant location in preparation for insertion of the implant , which is left in the patient . to use the instruments of this invention to insert spinal implants of the invention , a patient is placed , desirably in a lateral decubitus position with maximum flexion of the lumbar spine . lateral decubitus position permits easy orientation of the main body assembly during surgery . generally , the implant can be inserted between the spinous processes from the bottom or right side of the spinous processes to the top or left side of the spinous processes . such orientation permits easy visualization of the main body assembly when the universal wing is attached . the wings should be oriented properly , with cephalad portions 402 and 802 oriented in a cephalad direction , and caudad portions 402 a and 801 oriented in a caudal direction . the field is prepared for sterile surgery , and local anesthesia of the area is provided . once the entry point is determined , local anaesthetic is applied to the skin and the underlying musculature . to insert a spinal implant in one affected vertebral area for a single level implant process , a midline incision about 1 . 5 inches long is made at the entry point , exposing the supraspinous ligament overlying the spinous processes at the symptomatic level . the fascia may be incised on either side of the spinous processes and supraspinous ligament . the paraspinous musculature can be elevated laterally from both sides of the midline . the supraspinous ligament is desirably preserved . the interspinous ligament may be separated to permit insertion of main body assembly 400 . to insert spinal implants in adjacent portions of the spine for a double level implant process , a midline incision about 3 inches long is made at the entry point , exposing the supraspinous ligament overlying the spinous processes at the appropriate segments . the fascia is incised if necessary on either side of the spinous processes and supraspinous ligament . the paraspinous musculature can be elevated laterally from both sides of the midline . the first implant 400 can be inserted at the inferior level , and the second implant 400 of the same or different size , can be inserted at the superior , adjacent level after the first implant has been completely secured . if the supraspinous ligament is compromised during the procedure , it can be desirable to suture the excision in the ligament closed after insertion of the spinal implant . before installing the spinal implant 400 , the intraspinous space is prepared using trial implants . generally , the surgeon can first select the smallest trial implant , for example , trial implant 1000 . the trial implant 1000 is urged between the spinous processes of the patient , and if little resistance is encountered , the surgeon can select a larger sized trial implant , such as trial implant 1001 . if insufficient resistance is encountered , the surgeon can use progressively larger trial implants to distract the spinous process . when the correct trial implant is found , the spinal implant 400 is then chosen for insertion . additionally , the surgeon may choose to use a trial implant instrument that is larger than the implant to be used in order to further distract the spinous process to make the insertion of the implant easier . to insert the main body assembly , a surgeon or assistant engages such assembly with main body insertion instrument 100 of this invention . the leading edge of tissue expander 407 of the main body assembly is advanced through the interspinous ligament . if significant resistance is encountered during the insertion of the implant , the next smallest size main body assembly can be used . once the correct sized implant has been selected , the main body implant is inserted as shown in fig1 a and 11 b . fig1 a depicts a right lateral view of a portion of a spine of a patient . l 4 and l 5 refer to lumbar vertebrae 4 and 5 , respectively . for purposes of illustration only , these lumbar segments are depicted . however , any spinal segments can be the sites of insertion of the implants by use of the instruments of this invention . l 4 - 5 d refers to the intravertebral disk . l 4 d and l 5 d refer to the dorsal spinous processes of l 4 and l 5 , respectively . main body insertion instrument 100 having insertion tip 30 attached to main body assembly 400 is shown in position . cephalad portion 402 and caudad portion 402 a of a main body wing are shown . it can be desirable to urge main body assembly 400 ventrally within intraspinous space 1005 . fig1 b depicts a dorsal view of an inserted main body assembly 400 . spacer 405 is shown between dorsal spinous processes l 4 d and l 5 d . main body wing 401 is shown near the right lateral surfaces of spinous processes l 4 d and l 5 d . fig1 depicts a left lateral view of the l 4 - l 5 area of a patient . the main body assembly 400 has been inserted , and the tissue expander 407 is shown , urged ventrally in intraspinous space 1005 . main body wing portions 402 and 402 a are shown in dashed lines , being located behind ( i . e ., the right of ) the spinous process l 4 d and l 5 d , respectively . threaded hole 408 in tissue expander 407 is shown , and axis ( dashed lines ) is shown to depict the insertion of threaded portion 815 of bolt 812 of universal wing 800 . insertion tip 30 of wing insertion instrument 500 is shown , with a universal wing engaged 800 , as depicted in fig9 b and 9 c . the engaged wing is shown from the top view , in contrast to the view of fig9 c , which is from the bottom . while grasping main body insertion instrument 100 , the surgeon inserts the universal wing with wing insertion instrument 500 . when the universal wing is brought into the correct position relative to the main body assembly , bolt 812 can be inserted into hole 408 of the tissue expander 407 , and by rotation of the driver knob 50 of fig5 in a clockwise direction , driver 555 can rotate bolt 812 thereby engaging threads of the threaded end 815 with the threads of hole 408 . alternatively , if the threaded portions 815 of bolt 812 and hole 408 have left - handed threads , then driver knob 50 should be rotated in a counter - clockwise direction to engage bolt 812 with threaded hole 408 . before tightening bolt 812 , it can be desirable to urge universal wing 800 medially or closer to main body wing 401 to provide a desired degree of support of spinous processes l 1 d and l 2 d . once in the proper position , bolt 812 can be tightened , and the insertion instrument 100 and 500 are removed , the incisions sutured and closed . fig1 depicts a dorsal view of the spine of a patient , depicting an installed main body assembly 400 with universal wing 800 attached thereto . universal wing portion 802 is shown oriented in the cephalad direction , as is main body wing portion - 402 . caudad wing portions 801 and 402 a are shown oriented in the caudal direction . wing element 400 , 402 a are shown near the right lateral surface of the spinous process . universal wing 800 is shown placed near the left lateral surfaces of the spinous process . adjustment of the spacing between universal wing 800 and the spinous process is accomplished by urging the wing medially before tightening bolt 812 in oblong mounting ring 817 . accordingly , it is evident that the insertion instruments , implants and methods disclosed can be said to relieve pain associated with the spine . the above descriptions are for illustrative purposes and are not intended to be limiting to the scope of the invention . it is contemplated that instruments having locking pins and alignment pins can have other configurations . further , the implant can have other configurations . it is also contemplated that the additional methods of using the instruments with the implants described as well as with other implants are possible , and all such embodiments are considered to be within the scope of this invention .
the invention provides a method of inserting a two piece implant into a patient . a first insertion device is connected to a first piece of the implant , and a second insertion device is connected to a second piece of the implant . each piece of the implant is inserted with its associated insertion device . the inserted pieces are aligned relative to each other by mutual engagement of alignment structures of the insertion devices . the aligned pieces are connected to each other and the insertion devices are disengaged from the implant pieces .