Appendix A; Spectra Wavewriter Imageready Mri Head Only Patient Eligibility - Boston Scientific Spectra WaveWriter Mode D'emploi

Appendix A

Appendix A

Spectra WaveWriter ImageReady MRI Head Only Patient Eligibility

This form provides information about the patient's implanted Spectra WaveWriter SCS 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 therapy is OFF
• Refer to www.bostonscientific-elabeling.com for labeling and safety conditions
Patient Name:
Physician Name,
Office, Address
Phone:
A. MR Conditional Spectra WaveWriter SCS System Information
Implantable Pulse Generator (IPG)
1.
• Spectra WaveWriter IPG, 32-Contact IPG
• Other IPG______________________________________
Percutaneous and/or surgical paddle Leads (check all that apply)
2.
• 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 Spectra WaveWriter Spinal Cord Stimulator System
92089820-04 16 of 397
Date:
Model # MRI Eligible
□
SC-1160
□
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
□
□
□