| Brand Name | PROTEGE IPG, 16-CHANNEL RECHARGEABLE |
| Common Device Name | SCS IPG |
| Manufacturer (Section D) |
| ST. JUDE MEDICAL - NEUROMODULATION (PUERTO RICO, LLC) |
| lot a interior - #2 street km 67.5 |
| santana industrial park |
| arecibo PR 00612 |
|
| Manufacturer (Section G) |
| ST. JUDE MEDICAL - NEUROMODULATION (PUERTO RICO, LLC) |
| lot a interior - #2 street km 67.5 |
| santana industrial park |
| arecibo PR 00612 |
|
| Manufacturer Contact |
|
sara
speyerer
|
| 6901 preston road |
| plano, TX 75024
|
|
9723098000
|
|
| MDR Report Key | 22947507 |
| Report Number | 3006705815-2025-06413 |
| Device Sequence Number | 9124555 |
| Product Code |
LGW
|
| UDI-Device Identifier | 05415067020833 |
| UDI-Public | (01)05415067020833(10)4992965(17)170131 |
| Combination Product (Y/N) | N |
| Initial Reporter State | IN |
| Initial Reporter Country | US |
| PMA/510(K) Number | P010032 |
| Number of Events Summarized | 1 |
| Summary Report (Y/N) | N |
| Device Implanted Year | 2016 |
| Device Explanted Year | 2025 |
| Serviced by Third Party (Y/N) | N |
| Reporter Type |
Manufacturer
|
| Report Source |
Health Professional,Company Representative |
| Initial Reporter Occupation |
Physician
|
| Type of Report
| Initial |
| Report Date (Section B) |
09/02/2025 |
| 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? |
Yes
|
| Operator of Device |
Health Professional
|
| Device Expiration Date | 01/31/2017 |
| Device Model Number | 3789 |
| Device Catalogue Number | 3789 |
| Device Lot Number | 4992965 |
| Was Device Available for Evaluation? |
No
|
| Is the Reporter a Health Professional? |
Yes
|
| Was the Report Sent to FDA? |
No
|
| Type of Report(Section G) | Thirty-Day |
| Initial Date Received by Manufacturer | 08/12/2025 |
| Initial Report FDA Received Date | 09/02/2025 |
| Was Device Evaluated by Manufacturer? (Y/N) |
No
|
| Date Device Manufactured | 02/26/2015 |
| 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 |
Concomitant Medical Products and Therapy/Usage Dates | SCS ANCHORX2.; SCS LEADX2. |
| Outcome Attributed to Adverse Event |
Other;
|
| Patient Sex | Male |
| Patient Weight | 91 KG |