Pedicle Screw System

K201751 · Black Box Medical, LLC · NKB · Jul 22, 2020 · Orthopedic

Device Facts

• Record ID: K201751
• Device Name: Pedicle Screw System
• Applicant: Black Box Medical, LLC
• Product Code: NKB · Orthopedic
• Decision Date: Jul 22, 2020
• Decision: SESE
• Submission Type: Special
• Regulation: 21 CFR 888.3070
• Device Class: Class 2
• Attributes: Therapeutic

Intended Use

The Pedicle Screw System is intended to provide immobilization of spinal segments in skeletally mature patients as an adjunct to fusion in the treatment of the following acute and chronic instabilities of thoracic, lumbar, and sacral spine: degenerative disc disease (DDD) (defined as back pain of discogenic origin with degeneration of the disc confirmed by history and radiographic studies); spondylolisthesis; trauma (i.e., fracture or dislocation); spinal stenosis; tumor; pseudoarthrosis; and failed previous fusion.

Device Story

Pedicle Screw System provides spinal immobilization and stabilization; used as adjunct to fusion in thoracic, lumbar, and sacral spine. Components include longitudinal rods, polyaxial screws, and transverse connectors. Implanted by surgeons in clinical settings to treat acute/chronic instabilities including DDD, spondylolisthesis, trauma, stenosis, tumor, pseudoarthrosis, and failed fusion. Device functions as mechanical fixation system to stabilize spinal segments during fusion process; provides structural support to facilitate bone healing. No electronic, software, or algorithmic components.

Clinical Evidence

No clinical data. Bench testing not required as design changes were previously cleared under K181554.

Technological Characteristics

System consists of longitudinal rods, polyaxial screws, and transverse connectors. Material: Ti-6Al-4V alloy conforming to ASTM F136. Mechanical fixation device; no energy source, software, or connectivity.

Indications for Use

Indicated for skeletally mature patients requiring spinal immobilization as an adjunct to fusion for thoracic, lumbar, and sacral spine conditions including DDD, spondylolisthesis, trauma, spinal stenosis, tumor, pseudoarthrosis, and failed previous fusion.

Regulatory Classification

Identification

(1) Rigid pedicle screw systems are comprised of multiple components, made from a variety of materials that allow the surgeon to build an implant system to fit the patient's anatomical and physiological requirements. Such a spinal implant assembly consists of a combination of screws, longitudinal members (e.g., plates, rods including dual diameter rods, plate/rod combinations), transverse or cross connectors, and interconnection mechanisms (e.g., rod-to-rod connectors, offset connectors).(2) Semi-rigid systems are defined as systems that contain one or more of the following features (including but not limited to): Non-uniform longitudinal elements, or features that allow more motion or flexibility compared to rigid systems.

Special Controls

*Classification.* (1) Class II (special controls), when intended to provide immobilization and stabilization of spinal segments in skeletally mature patients as an adjunct to fusion in the treatment of the following acute and chronic instabilities or deformities of the thoracic, lumbar, and sacral spine: severe spondylolisthesis (grades 3 and 4) of the L5-S1 vertebra; degenerative spondylolisthesis with objective evidence of neurologic impairment; fracture; dislocation; scoliosis; kyphosis; spinal tumor; and failed previous fusion (pseudarthrosis). These pedicle screw spinal systems must comply with the following special controls:(i) Compliance with material standards; (ii) Compliance with mechanical testing standards; (iii) Compliance with biocompatibility standards; and (iv) Labeling that contains these two statements in addition to other appropriate labeling information: “Warning: The safety and effectiveness of pedicle screw spinal systems have been established only for spinal conditions with significant mechanical instability or deformity requiring fusion with instrumentation. These conditions are significant mechanical instability or deformity of the thoracic, lumbar, and sacral spine secondary to severe spondylolisthesis (grades 3 and 4) of the L5-S1 vertebra, degenerative spondylolisthesis with objective evidence of neurologic impairment, fracture, dislocation, scoliosis, kyphosis, spinal tumor, and failed previous fusion (pseudarthrosis). The safety and effectiveness of these devices for any other conditions are unknown.” “Precaution: The implantation of pedicle screw spinal systems should be performed only by experienced spinal surgeons with specific training in the use of this pedicle screw spinal system because this is a technically demanding procedure presenting a risk of serious injury to the patient.” (2) Class II (special controls), when a rigid pedicle screw system is intended to provide immobilization and stabilization of spinal segments in the thoracic, lumbar, and sacral spine as an adjunct to fusion in the treatment of degenerative disc disease and spondylolisthesis other than either severe spondylolisthesis (grades 3 and 4) at L5-S1 or degenerative spondylolisthesis with objective evidence of neurologic impairment. These pedicle screw systems must comply with the following special controls: (i) The design characteristics of the device, including engineering schematics, must ensure that the geometry and material composition are consistent with the intended use. (ii) Non-clinical performance testing must demonstrate the mechanical function and durability of the implant. (iii) Device components must be demonstrated to be biocompatible. (iv) Validation testing must demonstrate the cleanliness and sterility of, or the ability to clean and sterilize, the device components and device-specific instruments. (v) Labeling must include the following: (A) A clear description of the technological features of the device including identification of device materials and the principles of device operation; (B) Intended use and indications for use, including levels of fixation; (C) Identification of magnetic resonance (MR) compatibility status; (D) Cleaning and sterilization instructions for devices and instruments that are provided non-sterile to the end user; and (E) Detailed instructions of each surgical step, including device removal. (3) Class II (special controls), when a semi-rigid system is intended to provide immobilization and stabilization of spinal segments in the thoracic, lumbar, and sacral spine as an adjunct to fusion for any indication. In addition to complying with the special controls in paragraphs (b)(2)(i) through (v) of this section, these pedicle screw systems must comply with the following special controls: (i) Demonstration that clinical performance characteristics of the device support the intended use of the product, including assessment of fusion compared to a clinically acceptable fusion rate. (ii) Semi-rigid systems marketed prior to the effective date of this reclassification must submit an amendment to their previously cleared premarket notification (510(k)) demonstrating compliance with the special controls in paragraphs (b)(2)(i) through (v) and paragraph (b)(3)(i) of this section.

Predicate Devices

• Stowe Pedicle Screw System (K181554)

Submission Summary (Full Text)

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Black Box Medical LLC % Mr. Daniel Lanois Principal Consultant SurgOp Support LLC 101 Lamond Ct Prosper, Texas 75078

Re: K201751

Trade/Device Name: Pedicle Screw System Regulation Number: 21 CFR 888.3070 Regulation Name: Thoracolumbosacral Pedicle Screw System Regulatory Class: Class II Product Code: NKB Dated: June 23, 2020 Received: June 26, 2020

Dear Mr. Lanois:

We have reviewed vour Section 510(k) premarket notification of intent to market the device referenced above 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. Although this letter refers to your product as a device, please be aware that some cleared products may instead be combination products. The 510(k) Premarket Notification Database located at https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmp/pmn.cfm_identifies_combination product submissions. 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. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to 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

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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); medical device reporting of medical device-related adverse events) (21 CFR 803) for devices or postmarketing safety reporting (21 CFR 4, Subpart B) for combination products (see https://www.fda.gov/combination-products/guidance-regulatory-information/postmarketing-safety-reportingcombination-products); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820) for devices or current good manufacturing practices (21 CFR 4, Subpart A) for combination products; and, if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21 CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to https://www.fda.gov/medical-device-safety/medical-device-reportingmdr-how-report-medical-device-problems.

For comprehensive regulatory information about mediation-emitting products, including information about labeling regulations, please see Device (https://www.fda.gov/medicaldevices/device-advice-comprehensive-regulatory-assistance)and CDRH Learn (https://www.fda.gov/training-and-continuing-education/cdrh-learn). Additionally, you may contact the Division of Industry and Consumer Education (DICE) to ask a question about a specific regulatory topic. See the DICE website (https://www.fda.gov/medical-device-advice-comprehensive-regulatoryassistance/contact-us-division-industry-and-consumer-education-dice) for more information or contact DICE by email ([e-mail]) or phone [phone] or 301-796-7100).

Sincerely,

for

Colin O'Neill. M.B.E. Acting Assistant Director DHT6B: Division of Spinal Devices OHT6: Office of Orthopedic Devices Office of Product Evaluation and Quality Center for Devices and Radiological Health

Enclosure

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# Indications for Use

510(k) Number (if known)

K201751

Device Name Pedicle Screw System

#### Indications for Use (Describe)

The Pedicle Screw System is intended to provide immobilization of spinal segments in skeletally mature patients as an adjunct to fusion in the treatment of the following acute and chronic instabilities of thoracic, lumbar, and sacral spine: degenerative disc disease (DDD) (defined as back pain of discogenic origin with degeneration of the disc confirmed by history and radiographic studies); spondylolisthesis; trauma (i.e., fracture or dislocation); spinal stenosis; tumor; pseudoarthrosis; and failed previous fusion.

Type of Use (Select one or both, as applicable)

| <span></span> | <label><input checked="" type="checkbox"/> Prescription Use (Part 21 CFR 801 Subpart D)</label> |
|---------------|-------------------------------------------------------------------------------------------------|
| <span></span> | <label><input type="checkbox"/> Over-The-Counter Use (21 CFR 801 Subpart C)</label> |

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| Date Prepared | July 21, 2020 | |
|-----------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------|
| Manufacturer | Black Box Medical LLC | |
| Address | 4516 East County Road 45, Midland, Texas 79705 | |
| Telephone | [phone] | |
| Fax | | |
| Contact Person | Daniel Lanois | |
| | Consultant | |
| Address | SurgOp Support LLC | |
| | 101 Lamond Ct, Prosper, TX 75078 | |
| Telephone | 678-371-3605 | |
| Fax | | |
| Email | [e-mail] | |
| Trade Name | Pedicle Screw System | |
| Common Name | Posterior Pedicle Screw System | |
| Panel Code | Orthopedic/87 | |
| Classification Name | Thoracolumbosacral pedicle screw system | |
| Class | Class II | |
| Regulation Number | 21 CFR 888.3070 | |
| Product Code | NKB | |
| Name of Predicate Device(s) | 510(k) # | Applicant |
| Stowe Pedicle Screw System | K181554 | Black Box Medical |
| Description | The Pedicle Screw System consists of longitudinal rods, polyaxial<br>screws, and transverse connectors. It is manufactured from Ti-6Al-<br>4V alloy conforming to ASTM F136. | |
| Indications for Use | The Pedicle Screw System is intended to provide immobilization<br>and stabilization of spinal segments in skeletally mature patients as<br>an adjunct to fusion in the treatment of the following acute and<br>chronic instabilities or deformities of thoracic, lumbar, and sacral<br>spine: degenerative disc disease (DDD) (defined as back pain of<br>discogenic origin with degeneration of the disc confirmed by history<br>and radiographic studies); spondylolisthesis; trauma (i.e., fracture<br>or dislocation); spinal stenosis; tumor; pseudoarthrosis; and failed<br>previous fusion. | |
| Technological<br>Characteristics/<br>Substantial<br>Equivalence | Documentation was provided to demonstrate that the Subject<br>device, is substantially equivalent to the Predicates. The Subject<br>device is substantially equivalent to the Predicate device in intended | |
| | use, indications for use, materials, technological characteristics, and<br>labeling. | |
| Performance<br>Data | Performance data is not included in this submission. The design<br>changes being included for review are the same changes<br>implemented and approved under K181554. No additional changes<br>have been made for this submission that would require additional<br>performance testing. | |
| Conclusion | Based on the intended use, indications for use, technological<br>characteristics, materials, and comparison to Predicate devices, the<br>Subject device has been determined to be substantially equivalent<br>to legally marketed Predicate devices. | |

## 510(k) Summary (as required by 21 CFR 807.92)

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