The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on deep brain stimulation for Parkinson's disease.
Further recommendations have been made as part of the clinical guideline on Parkinson's disease published in June 2006. Clinical and cost-effectiveness evidence was reviewed in the development of this guideline which has led to this more specific recommendation. The IP guidance on deep brain stimulation for Parkinson's disease remains current, and should be read in conjunction with the clinical guideline.
This procedure is used to treat Parkinson's disease.
Parkinson's disease is a chronic disease of the brain characterised by gradually worsening tremor, muscle rigidity and difficulties with starting and stopping movements. The condition is usually treated with drugs. Surgery may be considered in people who have responded poorly to drugs, who have severe side-effects from medication, or who have severe fluctuations in response to drugs (on-off syndrome).
Parkinson's disease is common, affecting about 0.5% of people aged 65 to 74 and 1-2% of people aged 75 and over. Experts believe that 1 to 10% of people with Parkinson's disease might be suitable for brain surgery.
Surgery for Parkinson's disease is carried out on structures within the brain that are responsible for the modification of movements, such as the thalamus, the globus pallidus and the subthalamic nucleus. Each of these structures consists of two parts; one on the left hand side of the brain and one on the right. Surgery may be carried out on one or both sides.
Surgical treatment aims to correct the imbalance created by diminished function of the substantia nigra, the underlying abnormality in Parkinson's disease. Surgery alters, through either destruction or electrical stimulation, the function of brain nuclei - such as the thalamus, globus pallidus or subthalamus - that interact functionally with the substantia nigra. Deep brain stimulation is one form of surgery for Parkinson's disease.
This procedure involves inserting very fine needles into the brain through small holes made in the skull to determine the exact position of the nucleus, which may be different in each patient. This part of the procedure is usually carried out under local anaesthetic. Once the nucleus is identified, a permanent electrode is placed into it. Under general anaesthetic, this electrode is then connected to a pulse generator, which is implanted subcutaneously on the anterior chest wall.
Guidance development process
This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account, and specifically any special arrangements relating to the introduction of new interventional procedures. The guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.
Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. Providers should ensure that governance structures are in place to review, authorise and monitor the introduction of new devices and procedures.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.