Lumbar subcutaneous shunt

# Guidance
Current evidence on the safety and efficacy of lumbar subcutaneous shunt does not appear adequate for this procedure to be used without special arrangements for consent and for audit or research.
Clinicians wishing to undertake lumbar subcutaneous shunt should take the following actions.
Inform the clinical governance leads in their Trusts.
Ensure that patients understand the uncertainty about the procedure's safety and efficacy and provide them with clear written information. Use of the Institute's information for the public is recommended.
Audit and review clinical outcomes of all patients having lumbar subcutaneous shunt.
Publication of safety and efficacy outcomes will be useful in reducing the current uncertainty. The Institute may review the procedure upon publication of further evidence.# The procedure

# Indications
This procedure is used to treat communicating hydrocephalus (normal pressure hydrocephalus) and benign intracranial hypertension (pseudotumour cerebri).
Communicating hydrocephalus is an uncommon condition caused by excess cerebrospinal fluid collecting in the subarachnoid space. Causes include congenital abnormality, brain haemorrhage and meningitis, but in some cases, no cause is found. The symptoms include confusion, gait disturbance and urinary incontinence. Untreated, the condition may cause brain damage or death.
Benign intracranial hypertension is an uncommon condition of unknown cause, in which the pressure of the cerebrospinal fluid is increased. The symptoms include headache, dizziness and visual problems. The prognosis is generally good, although a few people may experience permanent visual loss.

# Outline of the procedure
A cerebrospinal fluid shunt is a system of valved tubes that carries cerebrospinal fluid from the subarachnoid space to another part of the body to drain it and prevent damage to the brain or eyes. Usually, a shunt is tunnelled under the skin, with the upper end in a cerebral ventricle and the lower end in the heart (ventriculoatrial shunt) or in the peritoneum (ventriculoperitoneal shunt). Alternatively, the upper end of the shunt may be placed in the subarachnoid space in the lumbar part of the back, with the lower end draining fluid into the peritoneum (lumbarperitoneal shunt).
A lumbar subcutaneous shunt differs from the types of shunt described in section 2.2.1 in that the cerebrospinal fluid drains into the space immediately under the skin. A narrow tube is inserted percutaneously into the subarachnoid space in the lumbar part of the back and is tunnelled under the skin to a site where fluid can drain, usually in the flank or abdomen. The advantage is that general anaesthetic is not required, unlike for other shunt procedures.

# Efficacy
No studies reporting efficacy outcomes of lumbar subcutaneous shunt were identified.
The Specialist Advisors noted that this procedure is only being undertaken by one surgeon in the UK. One Advisor was unsure about the efficacy of the procedure because the subcutaneous tissues do not absorb cerebrospinal fluid; however, data are being collected to investigate this.

# Safety
No studies reporting safety outcomes of lumbar subcutaneous shunt were identified.
One Specialist Advisor considered the main potential adverse effects of the procedure to be infection, subdural haematoma and irritation of nerve roots.# Further information
The surgeon who has been carrying out this procedure has been collecting data for several years on patients who have undergone the procedure, but there have been no publications to date.
Andrew DillonChief ExecutiveJune 2004

# Sources of evidence
The evidence considered by the Interventional Procedures Advisory Committee is described in the following document.
'Interventional procedure overview of lumbar subcutaneous shunt', December 2002.

# Information for the public
NICE has produced information on this procedure for patients and carers. It explains the nature of the procedure and the guidance issued by NICE, and has been written with patient consent in mind.# Changes since publication
As part of the NICE's work programme, the current guidance was considered for review but did not meet the review criteria as set out in the IP process guide. This guidance therefore remains current.
January 2012: minor maintenance.# About this guidance
NICE interventional procedure guidance makes recommendations on the safety and efficacy of the procedure. It does not cover whether or not the NHS should fund a procedure. Funding decisions are taken by local NHS bodies after considering the clinical effectiveness of the procedure and whether it represents value for money for the NHS. It is for healthcare professionals and people using the NHS in England, Wales, Scotland and Northern Ireland, and is endorsed by Healthcare Improvement Scotland for implementation by NHSScotland.
This guidance was developed using the NICE interventional procedure guidance process.
We have produced a summary of this guidance for patients and carers. Information about the evidence it is based on is also available.
Your responsibility
This guidance represents the views of NICE and was arrived at after careful consideration of the available evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
Copyright
 National Institute for Health and Clinical Excellence 2004. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.
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