Psychosurgery: History of the Neurosurgical Management of Psychiatric Disorders

The persistent value of lesions in psychiatric neurosurgery

Neurosurgery for intractable psychiatric conditions has seen a resurgence with the increasing use of deep brain stimulation (DBS). Although DBS promises reversible neuromodulation and has become more popular than older lesioning methods, lesioning might still be preferred in specific cases. Here, we review the evidence for DBS and lesions in the treatment of intractable neuropsychiatric conditions and consider the factors that favour the continued use of lesioning procedures in appropriately selected cases. Broadly, systemic factors including comparative effectiveness, cost, and ethical arguments support an ongoing role for lesioning. Such a role is also supported by practical considerations including patient experiences of this type of therapy, the relative intensity of follow-up care, access to sparse or specialised follow-up care, and relative infection risk. Overall, we argue that neurosurgical lesion procedures remain an important alternative to DBS and their continued availability is necessary to fulfil the imperatives of mental health parity and enhance access to effective mental health treatments. Nonetheless, the efficacy of DBS and recent advances in closed-loop stimulation and remote programming might provide solutions to some of the challenges associated with wider use of electrical neuromodulation. Concerns about the scarcity of high-level evidence for the efficacy of lesioning procedures as well as the potential irreversible adverse effects of lesioning remain to be addressed.

New Directions for Surgical Ablation Treatment of Obsessive Compulsive Disorder

Although there are effective treatments available for many, probably most, patients with OCD, a significant number do not respond, or fail to experience a sustained beneficial response. For patients with such chronic, disabling and 'treatment-refractory' OCD, neurosurgical treatments may be considered. The best-established neurosurgical treatments are so-called ablative procedures, where targeted lesions are created with the intention of interrupting and modifying specific circuitry functions. There is a lengthy history of such procedures and a substantial literature although this is largely of an observational nature. However, both stereotactic radiosurgery (gamma knife) and MR-guided high intensity focused ultrasound are methods of lesion generation that lend themselves to the conduct of blinded randomised trial designs and these are beginning to be utilised. In this chapter, we present a narrative review of the key recent literature that describes the evidence for the safety and efficacy of lesion procedures for OCD. For context, we also consider the strength and quality of evidence relating to intensive residential treatment for OCD (sometimes proposed as an alternative to neurosurgery), furthermore, we also present some comparative data for lesion surgery and deep brain stimulation (DBS).