Bilateral cingulotomy

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Bilateral cingulotomy
ICD-9-CM01.32

Bilateral cingulotomy is a form of

anterior cingulate gyrus.[6]

History

Cingulotomy was introduced in the 1940s as an alternative to standard pre-frontal leucotomy/lobotomy in the hope of alleviating symptoms of mental illness whilst reducing the undesirable effects of the standard operation (personality changes, etc.). It was suggested by American physiologist John Farquhar Fulton who, at a meeting of the Society of British Neurosurgeons in 1947, said "were it feasible, cingulotomy in man would seem an appropriate place for limited leucotomy". This was derived from the hypothesis of James Papez who thought that the cingulum was a major component of an anatomic circuit believed to play a significant role in emotion.[7] The first reports of the use of cingulotomy on psychiatric patients came from J le Beau in Paris, Hugh Cairns in Oxford, and Kenneth Livingston in Oregon.[7]

Target

Bilateral cingulotomy targets the

cingulate gyrus, parahippocampal gyrus, amygdala, and the hippocampal formation.[8]

Studies in patients who were subject to bilateral cingulotomy, involving

cognitive control and is highly likely to be involved in the control of attentional response, whereas the dorsal part of that region of the brain was not identified to be involved in such a process, although this is still under dispute.[9] The function of the dorsal part of the cingulate cortex was connected to the sorting out and processing of conflicting information signals. In addition, neuroimaging studies also indicated that the anterior cingulate cortex participates in the modulation of cortical regions that are of higher order, as well as sensory processing areas.[10]

These findings have also been confirmed by

cognitive tasks that require attention, based on the fact that there was a change in the basal firing rate of neurons in that region during simulation of such tasks.[9]

Neuroimaging also uncovered different sub-regions in the anterior cingulate cortex itself, based on their function. These studies showed that the

electrophysiological investigation of the function of neurons in the anterior cingulate cortex, have provided insights that can be used in the improvement of cingulotomy performed on patients treated for obsessive–compulsive disorder (OCD). The basis behind this idea is the fact that a variation of certain tasks, emotional Stroop tasks (ES), which have been particularly identified as exerting effects in OCD patients, activate neurons in the more rostral part of the anterior cingulate cortex. Thus, theoretically, if bilateral cingulotomy is performed in such a patient in the rostral anterior cingulate cortex, better results should be obtained.[9][10]

Moreover, OCD has been associated with a malformation of the

supplementary motor cortex.[14]
All these underline the high likelihood that the anterior cingulate cortex must have some involvement in OCD.

Functional

nociceptive information input. In particular, the role of the anterior cingulate cortex is in the interpretation of how a stimulus affects a person rather than its actual physical intensity.[15][16]

Procedure

A book published in 1992 described how the operation was carried out at that time. In most cases the procedure started with the medical team taking a number of

lesions were created. In order to confirm whether lesions are made at the right place, scan images were taken postoperatively and analyzed.[17]

Recent technological advances, however, have made bilateral cingulotomy a more precise operation. For example, nowadays a

stereotactic coordinates of the target in the anterior cingulate cortex, where lesions need to be made. Moreover, the MRI enables more precise differentiation of the cell composition, and thus easily permits the identification of the grey matter in that region. This can then be further confirmed with the help of microelectrode recordings.[18]

Side effects

Patients usually recover from this operation over a period of four days. However, there are cases of subjects being released from hospital after as few as 48 hours after the operation. The mild shorter postoperative complications that are most commonly related to bilateral cingulotomy are typical of head interventions and include but are not limited to

seizures that sometimes appear up to two months after the surgical intervention. It has been questioned whether this is relevant and can be attributed to cingulotomy because such seizures were observed in patients who already had a history of this condition.[19]

Case studies

A 2002 study conducted at the Massachusetts General Hospital analyzed the outcome of bilateral cingulotomy in 44 patients for the treatment of OCD in the period between 1965 and 1986. Patients were followed up over a long term and evaluated based on several criteria: 1) how many of them were responders[a] after a period of six months, 2) how many cingulotomies a patient had undergone before the examination of the effectiveness of the procedure, 3) whether the patient showed any significant change after the most recent procedure, and 4) what the side effects related to the procedure were.[19]

The follow-up of the patients produced contradictory results, which indicated that bilateral cingulotomy is not the optimal treatment for OCD.

urinary disturbance, ranging from urinary retention to incontinence. Hydrocephalus (2%) and seizures (2%) were also observed.[19]

Bilateral cingulotomy has also been used in the treatment of chronic refractory pain. A systematic review of 11 studies encompassing 224 patients found that anterior cingulotomy led to significant pain relief in greater than 60% of patients post-operatively as well as at one year following the procedure.[5] Of the included studies, one clinical study investigated the effect of bilateral cingulotomy for the treatment of refractory chronic pain.[20] In this case, 23 patients who were subject to 28 cingulotomies in total were followed up. The analyses aimed at determining how much the pain of each individual was affected after the procedure with the help of a questionnaire. In addition, the examiners tried to evaluate the impacts on social and family relations of the participants in the study. Based on the data obtained, cingulotomy for treatment of chronic pain showed promising results. 72% reported improvement in the level of pain experienced, and 50% indicated that they no longer required painkillers after cingulotomy. More than half of the patients also claimed that the surgical procedure was beneficial and contributed to the improvement of their social interactions.[20]

See also

Notes

  1. Yale–Brown Obsessive Compulsive Scale
    metric as well as self-reported OCD symptoms, depression, or anxiety as either "moderately" or "much better" as a result of a cingulotomy. The study also considers "partial responders", or individuals who saw clinical noted improvement in just one metric or were able to attribute their health outcomes to another procedure or intervention.

References

  1. S2CID 24413156
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  2. S2CID 33760018
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  3. S2CID 27264612
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  4. ^ A. Carter and W. Hall 2012 Addiction neuroethics: the promises and perils of neuroscience research on addiction. Cambridge University Press: 188-9.
  5. ^
    PMID 27906933
    .
  6. doi:10.1192/apt.10.3.189
    .
  7. ^ a b S Corkin (1980) A prospective study of cingulotomy. In ES Valenstein (ed) The psychosurgery debate: scientific, legal, and ethical perspectives. San Francisco, WH Freeman and Co: 164-204
  8. ^ Kandel E., Schwartz J., Jessel T., .. (2000). Principles of Neural Science.4th edition, McGraw-Hill, New York, 853-857.
  9. ^
    S2CID 2305149
    .
  10. ^
    S2CID 17231967
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  11. ^ a b Kandel E., Schwartz J., Jessel T., .. (2000). Principles of Neural Science.4th edition, McGraw-Hill, New York, 1223-1224.
  12. ^ a b c Leckman. (2000). Tic Disorder. Neuropsychopharmacology: The Fifth Generation of Progress
  13. ^
    S2CID 44408152
    .
  14. PMID 10570756
    .
  15. PMID 9772262
    .
  16. PMID 12571120
    .
  17. ISBN 0-06-016405-0
  18. S2CID 23872653
    .
  19. ^
    PMID 11823270
    .
  20. ^
    PMID 10549929
    .

External links
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