Ablative neurosurgery for mental disorders: is there still a role in the 21st century? A personal perspective

Abstract

<jats:sec><jats:title>Object</jats:title><jats:p>The author presents his personal perspective on ablative neurosurgical techniques used to perform bilateral anterior cingulotomy (BACI) and bilateral anterior capsulotomy (BACA) for ameliorating the symptoms of refractory obsessive-compulsive disorder (OCD) and treatment refractory depression (TRD). With depression predicted to be the second most common cause of disability in the world by the year 2020 and the birth of electric neurostimulation representing an attractive alternative treatment option for TRD and OCD, it is desirable to revisit the pros and cons of these treatment options.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>The author reviewed the surgical methods and outcome (including neuroimaging findings) in all cases in which ablative neurosurgery was performed at Ninewells Hospital and Medical School over the last 2 decades.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>The advantages of ablative procedures (BACI and BACA) from patients’ and psychiatrists’ perspectives are that the ablative procedures are one-off procedures that do not require lifelong commitment to program the stimulation devices, fix hardware failures, or change exhausted batteries. From the perspective of healthcare funding bodies, the relatively low cost of these treatments is an advantage. The main disadvantages of BACI and BACA are the perceived higher complication rates, the irreversibility of the surgical lesions, and the stigma associated with brain destruction in psychiatric patients that are still unpalatable in the community at large. However, some patients still choose a one-off procedure in preference to any other options presented to them.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>There is still place for BACI and BACA in modern neurosurgery for mental disorders, at least in the short term for those who do not want to commit to lifelong device programming and maintenance.</jats:p></jats:sec>

Long-Term Follow-Up of MRI-Guided Bilateral Anterior Capsulotomy in Patients with Refractory Schizophrenia

“…One patient had a seizure and was controlled with antiepileptic medication (sodium valproate: 200 mg/t.i.d.). The occurrence of surgical complications was similar to other stereotactic neurosurgeries [34,35]. There were no fatalities during our study (table 3).…”

“…MRI-guided capsulotomy is a well-established and relatively safe procedure. It is a kind of procedure which does not require a lifelong commitment to regulating the stimulation devices, fixing hardware failures, or changing exhausted batteries [34]. For patients who do not want regular device programming and maintenance, capsulotomy would be an optional choice.…”

Deep Brain Stimulation for Obsessive-Compulsive Disorder: Subthalamic Nucleus Target

“…Leukotomies combined cingulotomy and subcaudate tractotomy. Different centers worldwide have established the efficacy of such surgical treatments, which are still proposed in cases of intractable OCD (7,8,11,20,29). In the past decade, the use of deep brain stimulation (DBS) has progressively replaced lesions and Bart Nuttin and his team (25) were the first to apply the concept of high frequency stimulation of a deep target, the anterior limb of the internal capsule, to treat patients suffering from severe OCD.…”

Strategies for the return of behavioral surgery

“…In my institution, prospective patients for BS are evaluated by a multidisciplinary team in the Advanced Interventions Service (AIS) led by experienced psychiatrists and psychotherapists in this field. [57] On average, the AIS screens 40–50 patients annually and only a handful of patients move on to have BS. The definitions of TRes- and TRef-MDD or -OCD have also been established.…”