BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    OCTRODE

    MDR report key: 2913536 · Received December 21, 2012

    Report

    Report Number
    1627487-2012-15097
    Event Type
    Malfunction
    Date Received
    December 21, 2012
    Date of Event
    November 30, 2012
    Report Date
    November 30, 2012
    Manufacturer
    ST. JUDE MEDICAL - NEUROMODULATION
    Product Code
    LGW
    PMA / PMN Number
    P010032
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    TX, US
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

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

    Description of Event or Problem · 1

    IT WAS REPORTED THE PHYSICIAN ATTEMPTED TO ADD AN ADDITIONAL SCS LEAD BECAUSE THE PATIENT WAS NOT RECEIVING EFFECTIVE STIMULATION. THE PHYSICIAN WAS UNABLE TO OBTAIN CORRECT LEAD PLACEMENT. NO ADDITIONAL INFORMATION IS AVAILABLE AT THIS TIME.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 OCTRODE SCS LEAD LGW ST. JUDE MEDICAL - NEUROMODULATION 3186 3511162

    Patients

    Seq Age Sex Outcome Treatment
    1 76 YR Required Intervention IMPLANT DATE:| IMPLANT DATE:| IMPLANT DATE:| SCS LEAD, MODEL 3186| SCS EXTENSION: MODEL 3383| SCS IPG: MODEL 3688| IMPLANT DATE:| SCS ANCHOR, MODEL 1192