LASER ENDOSCOPIC DECOMPRESSION KIT, MODEL 1100, AND PERCUTANEOUS DISCECTOMY KIT, MODEL 1120

K040424 · Clarus Medical, LLC · GEX · May 11, 2004 · General, Plastic Surgery

Device Facts

• Record ID: K040424
• Device Name: LASER ENDOSCOPIC DECOMPRESSION KIT, MODEL 1100, AND PERCUTANEOUS DISCECTOMY KIT, MODEL 1120
• Applicant: Clarus Medical, LLC
• Product Code: GEX · General, Plastic Surgery
• Decision Date: May 11, 2004
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 878.4810
• Device Class: Class 2
• Attributes: Therapeutic

Intended Use

The Clarus Model 1100 Laser Endoscopic Decompression Kit is intended to be used on patients with contained lumbar or cervical disc herniations or bulges. This is a identical, with the addition of cervical, to the predicate device, Model 1100 Laser Endoscopic Decompression Kit (K922881)

Device Story

Kit provides instruments for endoscopic laser disc decompression; includes deflectable endoscope, fixed laser fiber, flexible trocar, cannulas, dilators, trephine, obturator, measuring scale, marking pen, and scalpel. Used by physicians in clinical settings for visualization and laser surgical removal of inner disc material. Device enables minimally invasive access to spine; shortened working length compared to predicate allows cervical application. Output is visual field for surgeon and laser energy for tissue ablation; aids in decompression of herniated or bulging discs.

Clinical Evidence

No clinical data provided; substantial equivalence based on design, material, and intended use similarity to previously cleared predicate devices.

Technological Characteristics

Stainless steel cannulas, dilators, and trephine with molded plastic proximal ends. Deflectable endoscope with fixed laser fiber. System includes manual surgical instruments. Sterilization is identical to predicate. No software or electronic sensing/actuation described.

Indications for Use

Indicated for laser disc decompression in lumbar and cervical spine regions for patients with contained disc herniations or bulges; used to remove inner disc material.

Regulatory Classification

Identification

(1) A carbon dioxide laser for use in general surgery and in dermatology is a laser device intended to cut, destroy, or remove tissue by light energy emitted by carbon dioxide.(2) An argon laser for use in dermatology is a laser device intended to destroy or coagulate tissue by light energy emitted by argon.

Predicate Devices

• Model 1100 Laser Endoscopic Decompression Kit (K922881)
• Model 2180 Spinescope Endoscope (K011454)
• Model 1150 Laser Fiber (K022610)

Submission Summary (Full Text)

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MAY 11 2004

Section 4

# 510(k) Summary

## General Information:

| Submitted by: | | Clarus Medical, LLC<br>1000 Boone Avenue North<br>Minneapolis, MN 55427 | | |
|----------------------|----------------------------------------------------------------------------|-------------------------------------------------------------------------|--|--|
| Contact: | Tom Barthel, President<br>Telephone [phone]<br>Facsimile 763-525-8656 | | | |
| Summary Date | February 4, 2004 | | | |
| Device Name: | Model 1100 Laser Endoscopic Decompression Kit | | | |
| Common Name: | Spinal endoscope w/ laser fiber. | | | |
| Classification Name: | Laser Instrument, Surgical, Powered; 878.4810 | | | |

### Predicate Devices:

| 510(k) | Description | Manufacturer |
|---------|-----------------------------------------------|---------------------|
| K922881 | Model 1100 Laser Endoscopic Decompression Kit | Clarus Medical, LLC |
| K011454 | Model 2180 Spinescope Endoscope | Clarus Medical, LLC |
| K022610 | Model 1150 Laser Fiber | Clarus Medical, LLC |

### Intended Use:

The Clarus Model 1100 Laser Endoscopic Decompression Kit is intended to be used on patients with contained lumbar or cervical disc herniations or bulges. This is a identical, with the addition of cervical, to the predicate device, Model 1100 Laser Endoscopic Decompression Kit (K922881)

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# K040424 2/2

#### Device Description:

#### General

This 510(k) submission is a modification of the existing Clarus Model 1100 Laser Endoscopic Decompression Kit, previously filed as K922881, and found to be substantially equivalent by the FDA on November 16, 1992. The K922881 510(k) device is intended for lumbar disc decompression in the spine. The modifications, represented by this submission, is the addition of cervical indications.

The Clarus Model 1100 Laser Endoscopic Decompression Kit intended use is to be endoscopic laser decompression of discs in the spine (lumbar and cervical). The kit consists of components necessary for endoscopic laser surgery where visualization and laser surgical techniques are required. The Model 1100 consists of a deflectable endoscope with a fixed laser fiber, a flexible trocar, straight and curved cannulas with dilators, a trephine and obturator, a measuring scale, a skin marking pen, and a scalpel. The cervical LASE is identical to the Clarus Model 2180 Spinescope (previously cleared for cervical visualization, K011454) with a shorter working length and the addition of a fixed laser fiber. The fixed laser fiber is identical to Clarus Model 1150 Laser Fiber (previously cleared for cervical soft tissue, K022610).

Construction

The Clarus Model 1100 Laser Endoscopic Decompression Kit, contain the same items, and are manufactured, packaged, and sterilized identically, with one exception, to the device which have been previously filed with FDA under 510(k) application K922881 and found to be equivalent. This exception is that the working length of the device is being shortened for cervical applications. The cannulas, trocars, dilators, and trephine will likewise be changed to accommodate the working length of the device

As with the previous kits, the main components, (the endoscope, cannulas, and dilators) are manufactured by Clarus. The other individual components have been selected by Clarus to offer the user a comprehensive set of instruments for endoscopic laser disc decompression.

The cannulas and dilators are manufactured of stainless steel with a molded plastic proximal end. The trephine (coring needle) is of similar construction as well. These materials are standard to the industry for surgical instruments.

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Image /page/2/Picture/1 description: The image shows the logo for the U.S. Department of Health & Human Services. The logo consists of a circular seal with the words "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" around the perimeter. Inside the circle is a stylized symbol that resembles a caduceus, a traditional symbol of medicine, but with three wavy lines instead of snakes.

Food and Drug Administration 9200 Corporate Boulevard Rockville MD 20850

MAY 1 1 2004

Mr. Tom Barthel President Clarus Medical, LLC 1000 Boone Avenue North Minneapolis, Minnesota 55427

Re: K040424

Trade/Device Name: Model 1100 Laser Endoscopic Decompression Kit Regulation Number: 21 CFR 878.4810 Regulation Name: Laser surgical instrument for use in general and plastic surgery and in dermatology Regulatory Class: II Product Code: GEX Dated: February 17, 2004 Received: February 18, 2004

Dear Mr. Barthel:

We have reviewed your Section 510(k) premarket notification of intent to market the device wfo have and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration.

If your device is classified (sec above) into cither class II (Special Controls) or class III (PMA), it may be subject to such additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

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Page 2 - Mr. Tom Barthel

This letter will allow you to begin marketing your device as described in your Section 510(k) I mis letter will and will and on a finding of substantial equivalence of your device to a legally prematics notification: "The stassification for your device and thus, permits your device to proceed to the market.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please If you desire specific arrivation at [phone]. Also, please note the regulation entitled, Contact the Ories of Court Court Cation" (21CFR Part 807.97). You may obtain other general information on your responsibilities under the Act from the Division of Small other general international and Consumer Assistance at its toll-free number [phone] or [phone] or at its Internet address http://www.fda.gov/cdrh/dsma/dsmamain.html

Sincerely yours,

Muriam C. Provost

Celia M. Witten, Ph.D., M.D. Director Division of General, Restorative and Neurological Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

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| 10(k) Number (if known): | A 11 011 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 | |
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Model 1100 Laser Endoscopic Decompression Kit

Indications For Use:

Device Name:

The Clarus Model 1100 Laser Endoscopic Decompression Kit indicated for laser disc decompression in the lumbar and cervical regions of the spine, where the laser is used to remove inner disc material.

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Concurrence of CDRH, Office of Device Evaluation (ODE)

1 Prescription Use (Per 21 CFR 801.109)

iriam C. Provost
OR

Over-The-Counter Use_

(Division Sign-Off) Division of General, Restorative, and Neurological Devices

(Optional Format 1-2-96)

1040424 510(k) Number_