MAUDE Adverse Event Report: WRIGHTS LANE SYNTHES USA PRODUCTS LLC TI LOW PROFILE NEURO BURR HOLE COVER 24MM DIA; BONE PLATE

Model Number	421.528
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Cerebrospinal Fluid Leakage (1772); No Code Available (3191)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Without a lot number, the device history records review could not be completed as no product was received.The investigation could not be completed, no product was received; no conclusion could be drawn at the time of filing this report.(b)(4).Device was used for treatment, not diagnosis.If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Event or Problem Description
It was reported that on an unknown date, the patient underwent a microvascular decompression procedure due to trigeminal neuralgia.The patient was implanted with titanium low profile neuro burr hole cover.There was a surgical time of 93 minutes.There were no intraoperative complications.The duration of follow up was of 2050 days.The healing status/radiographic outcomes at final follow-up was that the patient pain relief from surgery continues to this day and reports improvement in symptoms from csf leak into middle ear.There was no postoperative complication presented.The patient underwent reoperation because of the right retrosigmoid craniotomy repair of csf leak.No further information is available.This complaint involved unknown number of devices.This report is for (1) ti low profile neuro burr hole cover 24mm dia.This is report 2 of 2 for (b)(4).

• Brand Name: TI LOW PROFILE NEURO BURR HOLE COVER 24MM DIA
• Common Device Name: BONE PLATE
• Manufacturer (Section D): WRIGHTS LANE SYNTHES USA PRODUCTS LLC; 1302 wrights lane east; west chester PA 19380
• MDR Report Key: 10414081
• Report Number: 2939274-2020-03564
• Device Sequence Number: 16755606
• Product Code: JEY
• UDI-Device Identifier: 10887587050607
• UDI-Public: (01)10887587050607
• Combination Product (Y/N): N
• Initial Reporter State: PA
• Initial Reporter Country: US
• PMA/510(K) Number: K022012
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: study
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 08/10/2020

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?: No
• Operator of Device: Health Professional
• Device Model Number: 421.528
• Device Catalogue Number: 421.528
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 08/10/2020
• Initial Report FDA Received Date: 08/17/2020
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: UNK - SCREWS: TRAUMA
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 55 YR