BEUDAMED
    FDA Adverse Event Injury Summary report: N

    PENTA

    MDR report key: 3052262 · Received April 4, 2013

    Report

    Report Number
    1627487-2013-02463
    Event Type
    Injury
    Date Received
    April 4, 2013
    Date of Event
    March 12, 2013
    Report Date
    March 12, 2013
    Manufacturer
    ST. JUDE MEDICAL - NEUROMODULATION
    Product Code
    LGW
    PMA / PMN Number
    P010032
    Adverse Event
    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

    THE PATIENT HAS TWO SYSTEMS (THORACIC AND OCCIPITAL). IT WAS REPORTED, THE PATIENT'S THORACIC LEAD HAD PARTIALLY PULLED OUT OF THE EPIDURAL SPACE, RESULTING IN A LOSS OF STIMULATION COVERAGE. SURGICAL INTERVENTION WILL BE UNDERTAKEN TO ADDRESS THE ISSUE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    139591 PENTA SCS LEAD LGW ST. JUDE MEDICAL - NEUROMODULATION 3228 3598227

    Patients

    Seq Age Sex Outcome Treatment
    1 44 YR Required Intervention SCS LEAD, MODEL 3149 (2)| IMPLANT DATE:| SCS IPG: MODEL 3788| IMPLANT DATE:| SCS IPG: MODEL 3788| IMPLANT DATE: