title: Spinal devices in the United States-investigational device exemption trials and premarket approval of class III devices.
abstract: Recently, there has been increased public awareness of regulatory actions by the United States Food and Drug Administration (FDA) on spinal devices. There has also been increased scrutiny of the pivotal clinical trials of these devices.
  
  
  
  To investigate the premarket approval (PMA) of class III spinal devices in the United States since the turn of the century. To explore clinically relevant issues that affect the interpretation of investigational device exemption trials.
  
  
  
  Literature review.
  
  
  
  From 2000 to 2015, data on PMA applications for spinal devices were obtained from two sources. First, meetings of FDA's Orthopaedic and Rehabilitation Devices Panel were identified from the Federal Register. Second, the FDA database of approved PMA applications was queried. For each device, two authors reviewed all archival data. There was no external source of funding.
  
  
  
  Twenty-one devices met the study criteria. There were 76.2% that received approval and 47.6% that went to panel. Arthroplasty devices were most common (52.4%), least likely to go to panel (3 of 11), and most likely to be approved after panel (3 of 3). Biologic devices were most likely to go to panel (3 of 3) and least likely to be approved after panel (1 of 3). Before and after 2009, there was no decrease in the number of spinal devices approved. All 21 devices were studied in a pivotal clinical trial. All trials except one were randomized controlled trials, and all trials except one were two-arm noninferiority designs.
  
  
  
  There has been no decrease in the number of new FDA-approved class III spinal devices since the turn of the century. The majority of devices have been for cervical arthroplasty. By contrast, biologic devices were most likely to go to panel and least likely to be approved after panel. The pivotal trials for nearly all devices were randomized, two-arm, noninferiority trials.
authors.affiliation: Department of Surgery, Jupiter Medical Center, Palm Beach, FL, USA. Electronic address: ray@golish.com.
authors.forename: S Raymond
authors.initials: SR
authors.lastname: Golish
authors.affiliation: North American Spine Foundation, Jupiter, FL, USA.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Reed
mesh_terms: D001178:Arthroplasty / Q000295:instrumentation; D002986:Clinical Trials as Topic / Q000592:standards*; D018795:Device Approval / Q000592:standards*; D006801:Humans; D009983:Orthopedic Equipment / Q000191:economics / Q000592:standards* / Q000706:statistics & numerical data; D014481:United States
keywords: Class III device; Investigation device exemption; Noninferiority trial; Premarket approval; Randomized clinical trial; Spinal device