SPINAL elements
CERES ANTERIOR CERVICAL PLATE System Instructions for Use
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Spinal Elements, Inc. · 3115 Melrose Dr., Suite 200 Carlsbad, CA 92010 · U.S.A. · 760.607.0121
CERES ANTERIOR CERVICAL PLATE SYSTEM IMPLANTS AND INSTRUMENTS This package insert covers the Ceres Anterior Cervical Plate System and Manual Surgical Instruments that are used for the implantation of this system. GENERAL INFORMATION The Ceres Anterior Cervical Plate System is a multiple component system comprised of non-sterile, single-use implantable components fabricated from Titanium alloy (Ti-6Al-4V) conforming to ASTM F136. The Ceres Anterior Cervical Plate System provides stabilization of cervical segments of the spine. The system consists of selftapping/self-drilling screws and plates. Screws are available in a variety of diameter and length combinations. Plates are available in a variety of lengths. INDICATION The Ceres Anterior Cervical Plate System is intended for anterior screw fixation of the cervical spine (C2-C7) as an adjunct to fusion. These implants have been designed to provide stabilization for the treatment of the following indications: degenerative disc disease (defined as neck pain of discogenic origin with the degeneration of the disc confirmed by history and radiographic studies), spondylolisthesis, trauma (i.e., fractures or dislocations), spinal stenosis, deformity (i.e., kyphosis, lordosis or scoliosis), tumor, pseudarthrosis or failed previous fusion. CONTRAINDICATIONS Contraindications include, but not limited to: The Ceres Anterior Cervical Plate System is contraindicated in patients with a systemic infection, with a local inflammation at the bone site, or with rapidly progressive joint disease or bone absorption syndromes such as Paget’s disease, osteopenia, osteoporosis, or osteomyelitis. Do not use this system in patients with known or suspected metal allergies. Use of the system is also contraindicated in patients with any other medical, surgical or psychological condition that would preclude potential benefits of internal fixation surgery such as the presence of tumors, congenital abnormalities, elevation of sedimentation rate unexplained by other disease, elevation of white blood cells or a marked shift in white blood cell differential count. WARNINGS Some instruments may be sharp, depending on their intended use. Care should be taken in handling such instruments to avoid injury to the user or patient. A successful result is not always achieved in every surgical case. This fact is especially true in spinal surgery where many extenuating circumstances may compromise the results. System components are temporary implants used for the correction and stabilization of the spine. Devices are intended to be used to augment the development of a spinal fusion by providing temporary stabilization. Devices are not intended to be the sole means of spinal support. Use of these products without a bone graft or in cases that develop into a non-union will not be successful. No spinal implant can withstand body loads without the support of bone. In this event, bending, loosening, disassembly and/or breakage of the device(s) will occur. Implantation of devices should be performed only by experienced surgeons with training in the use of spinal devices. This is a technically demanding procedure presenting a risk of serious injury to the patient. Preoperative and operating procedures including knowledge of surgical techniques, proper reduction, and proper selection and placement of the implant are important considerations in the successful utilization of this device by the surgeon. Further, the proper selection and compliance of the patient will greatly affect the results. The physician should consider the levels of implantation, patient weight, patient activity level, and all other patient conditions that may have an impact on the performance of the device. Patients who smoke have been shown to have an increased incidence of non-union. These patients should be advised of this fact and warned of this consequence. Obese, malnourished, and/or alcohol abuse patients are also poor candidates for spine fusion. Patients with poor muscle and bone quality and/or nerve paralysis are also poor candidates for spine fusion. The use of allograft material may not give as good a result as pure autograft.
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Patients with previous spinal surgery at the level(s) to be treated may have different clinical outcomes compared to those without a previous surgery. Physician Note: The physician is the learned intermediary between the company and the patient. The indications, contraindications, warnings, and precautions given in this document must be conveyed to the patient. MAGNETIC RESONANCE ENVIRONMENT The Ceres Anterior Cervical Plate has not been evaluated for safety and compatibility in the MR environment. It has not been tested for heating, migration, or image artifact in the MR environment. The safety of the device in the MR environment is unknown. Scanning a patient who has this device may result in patient injury. POSSIBLE ADVERSE EVENTS: 1. Early or late loosening of any or all of the components 2. Disassembly, bending, and/or breakage of any or all of the components 3. Foreign body (allergic) reaction to implants, debris, corrosion products, graft material, including metallosis, straining, tumor formation, and/or auto-immune disease 4. Pressure on the skin from component parts in patients with inadequate tissue coverage over the implant possibly causing skin penetration, irritation, and/or pain 5. Post-operative change in spinal curvature, loss of correction, height, and/or reduction 6. Infection 7. Dural tears, persistent CSF leakage, meningitis. 8. Loss of neurological function including paralysis (partial or complete), radiculopathy, and/or the development or continuation of pain, numbness, spasms, or sensory loss. 9. Cauda equina syndrome, neurological deficits, paraplegia, reflex deficits, irritation, and/or muscle loss. 10. Loss of bladder control or other types of urological system compromise. 11. Scar formation possibly causing neurological compromise or compression around nerves and/or pain. 12. Fracture, micro-fracture, resorption, damage, or penetration of any spinal bone. 13. Soft tissue injury, vertebral endplate injury, vascular or visceral injury. 14. Herniated nucleus pulposus, disc disruption or degeneration at, above, or below the level of surgery. 15. Non-union (pseudo-arthrosis), delayed union, mal-union. 16. Cessation of any potential growth of the operated portion of the spine. 17. Loss of or increase in spinal mobility or function. 18. Inability to perform the activities of daily living. 19. Death. Additional surgery may be necessary to correct some of these anticipated adverse events PREOPERATIVE MANAGEMENT 1. The surgeon should consider for surgery only those patients indicated for the use of this device. 2. The surgeon should not consider for surgery those patients contraindicated for the use of this device. 3. The surgeon should have a complete understanding of the device’s indications, contraindications, and applications. 4. The surgeon should have a complete understanding of the function and limitations of each implant and instrument. 5. Device components should be received and accepted only in packages that have not been damaged or tampered with. Damaged implants and/or instruments should not be used. All implants and instruments should be inspected prior to use. Components must be carefully handled and stored in a manner that prevents scratches, damage, and corrosion. 6. The type of implant to be used for the case should be determined prior to beginning the surgery. 7. All parts should be sterilized before use. INTRAOPERATIVE MANAGEMENT 1. Caution should be taken in handling the implants. Damage to the implants may affect their performance. 2. Forming or bending of the plates should be kept to a minimum. Bending of the plate near the screw holes should be avoided. Distortion of the screw holes may prevent proper locking of the screw. If bending of the plate is performed, only benders supplied with the system should be used for such bending. Notching of the plate may reduce its fatigue life. Care should be taken to avoid bending the plate multiple times in the same location.
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3. If the surgeon experiences difficulty in inserting screws (hard bone, etc.), drilling and/or tapping prior to screw insertion is recommended. 4. A drill guide should be used to limit the angle of drilling and subsequent insertion of screws. Insertion angles greater than what drill guides allow may prevent adequate locking of the screw. 5. To help prevent screws from disassociating from the plate postoperatively, the screw locking mechanism of each screw should be engaged. The screw locking mechanism is activated turning the cam lock ¼ turn using the screwdriver to partially cover the head of the screw, preventing backout. 6. Bone grafts must be placed in the area to be fused such that the grafts fits snugly against the upper and lower vertebral bodies 7. Breakage, slippage, or misuse of instruments or implant components may cause injury to the patient or operative personnel. 8. Whenever possible or necessary, an imaging system should be utilized to facilitate surgery. 9. Caution should be taken not to over-tighten threaded components, including instruments, implants, and interfaces between implants and instruments. 10. Implants should not be reused (used in additional patients) under any circumstances. POSTOPERATIVE MANAGEMENT Postoperative management by the surgeon, including instruction and warning to and compliance by the patient, of the following is essential: 1. Anterior cervical plate implant components are for temporary internal fixation during the formation of a spinal fusion. Implants are not meant to support a load for an indefinite period. After the formation of a fusion, the device may be removed. 2. The patient should have a complete understanding of and compliance with the purpose and limitations of the implant devices. 3. Postoperative patients should be instructed to limit activity as determined by their surgeon. 4. Retrieved implants should be properly disposed of and are not to be reused under any circumstances. SINGLE USE Reuse of a single use device that has come in contact with blood, bone, tissue or other body fluids may lead to patient or user injury. Possible risks associated with reuse of a single use device include, but are not limited to, mechanical failure, serious injury, transmission of infectious agents and death. Implants that have come in direct contact with a patient or bio-contaminants should be disposed of. CLEANING AND MAINTENANCE GENERAL INFORMATION Spinal Elements’ instruments are manufactured from various stainless steels, aluminums, and polymers. All materials used have a history of use in such instruments. CLEANING AND MAINTENANCE Devices must be free of packaging material prior to cleaning. Cleaning, maintenance and mechanical inspection must be performed by hospital personnel trained in the general procedures involving contaminant removal. Only neutral pH cleaners or detergents labeled for use in cleaning medical devices should be used for cleaning components. Only lubricants that are intended for use on surgical instruments should be used to lubricate instruments. Follow directions from the manufacturer of lubricating and cleaning agents regarding handling, concentration, and use of such agents. Cleaning instructions are provided in accordance with recognized standards and regulations and are intended to supplement a hospital’s existing device cleaning and disinfecting protocol. Contaminated devices should be wiped clean of visible soil at the point of use prior to transfer to a central processing unit for cleaning and sterilization. Contaminated devices must be cleaned promptly after use per the instructions provided in this insert to minimize drying and ensure an effective cleaning. AUTOMATED CLEANING INSTRUCTIONS All devices must be processed manually prior to automated cleaning. Follow the instructions below for the manual and automated washing.
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PRE-AUTOMATED WASHER: MANUAL CLEANING 1. Disassemble all instruments that come apart for cleaning. 2. Rinse under running tap water to remove gross contamination. Use a syringe, wire guide and/or pipe cleaner (as appropriate to the presented cleaning challenge) to push debris out of lumens/cannulations or other hard to reach areas. Pay special attention to lumens of the external shafts of disassembled instruments. 3. Prepare Enzol® (or equivalent neutral or mild pH enzymatic cleaner) according to manufacturer recommendations using warm tap water. Fully immerse devices in the enzymatic cleaner solution and allow to soak for a minimum of 1 minute. While soaking, actuate the instruments through a full range of motion (as appropriate) to allow complete penetration of the cleaning solution. Instruments that do not disassemble may require additional soaking. 4. After the soak, remove the instruments and wipe any soil or debris using a disposable towel. Then, place the instruments into a fresh batch of enzymatic cleaning solution using warm water. Scrub the entire surface of the devices with a soft bristle brush paying particular attention to hard to reach areas such as mated surfaces. A syringe, wire guide, and/or pipe cleaner should be used to aid in cleaning lumens/cannulations or other hard to reach areas. A minimum of 60ml of detergent should be used when flushing lumens and cannulations. Ensure no soil is visible in the rinse stream. 5. Remove from enzymatic cleaner solution and rinse with reverse osmosis or de-ionized (RO/DI) water for a minimum of 30 seconds to remove any residual cleaner solution. Thoroughly and aggressively flush lumens, holes and other hard to reach areas with a minimum of 60ml of water. 6. Prepare Prolystica® (or equivalent neutral pH detergent) according to manufacturer recommendations using warm tap water in an ultrasonic bath. Fully immerse into the sonication bath and sonicate for a minimum of 10 minutes. 7. Remove from the detergent solution and rinse by agitating and actuating in RO/DI water for a minimum of 30 seconds to remove any residual detergent and until no sign of soil is seen in the rinse stream. While rinsing, thoroughly and aggressively flush lumens, holes and other hard to reach areas with a minimum of 60ml of water. AUTOMATED CLEANING 8. Transfer the instruments into the washer for processing. Position the instruments to allow for proper drainage. Process per the cycle below. These are minimum validated parameters: Phase Pre-wash
Recirculation Time 2 minutes
Water Temp Cold tap water
Enzyme Wash
2 minutes
Hot tap water
Wash
2 minutes
65.5°C
PURW Rinse Drying
2 minutes 15 minutes
43°C 90°C
Detergent Type (if applicable) N/A Enzol or equivalent per manufacturer’s instructions Prolystica or equivalent per manufacturer’s instructions N/A N/A
9. If needed, dry devices using a clean lint-free cloth. Pressurized air (20psi) may be used to assist in drying. 10. Visually examine devices to ensure all visible soil has been removed. 11. Once instruments pass visual inspection, reassemble devices that come apart for cleaning. 12. After cleaning, an instrument lubricant (i.e. Steris Hinge-Free® or equivalent) should be applied to moving devices to maintain fluid movement between components. Pay special attention to the instruments called out in system specific sections. MANUAL CLEANING INSTRUCTIONS Follow the instructions listed below for manual cleaning prior to sterilization. 1. Disassemble all instruments that come apart for cleaning. For the Anterior Cervical Plate System, the only instruments requiring disassembly would be Drills that are left assembled to the Jeweler Handle. (note that these items are normally stored in the dedicated trays already disassembled). 2. Rinse under running tap water to remove gross contamination. Use a syringe, wire guide, and/or pipe cleaner (as appropriate to the presented cleaning challenge) to push debris out of lumens/cannulations or other hard to reach areas.
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3.
Prepare Enzol (or equivalent neutral pH enzymatic cleaner) according to manufacturer recommendations using warm tap water. Fully immerse devices in the enzymatic cleaner solution and allow to soak for a minimum of 20 minutes. After the soak, scrub devices with a soft bristle brush paying particular attention to hard to reach areas such as mated surfaces. A syringe, wire guide, and/or pipe cleaner should be used to aid in cleaning lumens/cannulations or other hard to reach areas. A minimum of 60ml of detergent should be used when flushing lumens and cannulations. 4. Remove from enzymatic cleaner solution and rinse with reverse osmosis/de-ionized (RO/DI) water for a minimum of three minutes to remove any residual cleaner solution. Thoroughly and aggressively flush lumens, holes and other hard to reach areas with a minimum of 60ml of water. 5. Prepare Prolystica (or equivalent neutral pH detergent) according to manufacturer recommendations using warm tap water in an ultrasonic bath. Fully immerse into the somication bath and sonicate for a minimum of 10 minutes. 6. Remove from the detergent solution and rinse with RO/DI water for a minimum of three minutes to remove any residual detergent and until no sign of soil is seen in the rinse stream. Thoroughly and aggressively flush lumens, holes and other hard to reach areas with a minimum of 60ml of water. 7. Repeat Steps 5 and 6. 8. Dry devices using a clean lint-free cloth. Pressurized air (20psi) may be used to assist in drying. 9. Visually examine devices to ensure all visible soil has been removed. 10. Once instruments pass visual inspection, reassemble devices that come apart for cleaning. 11. After cleaning, an instrument lubricant (i.e. Steris Hinge-Free® or equivalent) should be applied to moving devices to maintain fluid movement between components. Pay special attention to the instruments called out in system specific sections. STERILIZATION
Wrapped
All implants and instruments are provided non-sterile and must be sterilized before use. Non-sterile implants and instruments should be autoclave sterilized using one of the following validated cycle parameters. Method
Cycle Type
Exposure Time
Drying Times
Pre-Vacuum
Sterilization Temperature 270°F (132°C)
Steam
4 Minutes
30 Minutes
Steam
Gravity
250°F (121°C)
30 Minutes
30 Minutes
Sterilization parameters were validated per ANSI/AAMI/ISO 17665-1: 2006. Sterilization of Health Care Products – Moist Heat – Part 1 Requirements for the Development, Validation, and Routine Control of a Sterilization Process for Medical Devices and ANSI-AAM ST 79 - Comprehensive guide to steam sterilization and sterility assurance in health care facilities. These parameters were validated to a sterility assurance level (SAL) of 10-6. This sterilization cycle is not considered by the Food and Drug Administration to be a standard sterilization cycle. It is the end user’s responsibility to use only sterilizers and accessories (such as sterilization wraps, sterilization pouches, chemical indicators, biological indicators, and sterilization cassettes) that have been cleared by the Food and Drug Administration for the selected sterilization cycle specifications (time and temperature).
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INFORMATION
h Catalog Number g Batch Code M Manufacturer Caution, Consult Y Accompanying Documents
MAT
Material
QTY
Packaged Quantity
N D
Date of Manufacture Do Not Re-Use
Device Not Sterile Prescription Only
i
ifu.spinalelements.com
Instruction for Use are provided electronically at ifu.spinalelements.com
© 2019 Spinal Elements Inc. Patents: patent.spinalelements.com For additional information regarding any of Spinal Elements’ devices, please contact Spinal Elements, Inc. Customer Service at (760) 607-0121.
Caution: Federal law (USA) restricts these devices to sale by or on the order of a physician.
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