N. Eskandar MD, G. Rees Cosgrove MD FRCS, and Scott L. Rauch
Departments of Neurosurgery and Psychiatry,
Massachusetts General Hospital
Harvard Medical School,
Address for Correspondence:
N. Eskandar, M.D.
Massachusetts General Hospital
WACC Suite # 331
Boston , Massachusetts
Patient Appointments: 617.724.6590
Scott L. Rauch
Department of Psychiatry
Massachusetts General Hospital
Building 149-13th Street-Floor 9
Charlestown , Massachusetts
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neurosurgery involves the surgical ablation or disconnection of
brain tissue with the intent of altering abnormal affective and
behavioral states caused by mental illness. It is classified as
a functional neurosurgical procedure because it attempts to improve
or restore function by altering underlying physiology. The surgical
target may be cerebral cortex, nuclei or pathways that display either
normal or abnormal physiologic activity. Other functional neurosurgical
procedures include the surgical treatment of epilepsy in which a
temporal lobe may be removed or the surgical treatment of Parkinsons
Disease in which lesions are made in the basal ganglia. Whereas
the pathological substrates of these disorders are well understood
and their manifestations often include physical or neurologic findings,
the biological basis of most psychiatric illnesses remain poorly
understood and their expression involves mental or psychic symptoms
without objective physical signs. Chronic pain is similar to psychiatric
illness in that symptoms are often accompanied by mental anguish
without physical findings but the anatomical pathways for pain transmission
are well known and surgical results are predictable.
involved in psychiatric illness are poorly defined and surgical
results variable, therefore the practice of psychiatric neurosurgery
has often been surrounded by controversy. At various times it has
been widely accepted and at other times flatly rejected by both
the medical profession and society at large. To understand this
controversy one must appreciate the historical evolution of psychiatric
neurosurgery . Psychiatric neurosurgery was first introduced as
a treatment for severe mental illness by Egas Moniz in 1936 . At
that time, no satisfactory pharmacological treatment options existed
and a variety of unproven somatic therapies were being used including
insulin-shock therapy, metrazol-shock therapy, and electroconvulsive
therapy. Asylums for the insane were overflowing with the mentally
ill and therefore, despite a lack of objective therapeutic benefit,
psychiatric neurosurgery was enthusiastically adopted by practitioners
of the day. At the height of enthusiasm, psychiatric neurosurgery
was recommended for curing or ameliorating schizophrenia, depression,
homosexuality, childhood behavior disorders, criminal behavior and
uncontrolled violence. It is estimated that over 50,000 procedures
were performed in the United States alone between 1936 and the mid-1950's
and much of the controversy surrounding psychiatric neurosurgery
may relate to its overzealous and sometimes indiscriminate application
during this period.
The earliest procedures involved open operations with excision of
both frontal lobes (frontal lobectomy) or disconnection of the frontal
lobes from the remaining brain using a blunt instrument (frontal
leucotomy). Despite technical differences, these operations were
generally considered as one and the same (frontal lobotomy) and
were associated with a high complication rate including intellectual
impairment, personality change, seizures, paralysis and death. Despite
these complications, the operations were felt to be helpful in the
majority of patients and Moniz was awarded the Nobel Prize in Medicine
in 1949 "for his discovery of the therapeutic value of prefrontal
leucotomy in certain psychoses."
In an attempt to reduce the morbidity of the early interventions,
more selective excisions of cingulate and orbito-frontal cortex
(corticectomy) were employed with comparable success rates but fewer
complications. Stereotactic operations were subsequently developed
that allowed for accurate positioning of small electrodes in deep
brain structures. However, with the introduction of chlorpromazine
in 1954 along with subsequent psychotropic drugs, the role of surgery
declined dramatically. Nevertheless, some patients failed to respond
to appropriate pharmacological therapy and referrals to specialized
centers for neurosurgical intervention continued.
Even though the frontal lobotomy of earlier years had been abandoned
in favor of more selective stereotactic interventions and the number
of procedures performed were greatly reduced, the concern about
the use of psychiatric neurosurgery grew during the 1960's and 1970's.
This was due to questions about efficacy, reports of permanent sequelae
and the potential for abuse all fueled by publications in the lay
press. Public debate in the United States, England and Australia
prompted the formation of national commissions to investigate psychiatric
neurosurgery and encouraged legislation to regulate its use. Many
of the social, political and moral issues at the heart of the controversy
surrounding psychiatric neurosurgery have since been addressed but
some scientific and philosophical issues remain.
In the United
States, the report of the National Commission for the Protection
of Human Subjects of Biomedical and Behavioral Research indicated
that psychiatric neurosurgery was efficacious in more than half
of the 400 operations performed annually between 1971-1973 and that
no psychological deficits could be attributed to the procedures.
Fears that psychiatric neurosurgery was being used on minority and
disadvantaged populations for social control were unsubstantiated.
Preoperative and postoperative studies by independent observers
of smaller groups of patients undergoing cingulotomy demonstrated
excellent results in the majority and significant improvement in
full scale, verbal and performance IQ. Detailed neuropsychological
testing of patients undergoing a variety of more extensive psychosurgical
procedures also failed to demonstrate any worsening except in a
single category (Wisconsin card sorting) and over half of the patients
experienced a marked improvement in their psychiatric symptoms.
These independent evaluations of outcome and side effects appear
to corroborate the prevailing published experience. More modern
clinical series report similar success rates of 25 - 60% depending
on the psychiatric diagnosis and methodology. These results argue
against the initial public perception that psychiatric neurosurgery
was dangerous, ineffective and experimental but opposition remains
despite its formal acceptance in position statements by organized
psychiatry in many countries around the world.
One valid criticism
of psychiatric neurosurgery is that the theoretical basis of the
treatment is not well established. Neuropyschological, physiological
and neuroimaging studies have supplied some evidence to implicate
the limbic system and its interconnections with the basal ganglia
and forebrain in the pathophysiology of major affective illness,
obsessive-compulsive disorder and other anxiety disorders. Electrical
stimulation of specific areas within the limbic system (i.e. the
anterior cingulum), has been shown in humans to alter both autonomic
responses and anxiety levels. Abnormalities of glucose metabolism
have been found in the caudate nucleus, orbitofrontal cortex and
cingulum in patients with OCD on positron emission tomography (PET).
Similarly, PET studies have shown reduced glucose metabolism in
the lateral frontal cortex as a correlate of the depressive state
in certain patients. But while it is intuitively appealing to think
that these disorders might reflect a final common pathway of limbic
dysregulation, the neuroanatomical and neurochemical basis of emotion
in health and disease remains undefined. It is possible that as
the understanding of the pathophysiology improves, the medical community
and society at large will become more accepting of these procedures.
accepted therapeutic approach to most psychiatric disease involves
a combination of psychotherapy, pharmacotherapy and, in some instances,
electroconvulsive therapy. However, despite these modern treatment
methods, some patients fail to respond adequately and remain severely
disabled. In these patients, surgical intervention might be considered
appropriate despite a firm theoretical basis, if the therapeutic
result and overall level of functioning could be improved. On the
other hand, there is no consensus amongst practitioners about the
duration, intensity or degree to which other therapies should be
tried before resorting to psychiatric neurosurgery .
Critics of psychiatric
neurosurgery suggest that surgery may often be performed before
other alternative therapies are sufficiently tried. Currently, only
patients with chronic, severe and disabling psychiatric illness
that are completely refractory to all conventional therapy are considered
for surgery. This implies that well documented systematic trials
of pharmacologic, psychologic and when appropriate, electroconvulsive
therapy have been tried both singly and in combination before neurosurgical
intervention is considered. The severity of the patient's illness
must be manifest both in terms of subjective distress and a decrement
in psycho-social functioning. Chronicity refers to the enduring
nature of the illness and in some cases may be less important than
severity but generally requires several years duration.
number of psychosurgical procedures performed in the world today
is unknown, it is estimated that fewer than 25 patients are operated
upon annually in the United States and Great Britain, while only
1-2/year undergo psychiatric neurosurgery in Australia. Claims that
psychiatric neurosurgery is being overutilized seem exaggerated.
There was a
time when any patient with a severe psychiatric illness might be
considered a candidate for surgical intervention, with the only
major criterion being that the patient be in a "fixed state
of tortured self concern ". This global inclusion criterion
created a very heterogeneous subject population which made comparison
of outcomes difficult. The lack of accurate psychiatric diagnosis
made it impossible to predict outcome based upon clinical syndromes.
To be fair to practitioners of the day, psychiatric diagnosis was
less well defined and certain diagnoses such as OCD did not yet
exist as distinct entities.
It is now clear that the indications for psychiatric neurosurgery
are much more restrictive. There is general agreement that patients
with major affective disorder, chronic anxiety states and obsessive
compulsive disorder are the best candidates for surgery. These patients
must meet DSM for the respective diagnostic categories. Despite
the fact that the majority of patients who underwent psychiatric
neurosurgery in the past were diagnosed as schizophrenic, schizophrenia
is not currently considered an indication for surgery. Personality
disorders or psychoactive substance use disorder are significant
relative contraindications to surgery.
selection of patients for surgery remains a major issue and the
responsibility of the psychiatrist, guided by the informed and expert
opinions of the other members of the psychosurgical team. Ethical
objections about the use of psychiatric neurosurgery have been addressed
in all centers by insuring an informed consent from the patient
and family without coercion, along with unanimous agreement amongst
the referring and treating physicians.
Since the scientific
rationale for psychiatric neurosurgery is lacking, observations
and conclusions regarding its use have been largely empirical and
accumulated over many years from a variety of institutions. Although
many psychosurgical techniques have been used in the past, four
procedures have evolved as the safest and most effective. These
are all performed bilaterally under modern stereotactic conditions
to allow for precise identification and accurate lesioning of the
target structures. The contemporary procedures are anterior cingulotomy,
subcaudate tractotomy, limbic leucotomy, and anterior capsulotomy.
All involve lesions of limbic or paralimbic territories or interruptions
of their connections with deeper brain structures. In fact, all
psychosurgical procedures have been directed at some component within
this system and therefore some authors prefer the term limbic system
surgery to psychiatric neurosurgery . With currently available data,
it is impossible to determine whether there is one optimal surgical
technique or strategy. All forms of these modern procedures seem
to be safe and well tolerated with few side effects or complications.
evaluations of outcome in the past have allowed critics of psychiatric
neurosurgery to challenge the overall results with some validity.
Given the difficulty of assessing outcome in functional mental and
behavioral disorders, the criteria for cure or significant improvement
are not clear and have never been universally agreed upon. There
also exist many obstacles that prevent a direct comparison of results
across centers including diagnostic inaccuracies, nonstandardized
presurgical evaluation tools, center bias and varied outcome assessment
scales. However, if a global outcome rating of symptom free or much
improved is considered a satisfactory response, then in a recent
review of modern surgical series of patients with OCD, cingulotomy
was effective in 56%, subcaudate tractotomy in 50%, limbic leucotomy
in 61% and capsulotomy in 67%. In patients with major affective
disorder, cingulotomy was effective in 65%, subcaudate tractotomy
in 68%, limbic leucotomy in 78% and capsulotomy in 55%.
these methods of comparison, the clinical superiority of any one
procedure is not convincing although there is a suggestion that
anterior capsulotomy and limbic leucotomy may be slightly more effective
in patients with OCD. Cingulotomy is most commonly used in the United
States whereas in Europe, capsulotomy and limbic leucotomy are more
prevalent. They all appear roughly equivalent from a therapeutic
standpoint but in terms of unwanted side effects, cingulotomy appears
to be the safest of all procedures currently performed.
of psychiatric neurosurgery has been that no matter which structure
in the limbic system is chosen for ablation, the clinical outcome
appears similar. This lack of specificity is not necessarily evidence
against its use since many psychotropic agents and even ECT can
have benefit across a wide range of mental disorders. It more likely
underlines our incomplete understanding of the neurobiological basis
of psychiatric disease and our failure to perform careful controlled
trials comparing different surgical techniques within the same center.
Many psychiatrists would readily accept an empirical treatment if
the available clinical data supporting a favorable outcome were
substantial and convincing. To date only a few prospective long
term follow-up trials have been completed but these do appear to
support the contention that even using the most stringent outcome
criteria, cingulotomy and anterior capsulotomy are helpful in 25
- 50% of patients with intractable OCD. Using less stringent outcome
criteria, improvement is seen in 50 - 70% of patients which is similar
to earlier studies.
exists regarding the exact choice of surgical procedure to be employed,
there is unanimous agreement that the presurgical evaluation must
be performed by committed multi-disciplinary teams with expertise
and experience in the surgical treatment of psychiatric illness.
Diagnosis based upon a formal classification scheme is essential.
Although it is impossible to mandate across all centers , prospective
trials employing standardized clinical instruments with long term
follow-up are needed.
of preoperative and postoperative functional status remain an important
parameter in addition to target psychiatric symptoms, in characterizing
outcome. The operation is not curative and should be considered
as only one aspect in the overall management of these patients.
All centers with experience emphasize the importance of rehabilitation
postoperatively and the need for ongoing psychiatric follow-up.
It appears that many patients are greatly improved after surgery
and the complications or side effects are few.
Despite the advent of new and effective psychopharmacologic agents,
it is generally felt by centers employing this form of surgical
intervention, that psychiatric neurosurgery remains an important
therapeutic option for disabling psychiatric disease and is probably
underutilized. Caution must be urged however regarding its use,
to ensure that the overzealous and indiscriminate application of
this form of therapy never recurs. Hopefully, as our understanding
of the neurobiological basis of psychiatric illness improves, the
rationale and theoretical basis for surgical intervention will become
apparent. Until then, only carefully controlled, prospective long
term follow up studies by independent observers can improve our
empirical assessment of psychiatric neurosurgery .
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