MAUDE Adverse Event Report: BOSTON SCIENTIFIC NEUROMODULATION CORPORATION; STIMULATOR, SPINAL-CORD, TOTALLY IMPLANTED FOR PAIN RELIEF

Model Number	SC-3138-35
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Weight Changes (2607); No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	02/14/2025
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Product family: scs-extension.Upn: m365sc3138350.Model: sc-3138-35.Serial: (b)(6).Batch: 7086626.Product family: scs-adapters.Upn: m365sc9208150.Model: sc-9208-15.Serial: (b)(6).Batch: 7074145.Product family: scs-adapters.Upn: m365sc9208150.Model: sc-9208-15.Serial: (b)(6).Batch: 7073088.
Event or Problem Description
It was reported that the spinal cord stimulation (scs) system underwent a revision procedure for an unknown reason.The location of the device is currently unknown.No additional adverse patient effects were reported.No additional information was available.
Additional Manufacturer Narrative
Block b3: approximated based on the date the manufacturer became aware of the event.Additional pro code selection that applies to the indication of this device .Product family: scs-extension.Upn: m365sc3138350.Model: sc-3138-35.Serial: (b)(6).Batch: 7086626.Udi: (b)(4).Product family: scs-adapters.Upn: m365sc9208150.Model: sc-9208-15.Serial: (b)(6).Batch: 7074145.Udi: (b)(4).Product family: scs-adapters.Upn: m365sc9208150.Model: sc-9208-15.Serial: (b)(6).Batch: 7073088.Udi: (b)(4).
Event or Problem Description
It was reported that the spinal cord stimulation (scs) system underwent a revision procedure for an unknown reason.The location of the device is currently unknown.No additional adverse patient effects were reported.No additional information was available.Additional information was received that the (scs) system underwent an explant procedure because patient has lost weight.The patient was doing fine post operatively.The current location of the device remains unknown.

• Brand Name: NA
• Common Device Name: STIMULATOR, SPINAL-CORD, TOTALLY IMPLANTED FOR PAIN RELIEF
• Manufacturer (Section D): BOSTON SCIENTIFIC NEUROMODULATION CORPORATION; 25155 rye canyon loop; valencia CA 91355
• Manufacturer (Section G): BOSTON SCIENTIFIC CORPORATION; road 698, lot no. 12; dorado PR 00646 -260; * 00646-2602
• Manufacturer Contact: erik sherburne ; 25155 rye canyon loop; valencia, CA 91355 ; 7632920920
• MDR Report Key: 21546972
• Report Number: 3006630150-2025-01311
• Device Sequence Number: 12726851
• Product Code: LGW
• UDI-Device Identifier: 08714729760559
• UDI-Public: (01)08714729760559(17)260421(10)7086586(21)7086586
• Combination Product (Y/N): N
• Initial Reporter State: NC
• Initial Reporter Country: US
• PMA/510(K) Number: P030017
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2024
• Device Explanted Year: 2025
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 04/25/2025

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: Lay User/Patient
• Device Expiration Date: 04/21/2026
• Device Model Number: SC-3138-35
• Device Catalogue Number: SC-3138-35
• Device Lot Number: 7086586
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/14/2025
• Supplement Date Received by Manufacturer: 04/24/2025
• Initial Report FDA Received Date: 03/07/2025
• Supplement Report FDA Received Date: 04/25/2025
• Date Device Manufactured: 04/21/2024
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 63 YR
• Patient Sex: Male