BEUDAMED
    FDA Adverse Event Injury Summary report: N

    DUAL EXTENSION

    MDR report key: 2892937 · Received December 28, 2012

    Report

    Report Number
    1627487-2012-12861
    Event Type
    Injury
    Date Received
    December 28, 2012
    Date of Event
    November 4, 2012
    Report Date
    December 4, 2012
    Manufacturer
    ST. JUDE MEDICAL - NEUROMODULATION
    Product Code
    LGW
    PMA / PMN Number
    P010032
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    TX, US
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

    SJM HAS LIMITED INFO RELATED TO THE PT'S MEDICAL HISTORY AND IS UNABLE TO FORM AN OPINION AS TO THE RELEVANCY OF THE PT'S HISTORY TO THE EVENT REPORTED. SJM DEFERS TO THE PT'S PHYSICIAN REGARDING MEDICAL HISTORY.

    Description of Event or Problem · 1

    DEVICE 1 OF 2. REFERENCE MFR REPORT # 1627487-2012-12862. IT WAS REPORTED THE PT EXPERIENCED PAIN AT THE EXTENSION SITE. THE PT WILL MEET WITH A DIFFERENT PAIN PHYSICIAN FOR A CONSULTATION. NOTE: THE PT RECEIVED TWO MODELS OF EXTRUSIONS. BOTH ARE BEING REPORTED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 DUAL EXTENSION SCS EXTENSION LGW ST. JUDE MEDICAL - NEUROMODULATION 3343 176408

    Patients

    Seq Age Sex Outcome Treatment
    1 51 YR Required Intervention IMPLANT:| IMPLANT:| SCS IPG: MODEL 3788| SCS LEAD: MODEL 3163| SCS LEAD: MODEL 3186| IMPLANT: