Appendix A; Precision Spectra™ Imageready™ Mri Head Only Patient Eligibility - Boston Scientific ImageReady Mode D'emploi

Appendix A

Appendix A
Precision Spectra™ ImageReady™ MRI Head Only Patient Eligibility
This form provides information about the patient's implanted Precision Spectra Spinal Cord Stimulator System and MRI head
scan eligibility. It may be provided to the radiologist to support the confirmation of the patient's scan.
• Prior to performing and MRI Head Scan, confirm that the patient's stimulation is OFF
• Refer to www.controlyourpain.com/dfu for labeling and safety conditions
Patient Name:
Physician Name,
Office, Address
Phone:
A. MR Conditional Precision Spectra System Information
Implantable Pulse Generator (IPG)
1.
• Precision Spectra IPG, 32-Contact IPG
• Precision IPG, 16-Contact IPG
• Other IPG______________________________________
2. Percutaneous and/or surgical paddle leads (check all that apply)
• Linear Lead, 8-contact lead, 30 cm
• Linear Lead, 8-Contact lead, 50 cm
• Linear ST Lead, 8-Contact Lead, 30 cm
• Linear ST Lead, 8-Contact Lead, 50 cm
• Linear 3-4 Lead, 8-Contact Lead, 50 cm
• Linear 3-6 Lead, 8-Contact Lead, 50 cm
• Artisan Paddle Lead, 16-Contact Paddle, 50 cm
• CoverEdge 32 Paddle Lead, 32-Contact Paddle, 50 cm
• CoverEdge X 32 Paddle Lead, 32-Contact Paddle, 50 cm
• Infinion Lead, 16-Contact Lead, 50 cm or 70 cm
• Leads longer than 50 cm, other leads, Adapters, Extensions, or Splitters:
3. Surgical Accessories (check all that apply)
• Clik Anchor
• Clik X Anchor
• Med-A
• Silicone Suture Sleeves
• Other:__________________________________________
Note: Leads should be connected directly into the IPG, Patient should not be implanted with lead extensions, splitters, or adapters.
ImageReady™ MRI Guidelines for Precision Spectra™ Spinal Cord Stimulator System
91061672-02 Rev A 16 of 397
Date:
Model # MRI Eligible
□
SC-1132
SC-1110-xx
See Precision SCS System
1.5T MRI Guidelines
□
SC-2158-30
□
SC-2158-50
□
SC-2218-30
□
SC-2218-50
□
SC-2352-50
□
SC-2366-50
□
SC-8216-50
□
SC-8336-50
□
SC-8352-50
SC-2316-xx
□
SC-4316
□
SC-4318
□
SC-4320
□
Not MRI
Eligible
□
□
□