Bi-frontal Stereotactic Tractotomy: An Atraumatic Operation of Value in the Treatment of Intractable Psychoneurosis

Abstract

Stereotactic surgery has provided a means of producing accurate lesions at selected points in the nervous system where concentrations of nerve cells or fibre pathways possessing specific functions permit some small area of anatomical destruction to produce widespread physiological effects. The value of this method in relation to motor and sensory activity is illustrated by the results of thalamotomy in the treatment of Parkinsonian tremor and by stereotactic division of the spinothalamic tract in the cervical cord for the relief of incurable pain. The accuracy of approach and minimal disturbance of tissue ensures that the beneficial effects of these operations are produced in isolation without associated disfunction in the nervous system. That a similar principle can be applied in relation to the control of emotion has been shown in cases of intractable psychoneurosis treated by the operation of bifrontal stereotactic tractotomy in the substantia innominata (Knight, 1964). Owing to the influence of emotion in psychoneurotic states it is possible to influence many syndromes satisfactorily by operation at a site where connections of the limbic system concerned with instinctive and emotional activity rather than cognitive processes converge to a point beneath the head of the caudate nucleus, thereby producing a reduction in the intensity of emotional reaction without undesirable personality change or post-operative epilepsy. It is felt that it would be useful to summarize the anatomical features in order that the differences between this operation and the old leucotomy procedure can be generally appreciated. It is particularly among cases of chronic and recurrent depression that this form of surgery can be most usefully employed.

Tractographic Analysis of Historical Lesion Surgery for Depression

“…In SCT bilateral lesions are placed, among other areas, in the substantia innominata of the basal forebrain immediately ventral to the head of the caudate (Knight, 1969). SCT has been used for many decades to treat refractory affective and anxiety disorders, including major depression and OCDs.…”

“…Various operations specifically designed for the treatment of major depression were developed in the second half of the twentieth century (Richardson, 1973;Knight, 1969;Bailey et al, 1973;Meyerson and Mindus, 1988). Four main lesion sites, alone or in combination, were identified.…”

“…ACT was probably the least effective of the surgical procedures. (iii) Subcaudate tractotomy (SCT) was introduced by Knight in the 1950s (Knight, 1969;Bridges et al, 1994). Initially, radioactive seeds were placed in the target region posterior to the orbito-frontal cortex.…”

Obsessive-Compulsive Disorder: Development of Demand-Controlled Deep Brain Stimulation with Methods from Stochastic Phase Resetting

“…The importance of the nucleus accumbens is further stressed by the reports of beneficial effects of subcaudate tractotomy on OCD, anxiety disorders, and depression (Knight, 1969), a bilateral procedure that would interrupt parts of the nucleus accumbens. The finding that, different from the classical bilateral anterior capsulotomy and DBS of the internal capsule in OCD (Meyerson, 1998;Nuttin et al, 1999), right-sided DBS of the nucleus accumbens was sufficient to achieve significant clinical improvement is supported by Lippitz et al (1999) who found right-sided thermo-lesions in the middle part of the anterior limb of the internal capsule to be decisive for a good therapeutic outcome.…”

Stereotactic surgery for the relief of suicidal and severe depression and intractable psychoneurosis

“…The accuracy of approach, with minimal disturbance of tissue, ensures that beneficial effects of stereotactic operation are produced in isolation without associated dysfunction of the nervous system. I have shown that this principle can now be applied in relation to the control of emotion (Knight, 1969). Owing to the influence of emotion in depression and psychoneurotic states it is possible to influence many syndromes satisfactorily by operation at a site where connections of primitive cortical areas concerned with instinctive and emotional activity converge beneath the corpus striatum.…”