Historic Evolution of Open Cingulectomy and Stereotactic Cingulotomy in the Management of Medically Intractable Psychiatric Disorders, Pain and Drug Addiction

Abstract

Stereotactic cingulotomy constitutes a psychosurgical procedure nowadays advocated in the treatment of medically intractable obsessive-compulsive disorder, chronic pain and drug addiction. From its theoretical conception to the first cingulectomies performed and modern stereotactic-guided cingulotomies, various target localization methods, different surgical techniques, and numerous lesioning devices have been utilized. In the current article, the authors performed a literature review related to cingular lesion placement in an effort to identify misconceptions of the past, recapitulate existing knowledge and recognize targets for further research. The initial animal and human electrophysiologic experimental data regarding the role of the cingulate cortex in various behavioral and cognitive functions were meticulously reviewed. The clinical indications, surgical technique and the clinical results and complications of open cingulectomies were examined. The anatomic target localization methodologies, surgical technique, and the outcome of the initial stereotactic cingulotomy procedures were reviewed, and the evolution of the imaging techniques, stereotactic devices, and lesioning strategies were followed. The modern advanced surgical techniques, clinical outcome and the procedure-associated complications were analyzed with particular emphasis on the emotional, behavioral, and cognitive procedure-induced changes. Large-scale prospective studies with strict inclusion and well-defined, objective outcome criteria are necessary for defining the role of stereotactic cingulotomy in the current psychosurgical armamentarium.

The neural basis of one's own conscious and unconscious emotional states

“…Insula damage has also been associated with decreases in emotionally motivated behavior (Ibañez et al, 2010), including the motivation for cigarette addicts to smoke (Naqvi et al, 2007). Damage to the insula, and the dACC regions it projects to (as in cingulotomy surgery for intractable pain), has also been associated with pain asymbolia (Berthier et al, 1988;Brotis et al, 2009;Ramachandran, 1998), a condition in which subjects still report feeling pain but are no longer bothered by it or motivated to cause it to cease. Prinz (2006) has also argued that lack of emotional phenomenology may be present in cases of akinetic mutism, which involves preserved awareness in conjunction with the lack of any affective motivation to behave (Nagaratnam et al, 2004).…”

Early MRI Characteristics after MRI-Guided Laser-Assisted Cingulotomy for Intractable Pain Control

“…4 For several decades, the cingulate gyrus has been a surgical target to treat a variety of disorders. 5 In 1948, open cingulectomies were first described for the treatment of schizophrenia. 6 In 1962, pneumoencephalographic guidance for performing closedcingulotomy was introduced by Foltz and White 7 for pain.…”

Laitinen’s Subgenual Cingulotomy: Anatomical Location and Case Report

“…Although the rostrocaudal location and the size of the lesions have varied, the target has consistently been the anterior-dorsal area above the genu of the corpus callosum [6]. This area, however, is mainly cognitive [14], while the emotional cingulate cortex resides in the pre- and, more importantly, subgenual area.…”

“…After this initial case report, cingulotomy became a common procedure in the 1960s through to the 1990s [6]. It was used in the treatment of various psychiatric conditions, such as obsessive-compulsive disorder, anxiety, depression, aggression, drug addiction, and chronic pain, and was popularized not least by Ballantine from Massachusetts General Hospital [7-10].…”