MAUDE Adverse Event Report: BOSTON SCIENTIFIC NEUROMODULATION CORPORATION SUPERION IDS KIT; PROSTHESIS, SPINOUS PROCESS SPACER/PLATE

Model Number	102-9800
Medical Device Problem Code	Material Integrity Problem (2978)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	04/19/2023
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Analysis of the returned driver revealed that the tips of the driver were damaged and completely sheared off which was likely caused by excessive force.A product labeling review identified that the device was used per the instructions for use (ifu)/product label.Additionally, labeling states avoid application of excessive stress on instrumentation and do not force deployment or implant breakage or damage to bony structures may result among other risks associated with the procedure.Therefore, engineers concluded that the probable cause was failure to follow instructions contributed to this event.
Event or Problem Description
It was reported that during the superion indirect decompression (id) procedure, the driver tip/s broke off while pushing the dilator down and deploying the implant.The physician retrieved the broken driver pieces and completed the procedure using another driver of the same model.The patient did well post-operatively.
Additional Manufacturer Narrative
A comprehensive review of events within the quality system identified this record as requiring remediation, including reporting and submission of an initial emdr per applicable criteria.Boston scientific has opened a corrective and preventive action (capa 8647) investigation to determine the root cause for why an initial emdr was not previously submitted to the fda in accordance with boston scientifics established mdr reporting process and fda adverse event reporting requirements.Information gained through these investigation efforts will be utilized to determine root cause and implement appropriate preventive action(s), as necessary.Fields h7 and h9 were updated.Analysis of the returned driver revealed that the tips of the driver were damaged and completely sheared off which was likely caused by excessive force.A product labeling review identified that the device was used per the instructions for use (ifu)/product label.Additionally, labeling states avoid application of excessive stress on instrumentation and do not force deployment or implant breakage or damage to bony structures may result among other risks associated with the procedure.Therefore, engineers concluded that the probable cause was failure to follow instructions contributed to this event.
Event or Problem Description
It was reported that during the superion indirect decompression (id) procedure, the driver tip/s broke off while pushing the dilator down and deploying the implant.The physician retrieved the broken driver pieces and completed the procedure using another driver of the same model.The patient did well post-operatively.
Event or Problem Description
It was reported that during the superion indirect decompression (id) procedure, the driver tip/s broke off while pushing the dilator down and deploying the implant.The physician retrieved the broken driver pieces and completed the procedure using another driver of the same model.The patient did well post-operatively.
Additional Manufacturer Narrative
Correction to follow up 1 mdr in block a1.A comprehensive review of events within the quality system identified this record as requiring remediation, including reporting and submission of an initial emdr per applicable criteria.Boston scientific has opened a corrective and preventive action (capa 8647) investigation to determine the root cause for why an initial emdr was not previously submitted to the fda in accordance with boston scientifics established mdr reporting process and fda adverse event reporting requirements.Information gained through these investigation efforts will be utilized to determine root cause and implement appropriate preventive action(s), as necessary.Fields h7 and h9 were updated.Analysis of the returned driver revealed that the tips of the driver were damaged and completely sheared off which was likely caused by excessive force.The damage to the driver was sufficient to prevent functional testing.A product labeling review identified that the device was used per the instructions for use (ifu)/product label.Additionally, labeling states avoid application of excessive stress on instrumentation and do not force deployment or implant breakage or damage to bony structures may result.It also states to carefully inspect all instruments prior to and after use.Do not use an instrument that is visibly damaged.If an instrument appears damaged after use confirm that no broken fragments are retained in the patient.Therefore, engineers concluded that the probable cause was failure to follow instructions contributed to this event.

• Brand Name: SUPERION IDS KIT
• Common Device Name: PROSTHESIS, SPINOUS PROCESS SPACER/PLATE
• Manufacturer (Section D): BOSTON SCIENTIFIC NEUROMODULATION CORPORATION; 25155 rye canyon loop; valencia CA 91355
• Manufacturer (Section G): BOSTON SCIENTIFIC CORPORATION; cashel road; clonmel ; EI
• Manufacturer Contact: erik sherburne ; 25155 rye canyon loop; valencia, CA 91355 ; 7632920920
• MDR Report Key: 22178917
• Report Number: 3006630150-2025-04204
• Device Sequence Number: 8841997
• Product Code: NQO
• UDI-Device Identifier: 00884662000574
• UDI-Public: (01)00884662000574(17)280103(10)40018346
• Combination Product (Y/N): N
• Initial Reporter State: MN
• Initial Reporter Country: US
• PMA/510(K) Number: P140004
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Remedial Action: Notification
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 08/19/2025

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: 102-9800
• Device Catalogue Number: 102-9800
• Device Lot Number: 40018346
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 05/01/2023
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/19/2023
• Supplement Date Received by Manufacturer: 06/10/2025; 07/31/2025
• Initial Report FDA Received Date: 06/10/2025
• Supplement Report FDA Received Date: 06/19/2025; 08/19/2025
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 01/04/2023
• 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
• If action reported to FDA under 21 USC 360i(g), list FDA-assigned Recall Number or include a statement: Z-1972-2023
• Patient Sequence Number: 1
• Patient Sex: Unknown