A term to describe a range of neurosurgical procedures conducted with the intention of minimizing or alleviating disabling psychological and emotional symptoms. Although crude behaviour modifying brain operations have been performed throughout human history (see TREPANNING) the introduction of modern neurosurgical procedures into the management of intractable mental disorders is generally attributed to the Portuguese neurologist Antonio Egas Moniz. His collaboration with the neurosurgeon Almeida Lima led to the therapeutic use of a widespread destructive LESION of WHITE MATTER tracts connecting the FRONTAL LOBE with posterior brain regions. Such was the reported success of these LEUCOTOMY (cutting the connections between frontal lobe and THALAMUS) or LOBOTOMY (disconnecting the frontal lobes from the remainder of the brain—also called FRONTAL LOBOTOMY) procedures in a previously untreatable population of psychiatric patients, particularly those with SCHIZOPHRENIA, Moniz was awarded the Nobel Prize for Physiology or Medicine in 1949. Unfortunately, adaptations of the Moniz and Lima procedure were enthusiastically and uncritically adopted across the world and many thousands of operations were conducted for a broad range of problems that strayed far beyond the original therapeutic remit, including criminal behaviour, AGGRESSION, childhood defiance and political opposition. As a consequence of such widespread and injudicious use of a poorly evaluated and irreversible treatment, a forceful and sustained opposition evolved that resulted in the abolition, or near-abolition, of such treatments in most developed countries.
Around the same time, the first effective chemical ANTIPSYCHOTIC and ANTIDEPRESSANT treatments were discovered, substantially alleviating the pressure to consider surgery.
Despite the disreputable history of psychosurgery, the combination of advances in modern FUNCTIONAL NEUROIMAGING and STEREOTAXIC SURGERY with an enhanced understanding of the anatomy and functional relationships between the FRONTAL CORTEX and other brain structures has resulted in the re-emergence of neurosurgery as a viable and ethical treatment option in intractable mental disorder. Stereotaxic neurosurgery is performed in a number of treatment centres around the world; reserved as an option for patients with severe DEPRESSION, ANXIETY or OBSESSIVE COMPULSIVE DISORDER that is considered unresponsive to all conventional treatments. Despite its original use, it is not considered as a treatment option for schizophrenia. As a refinement of earlier, indiscriminate procedures, two specific target sites appear to offer maximal benefit with relatively minimal adverse effects: the white matter fibres in the anterior limb of the INTERNAL CAPSULE (anterior CAPSULOTOMY) and the anterior cingulate cortex (anterior CINGULOTOMY). As evidence accumulates from structural and functional brain imaging studies that both the MEDIAL PREFRONTAL CORTEX and the ANTERIOR CINGULATED CORTEX are involved in the pathophysiology of depression, a potential rationale is emerging for neurosurgical treatments. Although definitive data on treatment efficacy are lacking, a proportion of patients within this otherwise untreatable population derives significant benefit from neurosurgical treatment. Despite well-founded concerns about the likely adverse effects, evidence for impairments in cognitive and intellectual performance and for personality change post-surgery is absent.
