MGH Psychiatric Neurosurgery Committee

Emad N. Eskandar MD and G. Rees Cosgrove, M.D., F.R.C.S. (C.)
Department of Neurosurgery
Massachusetts General Hospital

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Massachusetts General Hospital performs a limbic system surgery called bilateral stereotactic cingulotomy. The primary indications for this procedure is medically intractable obsessive compulsive disorder. Certain patients with chronic pain syndromes and refractory depression may also be candidates for this procedure.

This operation is an adjunct to and not a substitute for, ongoing psychiatric care. Hence, we require that the patient be referred by a letter from the treating psychiatrist. The letter should summarize the patient's history including the various treatments which have been tried. It should also provide evidence that (a) the patient has had all reasonable forms of non-operative treatment without benefit and (b) that the psychiatrist continue post-operative psychiatric care and supervision for as long as necessary. The patient and a close family member must give consent to the operation.

We are eager to be helpful to patients with obsessive-compulsive disorders, but it is our policy that those patients with obsessive and ritualistic behaviors have an adequate trial of exposure and response prevention behavior therapy before they are accepted for evaluation and that they are prepared to undergo similar behavioral therapy post-operatively.

A copy of the Behavior Therapy Guidelines for OCD is available by contacting the MGH Psychiatric Neurosurgery Committee at the address below. If a patient has undergone such a trial, psychiatric records describing the type of therapy and the response to it should be supplied. But if the patient has not had this trial, it should be emphasized that this is an essential part of the treatment for OCD, that it has been proven to be as effective as medication and that ordinarily, both behavior therapy and medication must be used simultaneously (before operation and after operation) to help patients badly afflicted with OCD.

Before a patient can be considered for cingulotomy at MGH, a referring physcian's form for cingulotomy needs to be completed. It can be obtained from the MGH Psychiatric Neurosurgery Committee at the address below. It should be returned with pertinent copies of hospital and treatment records.

After all of this necessary information is received, it will be reviewed by the MGH Psychiatric Neurosurgery Committee which consists of three MGH psychiatrists, two neurosurgeons and two neurologist. This Committee meets once a month and reviews the submitted information. The committee may decide: 1. That the patient is a suitable candidate for cingulotomy or 2. That further information is needed to clarify the diagnosis and need for operation or 3. Additional non-operative treatment would be helpful or 4. That, regrettably, the patient is not a suitable candidate for surgery. The treating psychiatrist will be informed of the Committee's decision by one of the committee members.

If the patient is considered to be a possible candidate, he/she will be seen and interviewed by one psychiatrist, one neurosurgeon, and one neurologist. This evaluation is concerned with being certain about the diagnosis and that the patient and his/her family are fully informed about the risks and possible benefits of surgical intervention. On rare occasions, these interviews yield further information that causes the patient to be rejected for cingulotomy.

An review of our recent experience with stereotactic cingulotomy is found in the following peer-reviewed, published manuscript [Am J Psychiatry. 2002 Feb;159(2):269-75.]:

Prospective long-term follow-up of 44 patients who received cingulotomy for treatment-refractory obsessive-compulsive disorder.

Dougherty DD, Baer L, Cosgrove GR, Cassem EH, Price BH, Nierenberg AA, Jenike MA, Rauch SL.

Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, USA.

OBJECTIVE: Long-term outcome associated with cingulotomy for obsessive-compulsive disorder (OCD) was prospectively assessed. Findings are reported for 18 patients previously described in 1995 and for 26 new patients. METHOD: An open preoperative and follow-up assessment was conducted at multiple time points for 44 patients undergoing one or more cingulotomies for treatment-refractory OCD. The patients were assessed by using the Structured Clinical Interview for DSM-III-R preoperatively and with the Yale-Brown Obsessive Compulsive Scale, the Beck Depression Inventory, and the Sickness Impact Profile both preoperatively and at all follow-up assessments. The patients completed clinical global improvement scales at all follow-up assessments. RESULTS: At mean follow-up of 32 months after one or more cingulotomies, 14 patients (32%) met criteria for treatment response and six others (14%) were partial responders. Thus, 20 patients (45%) were at least partial responders at long-term follow-up after one or more cingulotomies. Few adverse effects were reported. CONCLUSIONS: Thirty-two percent to 45% of patients previously unresponsive to medication and behavioral treatments for OCD were at least partly improved after cingulotomy. Cingulotomy remains a viable treatment option for patients with severe treatment-refractory OCD.

Dougherty DD, Baer L, Cosgrove GR, Cassem EH, Price BH, Nierenberg AA, Jenike MA, Rauch SL. Prospective long-term follow-up of 44 patients who received cingulotomy for treatment-refractory obsessive-compulsive disorder. Am J Psychiatry. 2002 Feb;159(2):269-75.

See also an overview of the history and current state of Psychiatric Neurosurgery.

Referring physicians, the patient, or the patient's family should contact:
The MGH Psychiatric Neurosurgery Committee
Neurosurgical Service - WACC331
Massachusetts General Hospital
Boston, MA 02114
PHONE: 617-726-3407

or

Emad N. Eskandar, M.D.
E-mail: eeskandar@partners.org
Patient Appointments: 617.724.6590
FAX: 6l7-726-7546

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