inforMED
DeathPML

MIS TI CFX FEN POLY 7X45

Received Nov 17, 2021 · Event occurred Sep 15, 2021

Report 1526439-2021-02428 · MDR key 12830212

Device

Generic name

Bone Cement, Posterior Screw Augmentation

Manufacturer

Depuy Spine Inc

Catalog number

186727745S

Product problems

  • Adverse Event Without Identified Device or Use Problem
  • Adverse Event Without Identified Device or Use Problem

Patient

75 YR · Female

  • Insufficient Information
  • Insufficient Information

Narrative

Description of Event or Problem

IT WAS REPORTED THAT DURING A LUMBAR SPINAL REVISION ON (B)(6) 2021, THE PATIENT PASSED AWAY. THE PROCEDURE WAS INTENDED TO REVISE A T12-L5 CONSTRUCT AND EXTEND THE CONSTRUCT TO T9. THE REVISION WAS TO ADDRESS SCREW PULL OUT ON THE RIGHT SIDE OF T12 AND L1. THE PATIENT HAD PREVIOUS LUMBAR SURGERIES. RADIOGRAPHS INDICATED THE PATIENT MAY HAVE ANTERIOR LUMBAR INTERBODY FUSIONS (ALIFS) AND POSTERIOR FIXATION FROM L2-L5 WITH THE CLICK-X SYSTEM. A SUBSEQUENT SURGERY EXTENDED THE CONSTRUCT TWO ADDITIONAL LEVELS TO T12. IN THIS PROCEDURE, THE SURGEON DECIDED TO EXTEND THE CONSTRUCT THREE ADDITIONAL LEVELS TO T9 AND TO AUGMENT THE VERTEBRAL BODIES WITH CONFIDENCE CEMENT VIA VIPER FENESTRATED SCREWS. EACH LEVEL RECEIVED ABOUT 4-5 CC OF CEMENT (~2 CC PER SCREW). TOTAL CEMENT USED IS APPROXIMATELY 15 CC. THE PROCEDURE WENT AS PLANNED. THE WOUND CLOSURE PROCESS WAS ALMOST COMPLETE, WHEN THE PATIENT WENT INTO CARDIAC ARREST AND DIED. THIS REPORT IS FOR A MIS TI CFX FEN POLY 7X45. THIS IS REPORT 9 OF 10 FOR (B)(4).

Additional Manufacturer Narrative

ADDITIONAL PROCODE: MNI. COMPLAINANT PART IS NOT EXPECTED TO BE RETURNED FOR MANUFACTURER REVIEW/INVESTIGATION. FAX NUMBER REPORTED AS (B)(6). WITHOUT A LOT NUMBER THE DEVICE HISTORY RECORDS REVIEW COULD NOT BE COMPLETED. PRODUCT WAS NOT RETURNED. BASED ON THE INFORMATION AVAILABLE, IT HAS BEEN DETERMINED THAT NO CORRECTIVE AND/OR PREVENTATIVE ACTION IS PROPOSED. THIS COMPLAINT WILL BE ACCOUNTED FOR AND MONITORED VIA POST MARKET SURVEILLANCE ACTIVITIES. IF ADDITIONAL INFORMATION IS MADE AVAILABLE, THE INVESTIGATION WILL BE UPDATED AS APPLICABLE. DEVICE WAS USED FOR TREATMENT, NOT DIAGNOSIS. IF INFORMATION IS OBTAINED THAT WAS NOT AVAILABLE FOR THE INITIAL MEDWATCH, A FOLLOW-UP MEDWATCH WILL BE FILED AS APPROPRIATE.