MAUDE Adverse Event Report: MDT Puerto Rico Operations Co, Med Rel CD HORIZON® Spinal System; APPLIANCE, FIXATION, SPINAL INTERLAMINAL

Model Number	55740005540
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	Pain (1994)
Type of Reportable Event	Serious Injury
Event or Problem Description
Information was received from healthcare provider (hcp) via a manufacturer representative regarding a patient implanted with screw h aving spinal therapy for pediatric scoliosis.It was reported that patient had pain due to screw fracture causing the head and rod to lift.Implant was used in combination with johnson¿s veptr.The screw was inserted into l2.The veptr side was fixed to the rib.Since the fixation strength was lost, the damaged screw was removed and a new screw was implanted.The defective product was discarded at hospital. there were no further complications reported regarding the event.
Additional Manufacturer Narrative
B3: event date is not known.D 6a: implanted date is unknown.Medtronic submits this report to comply with fda regulations 21 cfr parts 4 and 803.Medtronic has made reasonable efforts to provide as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.Medtronic will submit a supplemental report if additional relevant information becomes known.

• Brand Name: CD HORIZON® Spinal System
• Common Device Name: APPLIANCE, FIXATION, SPINAL INTERLAMINAL
• Manufacturer (Section D): MDT Puerto Rico Operations Co, Med Rel; road 909, km. 0.4., barrio mar; humacao PR 00792
• Manufacturer (Section G): MDT Puerto Rico Operations Co, Med Rel; road 909, km. 0.4., barrio mar; humacao PR 00792
• Manufacturer Contact: justin ellis ; 1800 pyramid place; memphis, TN 38132 ; +1(763)526-5677
• MDR Report Key: 50066906
• Report Number: 2647346-2026-00409
• Device Sequence Number: 21384178
• Product Code: KWP
• UDI-Device Identifier: 00613994995391
• UDI-Public: (01)00613994995391(17)281204(10)H5651747
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K202328
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2026
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 09/07/2026

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: 55740005540
• Device Catalogue Number: 55740005540
• Device Lot Number: H5651747
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/09/2026
• Supplement Date Received by Manufacturer: 08/21/2026
• Initial Report FDA Received Date: 07/29/2026
• Supplement Report FDA Received Date: 09/07/2026
• Date Device Manufactured: 12/04/2020
• 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 Sex: Unknown