MAUDE Adverse Event Report: MEDTRONIC, INC. RESTORE; STIMULATOR, SPINAL-CORD, TOTALLY IMPLANTED FOR PAIN RELIEF

Model Number	37022
Medical Device Problem Code	Migration or Expulsion of Device (1395)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	05/14/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Other relevant device(s) are: product id: 977d260, serial/lot #: (b)(4), ubd: 19-apr-2021, udi#: (b)(4) ; product id: 977d260, serial/lot #: (b)(4), ubd: 19-apr-2021, udi#: (b)(4).If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
Study article summary: the study aimed to determine the feasibility of polymodal modulation therapy in subjects with chronic intractable lower back pain with or without leg pain.The authors concluded that the results of the study confirmed the functionality, efficacy, and safety of pm-scs in a trial phase stimulation period.Reported events: 1 patient ((b)(6)) experienced lead movement that was ¿definitely¿ procedure or device related.The event severity was considered moderate and was resolved with reprogramming 1 day after the event.Additional information received from the study¿s director of research reported the lead movement was confirmed with x-ray imaging and that the event was resolved on (b)(6) 2017; reprogramming provided optimal pain relief.It was noted the event started on (b)(6) 2017.Though it was reported the event was not unanticipated, it was noted the cause of the event was not clearly determined.No further complications were reported or anticipated.Please note the first paragraph of the reported event was initially reported in regulatory report 3007566237-2017-04865, but has since been split into this separate regulatory report due to the receipt of unique identifiers involving the patient.All further information received regarding the above reported event will be reported as part of this regulatory report.

• Brand Name: RESTORE
• Common Device Name: STIMULATOR, SPINAL-CORD, TOTALLY IMPLANTED FOR PAIN RELIEF
• Manufacturer (Section D): MEDTRONIC, INC.; 8200 coral sea street ne; mounds view MN 55112
• MDR Report Key: 7335411
• Report Number: 2182208-2018-00329
• Device Sequence Number: 620527
• Product Code: LGW
• UDI-Device Identifier: 00643169513013
• UDI-Public: 00643169513013
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: P840001
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: health professional,study
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 03/13/2018

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: 37022
• Device Catalogue Number: 37022
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/11/2018
• Initial Report FDA Received Date: 03/13/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 79 YR
• Patient Weight: 86