US20080140135A1

US20080140135A1 - Polyaxial bone screw

Info

Publication number: US20080140135A1
Application number: US11/954,562
Authority: US
Inventors: David D. Konieczynski; Thomas Vincent Doherty; Dale Whipple; Niall Casey; Mark Hall
Original assignee: DePuy Spine LLC
Current assignee: DePuy Spine LLC
Priority date: 2003-06-27
Filing date: 2007-12-12
Publication date: 2008-06-12
Also published as: US20130103099A1; DE602004029887D1; WO2005004699A2; CA2524334A1; JP2007526007A; US20100131018A1; US20170215924A1; AU2004255155A1; ATE486533T1; EP1641405A4; BRPI0411970A; AU2004255155B2; US10980574B2; US20040267264A1; US9463049B2; US9655657B2; EP2218414B1; WO2005004699A3; CA2524334C; US10136924B2

Abstract

The present invention generally provides a polyaxial fixation device having a shank with a spherical head formed on a proximal end thereof, and a receiver member having an axial passage formed therein that is adapted to polyaxially seat the spherical head of the shank. The polyaxial bone screw further includes an engagement member that is adapted to provide sufficient friction between the spherical head and the receiver member to enable the shank to be maintained in a desired angular orientation before locking the spherical head within the receiver member.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS

The present application is a continuation of U.S. patent application Ser. No. 11/381,048 filed on May 1, 2006 and entitled “Polyaxial Bone Screw,” which is a continuation of U.S. patent application Ser. No. 10/608,904 filed on Jun. 27, 2003 and entitled “Polyaxial Bone Screw.” These references are hereby incorporated by reference in their entireties.

FIELD OF THE INVENTION

The present invention relates to polyaxial bone screws, and in particular to a polyaxial bone screw assembly in which the bone screw can be maintained in a desired angular orientation prior to locking the bone screw with respect to the rod-receiving member.

BACKGROUND OF THE INVENTION

Spinal fixation devices are used in orthopedic surgery to align and/or fix a desired relationship between adjacent vertebral bodies. Such devices typically include a spinal fixation element, such as a relatively rigid fixation rod, that is coupled to adjacent vertebrae by attaching the element to various anchoring devices, such as hooks, bolts, wires, or screws. The fixation rods can have a predetermined contour that has been designed according to the properties of the target implantation site, and once installed, the instrument holds the vertebrae in a desired spatial relationship, either until desired healing or spinal fusion has taken place, or for some longer period of time.
Spinal fixation devices can be anchored to specific portions of the vertebra. Since each vertebra varies in shape and size, a variety of anchoring devices have been developed to facilitate engagement of a particular portion of the bone. Pedicle screw assemblies, for example, have a shape and size that is configured to engage pedicle bone. Such screws typically include a bone screw with a threaded shank that is adapted to be threaded into a vertebra, and a rod-receiving element, usually in the form of a U-shaped slot formed in the head. The shank and rod-receiving assembly can be provided as a monoaxial screw, whereby the rod-receiving element is fixed with respect to the shank, or a polyaxial screw, whereby the rod-receiving element has free angular movement with respect to the shank. In use, the shank portion of each screw is threaded into a vertebra, and once properly positioned, a fixation rod is seated into the rod-receiving element of each screw. The rod is then locked in place by tightening a set-screw, plug, or similar type of fastening mechanism into the rod-receiving element.
While current spinal fixation systems have proven effective, it can be difficult to mount rods into the rod-receiving element of various fixation devices. In particular, it can be difficult to align and seat a rod into the rod-receiver of a polyaxial implant since the rod-receiver has polyaxial freedom of movement with respect to the shank. More particularly, the polyaxial freedom of movement of the rod-receiver can allow the receiver to “flop,” thereby requiring the surgeon or an assistant to hold the receiver in the desired position during rod introduction.
Accordingly, there remains a need for a polyaxial bone screw assembly in which the rod-receiving element can be maintained in a desired angular orientation before locking the shank with respect to the receiver member.

SUMMARY OF THE INVENTION

The present invention generally provides a polyaxial spinal fixation device (e.g., bone screws, hooks, etc.) having a shank with a spherical head formed on a proximal end thereof, and a receiver member having an axial passage formed therein that is adapted to polyaxially seat the spherical head of the shank. The polyaxial fixation device further includes an engagement member that is adapted to provide sufficient friction between the spherical head and the receiver member to enable the shank to be maintained in a desired angular orientation before locking the spherical head within the receiver member. The engagement member can have a variety of configurations, and in one embodiment the engagement member can be a ring member, such as a snap ring, that is positioned to engage a portion of the spherical head to provide frictional engagement between the head and the receiver member. The ring member can be disposed within a groove formed around an outer surface of the spherical head of the shank, and/or it can be disposed within a groove formed around an inner surface of the receiver member. The groove around the inner surface of the receiver member preferably has a depth that is equal to or greater than a thickness of the ring member to allow the ring member to be completely disposed within the groove. Alternatively, or in addition, the ring member can be adapted to expand or contract to be disposed completely within the groove.
In another embodiment, the engagement member can be a compression cap that is disposed within the receiver member and that has a concave distal surface adapted to seat at least a portion of the spherical head of the shank. The compression cap is preferably capable of mating with the receiver member such that the compression cap is effective to retain the spherical head of the shank in a spherical recess formed in the receiver member. The compression cap can have a variety of configurations, and in one embodiment it can include opposed leaf-spring members that are adapted to contract inward, biasing the cap distally, to frictionally engage the spherical head of the shank. In another embodiment, at least a portion of the compression cap has a diameter that is expandable to frictionally engage the spherical head. By way of non-limiting example, the compression cap can include a plurality of distally-extending finger-like members formed around a distal edge of the compression cap to frictionally engage the spherical head. In yet another embodiment, the compression cap can include at least one longitudinally oriented slot formed therein to allow the compression cap to be contracted to frictionally engage the spherical head.
In other aspects, a polyaxial fixation assembly is provided having a shank with a spherical head formed on a proximal end thereof, and a receiver member having a first, proximal opening adapted to receive a spinal fixation rod and a second, distal opening having a diameter sized to permit passage of the shank therethrough while maintaining the spherical head therein. The receiver member further includes a spherical seat adjacent the second, distal opening to polyaxially seat the spherical head of the shank. The polyaxial fixation assembly also includes means for frictionally engaging the spherical head to maintain the shank in a desired angular orientation such that a force greater than a frictional engagement force is required to change the angular orientation of the threaded shank with respect to the receiver member.

BRIEF DESCRIPTION OF THE DRAWINGS

The invention will be more fully understood from the following detailed description taken in conjunction with the accompanying drawings, in which:

FIG. 1 is a perspective view of a prior art polyaxial bone screw;

FIG. 2A is an enlarged, partially cross-sectional view of a polyaxial bone screw assembly having a ring member disposed therein in accordance with one embodiment of the present invention;

FIG. 2B illustrates several embodiments of a ring member that can be used with the polyaxial bone screw assembly shown in FIG. 2A;

FIG. 2C is an illustration of another embodiment of a bone screw having a ring member disposed therearound;

FIG. 3A is a perspective view of a polyaxial bone screw assembly, in the disassembled state, having a compression cap with a collet for engaging the head of a bone screw in accordance with another embodiment of the present invention;

FIG. 3B is an enlarged, partially cross-sectional view of a portion of the polyaxial bone screw assembly shown in FIG. 3A;

FIG. 3C illustrates the polyaxial bone screw assembly of FIG. 3B with a rod and closure mechanism disposed therein;

FIG. 4A is a perspective view of another embodiment of a polyaxial bone screw assembly, in the disassembled state, having a compression cap with a leaf-spring for engaging the head of a bone screw in accordance with the present invention;

FIG. 4B is an enlarged, cross-sectional view of the a portion of the polyaxial bone screw assembly shown in FIG. 4A;

FIG. 5A is a perspective view of yet another embodiment of a polyaxial bone screw assembly, in the disassembled state, having a compression cap with a slot formed therein to allow the compression cap to engage the head of a bone screw in accordance with the present invention; and

FIG. 5B is an enlarged, partially cross-sectional view of a portion of the polyaxial bone screw shown in FIG. 5A.

DETAILED DESCRIPTION OF THE INVENTION

FIG. 1 illustrates a prior art polyaxial bone screw assembly 10 that includes a bone screw 12, a receiver member 18, and a compression cap 24. As shown, the bone screw 12 generally includes a threaded shank 14 having a spherical head 16 formed on a proximal end 14 a thereof. An Allen or other female socket 15 is formed in the head 16 for applying torque along the axis of the shank 14 to insert the shank 14 into bone. The receiver member 18 is generally U-shaped and includes opposed side walls or legs 20 a, 20 b that are substantially parallel to one another and that define a rod-receiving portion 22 for seating a spinal fixation rod. A distal end 18 b of the receiver member 18 includes an axial opening (not shown) formed therein and having a diameter sized to permit passage of the shank 14 therethrough while maintaining the spherical head 16 therein. The receiver member 18 further includes a spherical seat (not shown) adjacent to the distal opening for polyaxially seating the spherical head 16 of the bone screw 12. The compression cap 24, which is adapted to be positioned within the receiver member 18, has a generally cylindrical shape and includes a rod-receiving proximal surface 26, and a concave distal surface (not shown) that is adapted to fit around and seat a portion of the spherical head 16 of the bone screw 12.
In use, the threaded shank 14 is disposed through the distal opening in the receiver member 18 and the spherical head 16 of the bone screw 12 is positioned within the spherical seat in the receiver member 18. The compression cap 24 is then inserted into the receiver member 18 such that the concave distal surface of the compression cap 24 is disposed around and seats a portion of the spherical head 16 of the bone screw 12. In order to retain the compression cap 24 within the receiver member 18, the receiver member 18 includes opposed sides bores (only one side bore 28 a is shown) having a deformable material (not shown) extending there across on an inner surface of the receiver member 18. The side bores 28 a allow the material to be deformed inward to extend into and engage opposed detents (only one detent 30 a is shown) formed in the compression cap 24. A tool can be used to deform the material into the detents 30 a once the compression cap 24 is disposed within the receiver 18. As a result, the compression cap 24 is maintained within the receiver member 18, thereby preventing removal of the bone screw 12 from the receiver member 18. The compression cap 24 is also effective to lock the bone screw 12 in a desired angular orientation with respect to the receiver member 18 once a rod is disposed and locked within the receiver member 18. A person skilled in the art will appreciate that a variety of techniques can be used to retain the compression cap 24 within the receiver member 18, and that the present invention is not intended to be limited to use with compression caps 24 having detents for receiving deformable material disposed within the receiver member. By way of non-limiting example, the compression cap 24 can be retained within the receiver 18 using a cross-pin.
Once the bone screw 12 is implanted within bone, and prior to insertion of a rod into the receiver member 18, the receiver member 18 of the prior art assembly is free to rotate and/or be angularly positioned with respect to the bone screw 12. While this advantageously allows alignment of the receiver member 18 with a rod adapted to be disposed therein, such free axial movement of the receiver member 18 can present challenges during surgery as the surgeon is required to hold the receiver member 18 in the desired position during rod introduction.
Accordingly, the present invention provides mechanisms for creating friction between the spherical head 16 and the receiver member 18 to allow the receiver member 18 to be provisionally maintained in a desired angular orientation prior to locking the receiver member 18 with respect to the a polyaxial fixation device. This is particularly advantageous in that it allows a surgeon to position and maintain the receiver member 18 in a desired orientation prior to rod introduction, thereby preventing the receiver member 18 from moving with respect to the bone screw 12 during introduction of a rod. While several different techniques can be used to create the necessary frictional forces to allow the angular orientation between the receiver member 18 and the bone screw 12 to be maintained, FIGS. 2A-5B illustrate several exemplary embodiments for frictionally engaging the spherical head of a bone screw with respect to a rod-receiver member. For convenience purposes, the reference numbers used in the embodiments shown in FIGS. 2A-5B correspond to the reference numbers used in FIG. 1, except that a different prefix is added to the reference numbers for each embodiment. A person skilled in the art will appreciate that a variety of other techniques can be used to create the frictional forces necessary to maintain the angular orientation of the shank with respect to the receiver member. Moreover, the techniques used to create friction between the spherical head and the receiver member can be adapted for use with virtually any polyaxial spinal fixation device in addition to the illustrated bone screw assembly, and the invention is not intended to be limited to the specific polyaxial bone screw assembly shown.
FIG. 2A illustrates one embodiment of a polyaxial bone screw assembly 210 that utilizes a ring member, e.g., a snap ring 234, to frictionally engage the spherical head 216 of the bone screw 212. The snap ring 234 can have a variety of configurations, shapes, and sizes, but it should be adapted to expand to fit around at least a portion of the spherical head 216. As shown, the snap ring 234 is in the shape of a loop with an opening 235 formed therein that allows the diameter d of the snap ring 234 to expand to fit around a portion of the spherical head 216 of the bone screw 212. While the snap ring 234 is shown having a C-shape, the snap ring can 234 can have a variety of other configurations. By way of non-limiting example, FIG. 2B illustrates a variety of different snap rings 234 a, 234 b, 234 c, 234 d, 234 e that can be used with the polyaxial bone screw assembly 210 shown in FIG. 2A. Snap rings 234 a and 234 c, for example, each have an irregular shape that allows the snap rings 234 a, 234 c to expand to fit around the spherical head 216 of the bone screw 212. Snap ring 234 e, on the other hand, includes several cut-out portions 235 e that allow the snap ring 234 e to expand. In other embodiments, the snap ring 234 can have a variety of different cross-sectional shapes such as, for example, a circular cross-sectional shape as shown on snap ring 234 d, or a C-shaped cross-section as shown on snap ring 234 b.
While the snap ring 234 can have a variety of configurations, the snap ring 234 should be adapted to fit within a corresponding groove 236 formed around an inner surface of the receiver member 218. The groove 236 maintains the snap ring 234 at a particular location with respect to the spherical head 216 of the bone screw such that the snap ring 234 is expanded around the head 216. More particularly, the groove 236 should be formed in a proximal portion of the spherical seat 219 formed in the distal end 218 b of the receiver member 218. Not only is the groove 236 effective to maintain the position of the snap ring 234 around the spherical head 216, but it is also effective to fully seat the snap ring 234 when the head 216 is locked within the receiver 218. As previously discussed, when a rod is seated within the receiver member 218, the compression cap 224 is forced distally to lock the bone screw 216 with respect to the receiver 218. The groove 236 receives the snap ring 234 to prevent the snap ring 234 from interfering with the locking function of the compression cap 224. Accordingly, the groove 236 preferably has a depth d_lthat is at least equal to, and more preferably is greater than, a thickness t_rof the snap ring 234. Alternatively, or in addition, the snap ring 234 can be adapted to expand or contract to be completely disposed within the groove 236. By way of non-limiting example, the snap ring 234 can be formed from a compressible or deformable material that allows the snap ring 234 to be forced completely into the groove 236.
Still referring to FIG. 2A, the bone screw assembly 210 can be assembled by first placing the snap ring 234 within the groove 236 in the receiver member 218. The threaded shank 214 of the screw 212 can then be inserted through the axial opening 237 formed in the distal end 218 b of the receiver member 218. As a result, the spherical head 216 will rest on top of the snap ring 234. The compression cap 224 can then be placed in the receiver 218 and can be used to push the head 216 into the recess 219, thereby causing the snap ring 234 to expand around the head 216 to engage the head 216. This can be achieved by using a tool to push the compression cap 224 in a distal direction. To prevent the compression cap 224 from popping out of the receiver 218, another tool can be inserted into each of the opposed bores 228 a, 228 b to deform the deformable material 232 a, 232 b, which extends across the inner surface of the receiver member 218, into the corresponding detents 230 a, 230 b formed in the compression cap 224. As a result, the compression cap 224 is prevented from moving in a proximal direction, thereby preventing the spherical head 216 from moving proximally and becoming disengaged with the snap ring 234. One skilled in the art will appreciate that a variety of other techniques and fastening members are known for use in retaining the spherical head 216 (and any rod) within the receiver 218.
Once the device 210 is assembled, the frictional forces created by the snap ring 234 that act on the spherical head 216 of the screw 212 will allow the screw 212 to be set at a desired angular orientation with respect to the receiver member 218, as shown in FIG. 2A. The frictional forces can simply be overcome by grasping and moving the bone screw 212 with respect to the receiver member 218 to change the angular orientation. In other words, a force greater than the frictional engagement force is required to change the angular orientation of the bone screw 212 with respect to the receiver member 218.
In another embodiment, shown in FIG. 2C, the snap ring 234 can be disposed within a groove 236′ formed around the spherical head 216′ of the bone screw 212′, rather than in a groove 236 formed within the receiver member 218. In this embodiment, the groove 236′ around the head 216′ of the bone screw 212′ preferably extends at an angle α, with respect to a longitudinal axis L of the screw 212′, around the proximal half of the spherical head 216′ to allow the head 216′ to fit within the spherical recess 219 in the receiver member 218. The angle α of the groove 236′ also allows the snap ring 234 to bear against the concave inner surface of the compression cap 224, thereby creating the necessary frictional forces to allow the angular orientation of the bone screw 212′ to be maintained with respect to the receiver member 218.
FIGS. 3A-3C illustrate another embodiment of a polyaxial bone screw assembly 310 that includes an engagement feature that is effective to maintain the angular orientation of a bone screw 312 with respect to a receiver member 318. In this embodiment, rather than providing a separate engagement member, such as snap ring 234 shown in FIGS. 2A-2C, the compression cap 324 is modified to include an expandable portion that is adapted to fit around and frictionally engage the spherical head 316 of the bone screw 312. While the expandable portion can have virtually any configuration, in an exemplary embodiment the distal end 324 b of the compression cap 324 includes a collet 333 formed therearound having several spaced apart finger-like members 334 that are separated by slots 335 which allow the finger-like members 334 to expand. The collet 333 can include any number of finger-like members 334 that can be spaced apart at varying distances. Once the cap is retained in place within the receiver member, the fingers 334 will bear upon the spherical head 316 of the screw 312. This can be achieved by deforming the fingers 334 on the cap inward prior to assembly, so that they contact the spherical head 316 of the screw 312 once inserted. Alternatively, the concave underside of the cap 324 can be machined so that the radius is smaller than a radius r of the spherical head 316 of the screw 312. This interference will also cause the fingers 334 to bear upon the head 316 of the screw 312. In use, as the compression cap 324 is moved distally on to the head 316, the collet 333 is forced to expand around the spherical head 316 of the bone screw 312 to engage the head and create the friction necessary to maintain the angular orientation of the screw 312 with respect to the receiver 318, as shown in FIG. 3B. As previously indicated, the compression cap 324 can be retained in this position by deforming the material 332 a, 332 b in the receiver member 318 into the corresponding detents 330 a, 330 b in the compression cap 324.
Still referring to FIG. 3B, in a further embodiment, the receiver member 318 can include an annular groove 336 formed therein for receiving the expandable fingers 334 of the collet 333. The groove 336, which is similar to groove 236 shown in FIG. 2A, prevents the collet 333 from interfering with the locking function of the compression cap 324. In other words, when a rod 50 is seated within the rod-receiving recess 326 formed in the compression cap 324, and a closure mechanism 60 is applied to lock the rod 50 within the receiver member 318, as shown in FIG. 3C, the compression cap 324 locks the position of spherical head 316 within the receiver member 318. The groove 336 thus receives the collet 333 to prevent the collet 333 from interfering with the locking forces created between the compression cap 324 and the spherical head 316.
FIGS. 4A-4B illustrate yet another embodiment of a polyaxial bone screw assembly 410 in which a leaf-spring compression cap 424 is used to engage the spherical head 416 of the bone screw 412 to create the frictional forces necessary to maintain the angular orientation of the bone screw 412 with respect to a receiver member 418. As shown in FIG. 4A, the compression cap 424 includes a first pair of slots 431 a ₁, 431 a ₂formed on opposed sides of the first detent 430 a, and a second pair of slots 431 b ₁, 431 b ₂formed on opposed sides of the second detent 430 b. Each pair of slots 431 a, 431 a ₂, 431 b ₁, 431 b ₂extends from a proximal end 424 a of the compression cap 424 toward the distal end 424 b, terminating just proximal to the distal end 424 b. As a result, the slots 431 a ₁, 431 a ₂, 431 b ₁, 431 b ₂ form sidewall portions 434 a, 434 b therebetween that are flexible, thereby forming a leaf spring. In use, as shown in FIG. 4B, when the deformable material 432 a, 432 b in the receiver member 418 is deformed into the corresponding detents 430 a, 430 b in the compression cap 424, the sidewall portions 424 a, 424 b flex inward thereby contracting around, and preferably creating a downward pressure on, the spherical head 416 of the bone screw 412. As a result, friction is created between the compression cap 424 and the spherical head 416 to maintain the angular orientation of the screw 412 with respect to the receive member 418. A person skilled in the art will appreciate that a variety of other techniques can be used to create a spring-like compression cap 424 that is effective to engage the spherical head 416 of the screw 412.
FIGS. 5A-5B illustrate yet another embodiment of a polyaxial bone screw assembly 510. In this embodiment, the compression cap 524 includes an axial slot 534 formed therein to allow the compression cap 524 to be contracted to engage the spherical head 516 of the bone screw 512. While the slot 534 can be formed anywhere in the compression cap 524, the slot 534 is preferably formed in the portion of the sidewall that extends between the opposed detents 530 a, 530 b, and more preferably the slot 534 is equidistant from each detent 530 a, 530 b to allow the compression cap 524 to be swaged evenly in a distal direction. FIG. 5B illustrates the compression cap 524 in the contracted state around the head 516 of the bone screw. The deformable material 532 a, 532 b in the receiver member 518 is deformed into the detents 530 a, 530 b in the compression cap 524 to contract the compression cap 524 around the spherical head 516. As a result, the frictional forces created by the compression cap 524 radially contracting around the spherical head 516 are effective to allow the bone screw 512 to be maintained at a desired angular orientation with respect to the receiver member 518.
A person skilled in the art will appreciate that a variety of other techniques can be used to apply friction to the spherical head of a polyaxial bone screw to allow the bone screw to be maintained in a desired angular orientation before locking the bone screw within the receiver member. By way of non-limiting example, the spherical head of the polyaxial screw can include a coating or surface treatment thereon to hinder movement of the screw head with respect to the receiver member. Alternatively, or in addition, the spherical head, the compression cap, and/or the receiver member can include one or more protrusions formed thereon to frictionally engage the spherical head to allow the orientation of the head to be maintained in a desired configuration. The protrusions can be, for example, formed from a plastic material that is effective to interfere with the free rotational movement of the screw within the receiver.
A person skilled in the art will appreciate that this design is application to other polyaxial fixation devices, including other screws, cross-connectors, hooks, bolts, etc., and it is not intended to be limited to use with a polyaxial bone screw. A person skilled in the art will also appreciate further features and advantages of the invention based on the above-described embodiments. Accordingly, the invention is not to be limited by what has been particularly shown and described, except as indicated by the appended claims. All publications and references cited herein are expressly incorporated herein by reference in their entirety.

Claims

1-31. (canceled)

32. A method of producing an apparatus for retaining bone portion in a desired spatial relationship, comprising:

providing a fastener having a longitudinal axis, a first threaded end portion engageable with a bone portion and a second end portion;

providing a housing having a first passage capable of receiving a longitudinal member and a second passage for receiving the fastener, the second passage having a longitudinal axis;

extending the fastener through an opening in the housing into the second passasge so that the fastener is pivotable relative to the housing and the longitudinal axis of the fastener is positionable in any one of a plurality of angular positions relative to the longitudinal axis of the second passage; and

limiting relative movement between the fastener and the housing by creating a frictional engagement that holds the position of the housing relative to the fastener when the longitudinal member is not recieved in the first passage of the housing.

33. The method of claim 32, wherein the first passage is transverse to the second passage.

34. The method of claim 32, wherein the first passage and the second passage intersect.

35. The method of claim 32, wherein the frictional engagement is created between the second end portion of the fastener and an inner surface of the housing.

36. The method of claim 32, further comprising inserting a spacer into the second passage of the housing, the spacer applying an axial force toward the fastener to create the frictional engagement between the second end portion of the fastener and the inner surface of the housing.

37. The method of claim 32, further comprising inserting a spring member into the second passage of the housing, the spring member compressing to apply an axial force to the spacer and urging the spacer axially toward the fastener to create the frictional engagement that holds the position of the housing relative to the fastener when the longitudinal member is not received in the first passage of the housing.

38. A method of producing an apparatus for retaining bone portions in a desired spatial relationship, comprising:

providing a housing having a first passage capable of receiving a longitudinal member and a second passage, the second passage having a longitudinal axis extending transverse to the first passage;

extending the fastener through an opening in the housing into the second passage so that the second end portion of the fastener engages an inner surface of the housing and the fastener is pivotable relative to the housing so that the longitudinal axis of the fastener is positionable in any one of a plurality of angular positions relative to the longitudinal axis of the second passage; and

inserting a spacer in the housing, the spacer configured to engage the longitudinal member, wherein the spacer applies an axial force toward the fastener to create a frictional engagement between the second end portion of the fastener and the inner surface of the housing;

wherein the frictional engagement holds the position of the housing relative to the fastener when the longitudinal member is disengaged from the spacer, and the fastener and the housing are manually moveable relative to each other when the longitudinal member is disengaged from the spacer and the spacer applies the axial force.

39. The method of claim 38, wherein the second end portion of the fastener comprises a part spherical surface.

40. The method of claim 39, wherein the part spherical surface of the fastener engages a concave part spherical surface of the housing.

41. The method of claim 38, wherein the spacer engages the fastener.

42. The method of claim 41, further comprising inserting a spring member in the housing and compressing the spring member to urge the spacer axially toward the fastener to prevent relative movement between the fastener and the housing when the longitudinal member is disengaged from the spacer and the spacer engages the fastener.

43. The method of claim 41, wherein the spacer has a concave part spherical surface that engages a part spherical surface of the fastener.

44. The method of claim 38, further comprising providing a cap screw, the cap screw configured to threadably engage the housing and apply a force to a longitudinal member positioned in the first passage of the housing to press the longitudinal member against the spacer.

45. A method of producing an apparatus for retaining bone portions in a desired spatial relationship, comprising:

providing a housing having a first passage capable of receiving a longitudinal member and a second passage for receiving the fastener, the second passage having a longitudinal axis, wherein the fastener extends through an opening in the housing into the second passage so that the fastener is pivotable relative to the housing and the longitudinal axis of the fastener is positionable in any one of a plurality of angular positions relative to the longitudinal axis of the second passage;

connecting the fastener to a vertebra, wherein a frictional engagement holds the position of the housing relative to the fastener prior to the longitudinal member being received in the first passage of the housing;

positioning the longitudinal member in the first passage of the housing; and

threadably engaging a set screw in the housing, the set screw engaging and applying a force to the longitudinal member.

46. The method of claim 45, wherein the frictional engagement is created between the second end portion of the fastener and an inner surface of the housing.

47. The method of claim 46, wherein the housing is provided with a spacer positioned within the second passage, and the longitudinal member engages the spacer.

48. The method of claim 47, wherein the housing is provided with a spring member that urges the spacer axially toward the fastener and the inner surface of the housing against the second end portion of the fastener.

49. The method of claim 45, further comprising, prior to positioning the longitudinal member in the first passage of the housing, moving the fastener relative to the housing to overcome the frictional engagement.

50. The method of claim 45, wherein the first passage is transverse to and intersects the second passage.

51. The method of claim 45, wherein the second end portion of the fastener is part spherical, and the part spherical end portion of the fastener engages a concave inner surface of the housing.

52. An apparatus comprising:

a housing having a top end, a bottom end, and first and second side walls;

the first and second walls defining an opening in the top end of the housing and a channel extending through the housing having a longitudinal axis defining a passageway for receiving a spinal rod; and

a fastener configured to engage to bone, the fastener having a longitudinal axis, the fastener extending from the bottom end of the housing;

wherein each of the first and second side walls includes a downwardly facing horizontal surface and at least a partially cylindrical inwardly extending recess on an exterior surface thereof.

53. The apparatus of claim 52, wherein the first and second side walls have an exterior side surface that is substantially arcuate.

54. The apparatus of claim 52, wherein each of the first and second side walls define an interior side surface and an exterior side surface, the interior side surface further defining the channel and the exterior side surface located opposite the internal surface.

55. The apparatus of claim 52, further comprising a rod positioned in the channel.

56. The apparatus of claim 55, further comprising a clamping mechanism that clamps said rod and housing to said fastener to prevent movement of said fastener relative to said housing.

57. The apparatus of claim 56, wherein the housing is internally threaded, and the clamping mechanism is a set screw.

58. The apparatus of claim 52, wherein said fastener extends through an opening in the bottom end of the housing and is movable in any one of a plurality of angular positions relative to said housing.

59. The apparatus of claim 52, wherein the recess extends partially through the housing.

60. An apparatus comprising:

a housing having a top end, a bottom end, and first and second side walls;

wherein each of the first and second side walls includes a downwardly facing horizontal surface extending along substantially the entirety of an exterior surface of each of the first and second side walls.

61. An apparatus comprising: a fastener having a longitudinal axis and engageable with a bone portion;

a housing having a passage with a first transverse dimension, said fastener extending through an opening in said housing into said passage and being movable relative to said housing, said longitudinal axis of said fastener being positionable in any one of a plurality of angular positions relative to said longitudinal axis of said passage;

a spacer received in said passage of said housing and engageable with said fastener, said spacer having an upper end and a lower end; and

a retaining structure having a second transverse dimension greater than the first transverse dimension;

wherein the retaining structure is configured to be press-fit into the passage, the distance between the retaining structure and the spacer determining an adjustable force applied by the spacer to the fastener to prevent relative movement between said fastener and said housing when the spacer engages the fastener; and

wherein an inner surface of the housing is substantially continuous at least from a location engaging the retaining structure to a location adjacent the lower end of the spacer.

62. An apparatus as defined in claim 61, wherein the retaining structure and the spacer are separate members.

63. An apparatus as defined in claim 61, wherein the retaining structure and the spacer are integral.

64. An apparatus as defined in claim 61, wherein the inner surface of the housing is substantially continuous at least from a location engaging the retaining structure to a location within a plane transverse to the longitudinal axis of the housing, said transverse plane containing the lower end of the spacer.

65. An apparatus comprising: a fastener having a longitudinal axis and engageable with a bone portion;

a housing having a passage and being configured to receive a longitudinal member, said fastener extending through an opening in said housing into said passage and being movable relative to said housing, said longitudinal axis of said fastener being positionable relative to said longitudinal axis of said passage;

a spacer having a lower end engaged with said fastener; and

means for preventing relative movement between said fastener and said housing before a longitudinal member is received in the housing.

66. An apparatus comprising: a fastener having a longitudinal axis and engageable with a bone portion;

a housing having a passage and being configured to receive a longitudinal member, said fastener extending through an opening in said housing into said passage and being movable relative to said housing, said longitudinal axis of said fastener being positionable relative to said longitudinal axis of said passage; and