The National Institute for Health and Clinical Excellence (NICE) has issued updated guidance to the NHS in England, Wales, Scotland and Northern Ireland on stereotactic radiosurgery for trigeminal neuralgia using the gamma knife. The Interventional Procedures Advisory Committee reconsidered the procedure based on the results of a systematic review commissioned by NICE.
It replaces previous guidance on stereotactic radiosurgery for trigeminal neuralgia (gamma knife) (Interventional Procedures Guidance no.11, September 2003).
This procedure is used to treat trigeminal neuralgia.
Trigeminal neuralgia is a condition characterised by sudden bursts (paroxysms) of facial pain. These may be triggered by touch; talking; eating, or brushing teeth. The pain occurs in the areas supplied by the trigeminal nerve: the cheeks, jaw, teeth, gums, lips and, less often, around the eye or forehead. Trigeminal neuralgia is rare; the mean annual incidence is 4 per 100 000 population.
Some people with mild symptoms recover without treatment. For most people paroxysmal bursts of severe pain continue indefinitely.
The first line treatment for trigeminal neuralgia is medication. Surgery is considered for people who experience severe pain despite medication, or who have side effects from medication.
Gamma knife radiosurgery involves aiming a focused beam of radiation at the trigeminal nerve to destroy it at the point where it leaves the brain. It does not require skin incision or needle insertion. General anaesthesia is not required.
Other treatments for severe trigeminal neuralgia include: glycerol injection, which involves inserting a needle into the nerve under X ray guidance; radiofrequency radiosurgery, which involves applying short bursts of radiofrequency to the nerve through a needle; balloon microcompression, which involves inflating a balloon near the nerve. All of these are minimally invasive surgical procedures. Microvascular decompression is a more invasive procedure involving opening the skull.
X65.4 Delivery of a fraction of external beam radiotherapy NEC
Y91.8 Other specified external beam radiotherapy
Y11.7 Gamma wave destruction of organ NOC
Z03.5 Trigeminal nerve (v)
In addition the ICD-10 code G50.0 Trigeminal neuralgia is assigned, or a combination of Dagger(†) and Asterisk(*) codes B02.2† Zoster with other nervous system involvement and G53.0* Postzoster neuralgia (B02.2†). In the ICD-10 4th Edition † and * codes must appear together, sequencing depends on which is the main condition treated or investigated during the consultant episode, if this is not clear the † code is assigned before the * code.
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. However, 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.
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.
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.