Ablative Neurosurgery For Mental Disorders: Is There Still A Role In The 21st Century? A Personal Perspective

M. Sam Eljamel, M.D., F.R.C.S.(Ire), F.R.C.S.(Edin), F.R.C.S.(Sn)

Disclosures

Neurosurg Focus. 2008;25(1):E4 

In This Article

Abstract and Introduction

Abstract

Object: 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.
Methods: 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.
Results: 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.
Conclusions: 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.

Introduction

The anterior cingulate gyrus has been thought to be involved in emotion rostrally, motion caudally, and cognition and experience of pain in the middle.[6,14,31,32,33,36] It consists of the cingulate cortex and the cingulum bundle that runs parallel to the cingulate cortex and projects to the striatum and the thalamus.[5,25] Functional imaging of the brains of healthy volunteers and depressed patients supports the observed effects of BACI in TRD. Functional imaging of depressed patients demonstrated that the rostral part of the cingulate cortex was the most likely part of the cingulate gyrus to be involved in depression.[9,31] Although BACI has been used for the treatment of TRD, OCD, and other psychiatric illnesses for many years, the exact location of the target is not clear, making comparative analysis of the results from different series difficult.

In this paper the ablative surgical procedures performed in the Department of Neurosurgery at Ninewells Hospital and Medical School over the last 2 decades are summarized and the issues surrounding the choices made by patients to treat their mental illness are discussed. Over the past 10 years, I have used the surgical techniques presented here with little variation. Nevertheless the size and location of the resultant lesions varied from patient to patient on long-term postoperative MR image analysis.[31] These inevitable variations make the interpretation of the clinical outcome even more difficult. There are several reasons for this imprecision of the target: 1) Distortion occurs in MR imaging due to continuous pulsations of the living human brain within the skull and image transformation during coordinate calculations. This inherent error can be as high as 5-8 mm in the vertical axis.[2,11,13] 2) Mechanical errors in framering position relative to the skull introduce tilt, yaw, and rotation, and manual frame adjustments must be made to translate the calculated coordinates to the aiming-bow of the stereotactic frame.[10,13,21] 3) Brain shift may be introduced by the change of head position on the operating table compared to the head position during the scan as well as by cerebrospinal fluid escape and air entry during electrode insertion through the dura mater.[10,11,13]

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