Rees Cosgrove MD. FRCS(C) and Scott L. Rauch MD
Departments of Neurosurgery and Psychiatry, Massachusetts General
Harvard Medical School, Boston, Massachusetts
Address for Correspondence:
N. Eskandar, M.D.
Massachusetts General Hospital
15 Parkman St. ACC # 331
Boston, MA 02114
Patient Appointments: 617.724.6590
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Since its introduction as a treatment
for severe mental illness in 1936, psychosurgery has at varied
times been enthusiastically embraced and flatly rejected by both
the medical profession and society at large. Currently, the accepted
therapeutic approach to most psychiatric disease involves a combination
of well-supervised psychotherapy, pharmacotherapy and, in some
instances, electroconvulsive therapy. However, despite these modern
treatment methods, many patients fail to respond adequately and
remain severely disabled. In these patients, surgical intervention
might be considered appropriate if the therapeutic result and
overall level of functioning could be improved.
In this chapter, we will explore
the historical background of psychosurgery and discuss the anatomic
and physiologic basis for such procedures. Guidelines for the
appropriate selection of surgical candidates will be presented
and the four most common psychosurgical procedures practiced today
will be described. Finally, the overall experience including indications,
results and complications for each procedure will be reviewed
Although trephination performed
by ancient civilizations may represent the earliest form of surgical
intervention for psychiatric disease, psychosurgery's first use
in modern times was reported by Burkhardt in 1891. He described
bilateral cortical excision in the treatment of six demented and
aggressive patients with mixed results. Following this report,
several other neurosurgical procedures were attempted for the
treatment of the mentally ill.(Puusepp, Hollander) In 1935, Fulton
and Jacobson presented their early experience with primate behavior
following ablation of the frontal cortices. They observed that
the lobectomized animals demonstrated less "experimental neurosis"
to task failures, although they were also less able to complete
the tasks successfully. These observations prompted Egas Moniz,
the inventor of cerebral angiography, to perform prefrontal leucotomies
by injection of absolute alcohol with the help of his neurosurgical
colleague, Almeida Lima. Moniz reported that 14 of 20 severely
ill, institutionalized patients showed "worthwhile" improvement
after operation and coined the phrase ' psychosurgery ' to describe
his interventions. ( Moniz, 1937)At that time, few satisfactory
treatment options existed and the asylums for the insane were
overflowing with the chronic mentally ill. Therefore, despite
the lack of objective data and long term follow-up, an enthusiastic
response was obtained from the medical community. This response
resulted in Moniz receiving the 1949 Nobel Prize in Medicine and
One of the most enthusiastic proponents
of the procedure was Walter Freeman, a neuropsychiatrist, and
within a few months of Moniz's publication, Freeman performed
the first prefrontal lobotomy in the United States with the neurosurgical
help of James Watts. The Freeman-Watts prefrontal lobotomy was
performed through bilateral burr holes placed in the inferior
frontal region at the level of the coronal suture. This disconnection
procedure was carried out with a specially designed calibrated
leucotome that was inserted blindly to the midline and swept back
and forth to surgically interrupt the white matter tracts in the
frontal lobes. In reporting their results on the first 200 patients
in 1942, Freeman and Watts were favorably impressed although they
did admit to a significant complication rate including frontal
lobe syndrome, seizures, apathy, decreased attention and inappropriate
behavior. Despite these side effects, prefrontal lobotomy became
widely performed throughout the United States largely because
of the lack of satisfactory therapeutic alternatives and the promotional
zeal of Freeman himself.
Tooth and Newton reviewed 10,365
standard prefrontal lobotomy operations performed between 1943
and 1954 and confirmed that the rate of " improvement " was about
70% but also reported a 6% mortality, 1% epilepsy rate and 1.5%
marked disinhibition. These complications prompted Fulton and
others to call for a less radical and more specific approach to
the surgery.(Fulton 1951) By the late 1940's more precise open
surgical procedures were described including bilateral inferior
leucotomy, bimedial leucotomy and orbital gyrus undercutting.
Cerebral topectomies and anterior cingulectomies were also proposed
and carried out during the same period. At the same time, Freeman
described a new technique of "transorbital leucotomy" which involved
inserting a small right angled instrument under the eyelids and
pushing it through the bony orbit into the frontal orbital cortex
with a sweeping motion to sever the thalamo-frontal radiations.
This so called " ice pick procedure " could be performed quickly
and with minimal anesthesia which led to its ready acceptance
and widespread use. The broad and somewhat indiscriminate application
of this particular technique contributed to the subsequent decline
The next major advance in the neurosurgical
treatment of psychiatric illness occurred with the introduction
of stereotactic techniques to create well localized and discrete
lesions in specific target sites. Stereotactic anterior cingulotomy
was first reported by Foltz and White in 1962 and subcaudate tractotomy
carried out in England by Knight in 1964. Lars Leksell described
his experience with anterior capsulotomy in 1972 and Kelley reported
limbic leucotomy (subcaudate tractotomy and cingulotomy combined)
in 1973. Isolated reports of hypothalamotomy, bilateral amygdalotomy
and thalamotomy can also be found in the literature during this
same time period.
With the introduction of chlorpromazine
in 1954, satisfactory medical management of psychiatric illness
became possible. The availability of effective drug therapy in
combination with the side effects of surgical intervention and
its excessive use in the preceeding decades led to the sudden
and almost complete disappearance of pyschosurgery for mental
illness. Despite newer and even more specific psychotrophic medications,
there remains a small percentage of patients with treatment refractory
psychiatric disease that might be considered for surgical treatment.
However, because of the ethical, legal and social implications
of psychosurgery, only a limited number of surgical procedures
are carried out at a handful of medical centers in the world today.
ANATOMIC AND PHYSIOLOGIC RATIONALE
In 1937, a year after Moniz reported
his initial experience with prefrontal lobotomy, Papez published
his paper entitled "A Proposed Mechanism of Emotion" in which
he postulated that a reverberating circuit in the brain might
be responsible for emotion, anxiety and memory. The components
of this circuit consisted of the hypothalamus, septal area, hippocampus,
mamillary bodies, anterior thalamic nuclei, cingulate gyri and
their interconnections. These structures comprise the rudimentary
limbic system of the human brain which was subsequently expanded
by McLean in 1952 to incorporate the orbital frontal, insular
and anterior temporal cortices, the amygdala and dorso-medial
thalamic nuclei. As illustrated in the previous section, neurosurgical
interventions for psychiatric disorders have all been directed
at various targets within this system and therefore some have
proposed the term ' limbic system surgery ' as an alternative
Although the neuroanatomical and
neurochemical basis of emotion in health and disease remains undefined,
there is evidence that this system and its interconnections with
the cortico-striato-thalamic circuits play a central role in the
pathophysiology of major affective illness, obsessive-compulsive
disorder and other anxiety disorders. [Nauta]. 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 [Kelly and Laitinen]. Stimulation of the hypothalamus
in animals produces autonomic, endocrine and complex motor effects
which suggest that the hyptohalamus integrates and coordinates
the behavioural expression of emotional states. (Ranson and Hess)
The Papez circuit represents the direct conduit to the hypothalamus.
Paralimbic structures which include anterior temporal, insular,
and parahippocampal cortex as well as anterior cingulate and medial
orbito-frontal cortex form the link between heteromodal cortex
and the limbic system proper. (mesalum) Thus, the limbic system
appears strategically located to mediate and interconnect somatic
and visceral stimuli with higher cortical functions and in this
way may "add emotional coloring to the psychic process". Therefore,
it is intuitively appealling, to believe that psychiatric disorders
that are characterized by affective and cognitive manifestations
(eg. depression, OCD, and other anxiety disorders) might reflect
a final common pathway of limbic dysregulation. Contemporary neurobiological
models of anxiety and affective disorders also emphasize the fundamental
role of the limbic system and its related structures. (Gorman
et al,Charney etal, Modell etal)Nauta, Gray, Warburton, Pitman,
Reiman and Moddell].
Data from neuropyschological, neurosurgical,
physiological and neuroimaging studies have also converged to
implicate a circuit composed of orbitofrontal cortex, striatum,
thalamus and anterior cingulate cortex in the pathophysiology
of OCD( Modell, Baxter 1990, Baxter et al 1992, Insel etal, Rauch
and Jenike, Rauch et al 1994) This frontal-striatal-pallido-thalamic-frontal
loop which has been so well characterized for its control of motor
function may well explain some features of OCD as many similarities
exist between OCD and the pathology seen in Sydenhams chorea,
Von Economos disease, focal striatal abnormalities and Tourettes
syndrome. Anatomic imaging with MRI has suggested focal abnormalities
in these striatal areas[Weilberg, 1989] and smaller caudate nuclei
in patients with OCD.(LUxinber1988) Functional neuroimaging research
has also suggested that abnormal activity in the lateral frontal
cortex is a correlate of the depressive state (Baxter et al 1989),
in concert with the presumed role of the limbic system.
Neurochemical models suggest that
the affective and anxiety disorders may be mediated via monoaminergic
systems. In particular, the serotonergic system has received emphasis
with respect to OCD. Because of the diffuse nature of the monoaminergic
projections and their role as neuromodulators, however, these
models are not particularly instructive in terms of the functional
neuroanatomy relevant to different neurosurgical treatments as
they are currently employed. Although the exact neuroanatomical
and neurochemical mechanisms underlying depression, OCD and other
anxiety states remain unclear, it is believed that the basal ganglia,
limbic system and frontal cortex play a principal role in the
pathophysiology of these diseases.
SELECTION OF PATIENTS
Only patients with severe, chronic,
disabling and treatment refractory psychiatric illness should
be considered for surgical intervention. Chronicity in this context
refers to the enduring nature of the illness without extended
periods of symptomatic relief. Moreover, the severity of the patient's
illness must be manifest both in terms of subjective distress
and a decrement in psycho-social functioning. In many cases, the
chronicity of the illness may be less important than the severity
of the illness. The illness must prove to be refractory to systematic
trials of pharmacologic, psychologic and when appropriate, electroconvulsive
therapy prior to considering neurosurgical intervention. As in
all medical decisions, the potential benefit from such an intervention
must be balanced against the risks imposed by surgery.
The major psychiatric diagnostic
groups as defined by the DSM-III-R that might benefit from surgical
intervention include 1.) obsessive compulsive disorder and 2.)
major affective disorder (ie. major depression or bipolar disorder).
In many instances patients present with mixed disorders combining
symptoms of anxiety, depression and OCD and these patients remain
candidates for surgery. Schizophrenia is not currently considered
an indication for surgery. A history of personality disorder,
substance abuse or other Axis II symptomatology is often a relative
contraindication to surgery. In rare instances only, patients
with severe violent outbursts and the potential for serious injury
or self mutilation, might be considered for bilateral amygdalotomy,
thalamotomy or hypothalamotomy.
Thoughtful assessment of psychosurgical
candidacy requires that criteria for severity, chronicity, disability
and treatment refractoriness be operationalized to form guidelines.
In this regard, chronicity would require at least one year of
enduring symptoms without significant remission although practically
speaking confirmation of treatment refractoriness usually requires
over five years of illness prior to surgery. Severity is usually
measured using validated clinical research instruments corresponding
to specific indicators such as a Yale-Brown Obsessive Compulsive
Scale (YBOCS) score of >20 for OCD or a Beck Depression Inventory
(BDI) score > 30. Disability may be reflected, for instance, by
a Global Assessment of Function (GAF) score of <50.
In order to determine that their
psychiatric illness is refractory to treatment despite appropriate
care, all patients must be referred for surgical intervention
by their treating psychiatrist. The referring psychiatrist must
demonstrate an ongoing commitment to the patient and the evaluation
process and must also agree to be responsible for post-operative
management. Detailed questionnaires that document the extent and
severity of the illness as well as a thorough account of the diagnostic
and therapeutic history must be provided by the psychiatrist.
The specifics of pharmacologic trials should include the agents
used, dose, duration, response and the reason for discontinuation
for any suboptimal trial. Adequate trials of electroconvulsive
therapy or behavioral therapy when clinically appropriate must
also be demonstrated.
The patient and their family must
also agree to participate completely in the evaluation process
as well as the post-operative psychiatric treatment program. In
general, only adult patients [greater than 18 years] who are able
to render informed consent and who express a genuine desire and
commitment to proceed with surgery are accepted. Obviously, the
surgery should only be performed to help a sick patient and never
for social or political reasons.
If the patient meets the above criteria,
at our institution they would undergo a more detailed presurgical
screening evaluation by an experienced, multidisciplinary group
of psychiatrists, neurosurgeons and neurologists (Cingulotomy
Assessnment Committee). Thorough review of the medical record
is carried out to insure that the illness is indeed refractory
to an exhaustive array of conventional therapies. The MGH evaluation
also includes an electroencephalogram (EEG), brain MRI, neuropsychological
testing and independently conducted clinical examinations by a
psychiatrist, neurologist and neurosurgeon in the outpatient setting.
Electrocardiogram and appropriate blood tests are obtained to
assess medical risks and to exclude organic etiologies for mental
status abnormalities. Validated clinical research instruments
are employed to quantify psychiatric symptom severity. There must
be unanimous agreement that the patient satisfies selection criteria,
that the surgery is indicated and that the requirements for informed
consent are fulfilled. A family member or close relative must
also understand the evaluation process, the indications for, risks
of and alternatives to surgery and agree to be available to provide
emotional support for the patient during the hospitalization.
While many methods have been utilized
in the neurosurgical treatment of psychiatric disease, four procedures
have evolved as the safest and most effective. These are all performed
bilaterally and under stereotactic conditions to allow for precise
lesioning of target structures. They include: 1.) Anterior cingulotomy.
2.) Subcaudate tractotomy. 3.) Limbic leucotomy. 4.) Anterior
capsulotomy. Each procedure has different indications, techniques,
results and complications which will be discussed in the following
Subcaudate tractotomy was introduced
by Knight in Great Britain in 1964 as one of the first attempts
to restrict the size of the surgical lesion and therefore minimize
the side effects seen with standard prefrontal lobotomy. The
aim was to interrupt white matter tracts between orbital cortex
and subcortical structures by placing a lesion in the region
of the substantia innominata just below the head of the caudate
nucleus. Surgical indications included major depressive illness,
obsessive compulsive disorder and anxiety states as well as
a variety of other psychiatric diagnoses.
The surgical procedure was performed
using stereotactic technique using boney landmarks and ventricular
outline. Target coordinates were calculated as 15 mm from the
midline and approximately 10 - 11 mm above the planum sphenoidale
at the most anterior part of the sella turcica. Lesions were
created using radioactive implantableYttrium 90 seeds. Lesional
volumes were estimated at approximately 2000 mm2.
In patients with depression and
OCD, total improvement or improvement with minimal symptoms
was clinically observed in two thirds of the patients. The best
review of the surgical results for subcaudate tractotomy was
presented by Goktepe in 1975. Using a five point global scale
and rating scales for depression and anxiety they reviewed 208
patients with a mean follow up of 2.5 years. Of the 134 patients
available for structured interview, good results were seen in
68% of patients suffering from depression, 62.5% of patents
with anxiety states and 50% of patients with obsessive neurosis.
Patients with schizophrenia, personality disorder, drug abuse
or alcohol abuse did poorly. Some patients who had only temporary
benefit from the initial lesion had second lesions created lateral
to the first with good results seen in about half.
The incidence of complications
was small but included post-operative seizures in 2.2 % and
undesirable personality traits in 6.7 %. Transient disinhibition
was common. Of the 25 patients that had died at the time of
review, 3 patients had committed suicide. One patient died from
inadvertent destruction of the hypothalamus when an yttrium
seed migrated off target.
Fulton was the first to suggest
that the anterior cingulum would be an appropriate target for
psychosurgical intervention and cingulotomy was initially carried
out as an open procedure. Foltz and White reported their experience
with stereotactic cingulotomy for intractable pain and noted
the best results were in those patients with concurrent anxiety-depressive
states. Ballantine subsequently demonstrated the safety and
effectiveness of cingulotomy in a large number of patients and
it has been the surgical procedure of choice in North America
over the last 30 years. Currently, the surgical indications
are treatment refractory major affective disorder, chronic anxiety
states or OCD. The procedure is still performed on occasion
for some patients with severe chronic pain.
Initially these procedures were
carried out with ventriculography but over the past several
years this has been replaced by MRI guided stereotactic techniques.
Target coordinates are calculated for a point in the cingulum
7 mm from the midline and 20 - 25 mm posterior to the tip of
the frontal horns. Lesions are created by thermocoagulation,
the technical details of which have been well described previously.
Intraoperative stimulation is not performed routinely but neurological
testing is carried out during lesioning to insure that no impairment
of motor or sensory function especially in the lower extremities
is incurred. On the day after surgery, a post-operative MRI
scan is obtained to document the placement and extent of the
lesions [Figure 1].
Although the patient may experience
an immediate reduction in anxiety, there is generally a delay
to the onset of beneficial effect on depression and obsessive
compulsive disorder. This latency may be as long as six to twelve
weeks and must be clearly explained to the patient and referring
psychiatrist. If there has been no response to the initial cingulotomy
after three to six months, then reoperation and enlargement
of the cingulotomy lesion is considered.
The results of bilateral cingulotomy
in 198 patients suffering from a variety of psychiatric disorders
were reported retrospectively by Ballantine et al in 1987. With
a mean follow-up of 8.6 years, 62% of patients with severe affective
disorder were found to have had worthwhile improvement. Similarly,
in patients with obsessive compulsive disorder approximately
56% were found to have undergone worthwhile improvement. In
14 patients suffering from nonobsessive anxiety disorders 50%
were found to be functionally well and 29% were found to have
shown marked improvement. A recent retrospective study evaluating
cingulotomy in 33 patients with refractory obsessive compulsive
disorder demonstrated that using very strict criteria for successful
outcome, at least 25 to 30% of patients benefited substantially
from the procedure. [Jenike and Baer, 1991]. In a prospective
long term follow-up study of 18 patients who underwent cingulotomy
for intractable OCD, five patients met very conservative criteria
as treatment responders and two others were considered possible
responders. [Baer and Rauch, submitted] Overall, the entire
group improved significantly in terms of functional status and
no serious adverse effects were found This is the first study
to demonstrate in a prospective way that cingulotomy is effective
in OCD as measured by standard psychiatric rating scales and
In over 800 cingulotomies performed
at the MGH since 1962, there have been no deaths and no infections.
Two acute subdural hematomas occurred early on in the series
secondary to laceration of a cortical artery at the time of
introduction of ventricular needles but only one patient suffered
permanent neurologic impairment. An independent analysis of
34 patients who underwent cingulotomy demonstrated no significant
behavioral or intellectual deficits as a result of the cingulate
lesions themselves. [Teuber and Corkin] They subsequently evaluated
57 patients before and after cingulotomy and found no evidence
of lasting neurological or behavioral deficits after surgery.
A comparison of preoperative and post-operative Weschler IQ
scores demonstrated significant gains postoperatively. This
improvement was greatest in patients with chronic pain and depression
but negligible in those with the diagnosis of schizophrenia.
Limbic leucotomy was introduced
by Kelly in 1973 and combines subcaudate tractotomy with anterior
cingulotomy. This procedure was designed to disconnect orbital-frontal-thalamic
pathways with the former lesion and interrupt an important portion
of Papez's circuit with the latter. Kelly et al reasoned that
these two lesions might lead to a better result for the symptoms
of OCD than either lesion alone. Indications for surgical intervention
included obsessional neurosis, anxiety states, depression and
a variety of other psychiatric diagnoses.
This procedure was carried out
stereotactically and three small (6mm diameter) lesion were
placed in the lower medial quadrant of each frontal lobe and
two lesions in each cingulate gyrus. Lesions were created using
a either cryoprobe or thermocoagulation. Intraoperative stimulation
was carried out and if pronounced autonomic responses were observed,
this was felt to provide physiologic proof of correct location.
Using the same five point scale
described in the study of Gotekpe, 66 patients were assessed
pre- and postoperatively (mean 16 mos). In patients with obsessional
neurosis, 89 % were clinically improved; in chronic anxiety,
66% were improved; in depression, 78% were improved and in a
small number of schizophrenics, over 80% were improved. Kelly
later reported in 49 patients with OCD, that 84% were improved
20 months after surgery. They too noted that post-operative
symptom improvement was not immediate with a fluctuating but
progressive reduction of symptoms over the first postoperative
Although many patients complain
of lethargy, confusion and lack of sphincter control in the
early postoperative period, persistent complications are rare.
No patients developed seizures postoperatively, one patient
suffered severe memory loss due to improper lesion placement
and 12% of patients complained of persistent lethargy. Measurements
of IQ showed slight improvement postoperatively.
Although Talairach was the first
to describe anterior capsulotomy, Leksell popularized the procedure
for patients with a variety of psychiatric disorders. The aim
was to interrupt presumed fronto-thalamic connections in the
anterior limb of the internal capsule where they pass between
the head of the caudate nucleus and the putamen. Clinical indications
for capsulotomy initially included schizophrenia, depression,
chronic anxiety states and obsessional neurosis.
The exact target coordinates as
described by Leksell are in the anterior one third of the anterior
limb of the internal capsule 5 mm behind the tip of the frontal
horns, 20 mm lateral to the midline at the level of the intercommisural
plane. Intraoperative electrical stimulation has not been helpful
in terms of determining optimal placement of lesions within
the capsule. Lesions were created by thermocoagulation using
a bipolar electrode system. Several cases were also performed
using the Gamma knife.
In the first 116 patients operated
on by Leksell, 50% of patients with obsessional neurosis and
48% of depressed patients had a satisfactory response. Only
20% of patients with anxiety neurosis and 14% of patients with
schizophrenia were improved. In this classification system,
only patients who were free of symptoms or markedly improved
were judged as having a satisfactory response. Of the patients
who were rated as worse after capsulotomy, 9 were schizophrenics,
4 depressives and 3 obsessives. In another series of 35 patients
with OCD who underwent capsulotomy and were followed prospectively
by independent psychiatrists, 16 were rated as free of symptoms
and 9 were much improved for an overall satisfactory result
of 70%. In a review of all cases of capsulotomy previously reported
in the literature, Mindus found sufficient data to categorize
outcome in 213 of 362 patients. Of these 137 [64%] were deemed
to have a satisfactory result.
More recently Mindus has followed
24 patients prospectively with standardized rating scales. Complications
of the surgery included transient episodes of confusion during
the first week in 19 of 22 patients available for followup with
occasional nocturnal incontinence. One patient was noted to
have an intracranial hemorrhage without neurological sequelae
and one patient suffered seizures. One patient committed suicide
in the postoperative phase and 8 patients suffered from depression
requiring treatment. Excessive fatigue was a complaint in 7
patients, 4 had poor memory. Two patients showed slovenliness.
Weight gain is common after capsulotomy with an overall mean
weight gain of about 10% in all patients. No evidence of cognitive
dysfunction has been reported in 200 capsulotomy patients studied
using a variety of psychometric tests. [Mindus et al] Reoperation
was required in 2 patients who did not achieve a satisfactory
result with only one improving after the second operation. Burzaco
subjected 17 of his 85 patients to a second procedure at which
time the lesions were enlarged and half of these reoperations
yielded satisfactory results.
Much of the controversy surrounding
the use of psychosurgery may be attributed to its rather indiscriminate
application and the high incidence of side effects seen with the
early procedures. Stereotactic techniques have certainly minimized
the side effects of surgery but the issue of case selection remains
a major consideration. Although initially any patient with a severe
psychiatric illness was once considered a candidate for surgical
intervention, it is now clear that the indications for psychosurgery
are more restrictive. There is general agreement among centers
that patients with major affective disorder, chronic anxiety states
and obsessive compulsive disorder are the best candidates for
surgery. It can be safely concluded that schizophrenia is not
an indication for psychosurgery although patients with concommitant
psychotic disorders and depression might still be helped with
surgery and should not be excluded. Personality disorders or psychoactive
substance use disorder are significant relative contraindications
to surgery. Appropriate 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
With currently available data, it
is impossible to determine whether there is one optimal surgical
technique or strategy. All procedures seem to be well tolerated
with minimal side effects or complications when applied with the
modern stereotactic techniques. No matter which structure in the
limbic system is chosen for ablation, the clinical outcome appears
There are many obstacles that prevent
a direct comparison of results across centers. These include diagnostic
inaccuracies, nonstandardized presurgical evaluation tools, center
bias and varied outcome assessment scales. However, in virtually
all published reports, some modification of the Pippard Postoperative
Rating Scale or equivalent has been used to determine clinical
outcome. The Pippard Scale rates outcome in five categories:
A. symptom free
B. much improved, some symptoms remaining but no additional treatment
C. slightly improved
Although comparisons are imperfect,
these scales do appear to have some clinical validity.(Mindus
1991, Waziri, 1990) If category A and B are considered satisfactory
outcome, then in patients with OCD, subcaudate tractotomy in 50%,
cingulotomy was effective in 56%, limbic leucotomy in 61% and
capsulotomy in 67%. In patients with major affective disorder,
subcaudate tractotomy in 50%, cingulotomy was effective in 56%,
limbic leucotomy in 61% and capsulotomy in 67%.
Kullberg attempted to compare cingulotomy
and capsulotomy in the treatment of 26 patients in a randomized
fashion. Six of 13 capsulotomy patients and 3 of 13 cingulotomy
patients were better but transient deterioration in mental status
was much more marked after capsulotomy than after cingulotomy.
Recently two prospective studies were concluded that attempted
to evaluate the efficacy of cingulotomy and capsulotomy in OCD.
Using the best available research methodologies and well accepted
rating scales of disease and outcome, exhaustive pre and post
operative evaluations were carried out. Of the capsulotomy patients,
45% had clear cut improvement and in cingulotomy patients 39%
Based upon these methods of comparison,
the clinical superiority of any one procedure is not convincing.
While many centers claim advantages for their specific surgical
intervention, at this point we are unable to determine whether
one of the four major psychosurgical procedures is superior to
the others. Cingulotomy is the treatment of choice in this country
whereas in Europe, capsulotomy and limbic leucotomy are more prevalent.
They all appear roughly equivalent therapeuticly but in terms
of unwanted side effects, cingulotomy appears to be the safest
of all procedures currently performed. Regardless of the choice
of procedure, surgical failures should be investigated and if
the lesion size or location is suboptimal than consideration should
be given to a repeat procedure. In 5 of the 24 patients in Mindus
series, a significant correlation was found between neuroradiologic
ranking of a target site and the psychiatric outcome suggesting
that the site and extent of lesion may be important factors influencing
outcome. At least 45% of patients undergoing cingulotomy require
repeat operation with good results being salvaged in half. Repeat
surgery in capsulotomy patients has been reported as 20%. The
exact size or volume of tissue required for an effective outcome
at each of the target sites has yet to be determined.
The method used for creating the
lesion itself does not appear to influence results or complication
rates. There is some interest in the potential use of external
radiosurgical techniques for psychosurgery but this remains controversial.
Although radiosurgery does not require introduction of a subcortical
electrode, it remains a surgical procedure with a small but significant
complication rate. Little is known about the exact dosimetry required
for satisfactory lesions and the latency to onset of beneficial
effect as radionecrosis develops may not be reasonable for patients
who are in grave psychiatric condition. In view of the proliferation
of radiosurgical centers and the inexperience of these same groups
with psychosurgery, the potential for misapplication of this technique
While controversy exists regarding
the exact choice of surgical procedure to be employed, there is
unanimous agreement that the presurgical evaluation be performed
by committed multi-disciplinary teams with expertise and experience
in the surgical treatment of psychiatric illness. Diagnosis based
upon the DSM classification scheme is encouraged and although
it is impossible to mandate uniformly across all centers , prospective
trials employing standardized clinical instruments with long term
follow-up are needed. Comparisons of preoperative and postoperative
functional status remain an important parameter in addition to
target psychiatric symptoms, in characterizing outcome. All centers
with experience emphasize the importance of rehabilitation postoperatively
and the need for ongoing psychiatric follow-up. The operation
is not a panacea and should be considered as only one aspect in
the overall management of these patients. Despite the advent of
new and effective psychopharmacologic agents it is generally felt
by centers employing this form of psychosurgery, that the procedure
is underutilized. Caution must be urged however regarding the
surgical treatment of psychiatric disease to ensure that the indiscriminate
application of this form of therapy never recurs.
The surgical treatment of psychiatric
disease can be helpful in certain patients with severe, disabling
and treatment refractory major affective disorders, obsessive
compulsive disorder and chronic anxiety states. Psychosurgical
treatment should only be carried out by an expert multidisciplinary
team with experience in these disorders. Surgery should be considered
as one part of an entire treatment plan and must be followed by
an appropriate psychiatric rehabilitation program. Many patients
are greatly improved after surgery and the complications or side
effects are few. Surgical intervention remains an important therapeutic
option for disabling psychiatric disease and is probably underutilized.
We are indebted to H. Thomas Ballantine
Jr MD, Ned Cassem MD and Ida Giriunas RN for their insight, experience
and guidance and to Rosemary Dolan for her expert secretarial assistance.
- American Psychiatric Association:
Diagnostic and Statistical Manual of Mental Disorders, Third Edition,
Revised. Washington, DC: American Psychiatric Association;1987.
- Ballantine HT, Bouckoms AJ, Thomas
EK et al: Treatment of psychiatric illness by stereotactic cingulotomy.
Biol Psychiatry 22:807-819, 1987.
- Ballantine HT, Giriunas IE: Treatment
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