MAUDE Adverse Event Report: ST. JUDE MEDICAL, NEUROMODULATION OCTRODE; SCS LEAD

Model Number 3186

Device Problems Detachment Of Device Component (1104); High impedance (1291); Low impedance (2285)

Patient Problem Inadequate Pain Relief (2388)

Event Date 03/12/2014

Event Type  Injury  

Event Description

Device 1 of 3.Reference mfr.Report: 1627487-2014-26270, 1627487-2014-26275.It was reported the patient is experiencing auto-reducing.Xrays were taken and showed the lead has pulled out of the ipg header.Lead diagnostics showed both low and high impedances.Surgical intervention is pending to address this issue.

Manufacturer Narrative

Sjm has limited info related to the patient's medical history and is unable to form an opinion as to the relevancy of the patient's history to the event reported.Sjm defers to the patient's physician regarding medical history.

• Brand Name: OCTRODE
• Type of Device: SCS LEAD
• Manufacturer (Section D): ST. JUDE MEDICAL, NEUROMODULATION; plano TX
• Manufacturer Contact: tanja hoffman ; 6901 preston rd.; plano, TX 75024 ; 9723098520
• MDR Report Key: 3764071
• MDR Text Key: 4487646
• Report Number: 1627487-2014-26269
• Device Sequence Number: 1
• Product Code: GZB
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: P010032
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Company Representative
• Reporter Occupation: Not Applicable
• Type of Report: Initial
• Report Date: 03/12/2014

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Expiration Date: 07/01/2015
• Device Model Number: 3186
• Device Lot Number: 4180991
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Initial Date Manufacturer Received: 03/12/2014
• Initial Date FDA Received: 04/01/2014
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 07/01/2013
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Treatment: SCS IPG, MODEL 3788; IMPLANT DATE:; SCS ANCHOR, MODEL 1192 (2); IMPLANT DATE:
• Patient Outcome(s): Other
• Patient Age: 65 YR