Chapter 42, Not Your Father’s Lobotomy: Psychiatric Surgery Revisited
Brian Harris Kopell, M.D., Andre G Machado, M.D. Ph.D., Ali R. Rezai M.D.
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DO NOTHING VERSUS DO SOMETHING: THE LEGACY OF LOBOTOMY
Over the past few years, interest in neurosurgery for psychiatric disorders has surged, largely owing to the success of neuromodulation devices such as Deep Brain Stimulation (DBS) for movement disorder surgery. With DBS now considered the gold standard of surgical treatment for advanced cases of Parkinson’s disease (PD), psychiatric surgery has become the new “cutting edge” of functional and restorative neurosurgical investigations. Yet, psychiatric surgery has an additional hurdle beyond the technical and epistemological challenges of any new medicine. It has to shed its own history. The connotations of the words “psychosurgery,” “lobotomy,” and “human experimentation” are obstacles beyond those usually encountered in the laboratory and operating room. In short, psychiatric neurosurgery enters the arena already possessing a bad name; an ignoble legacy that is more than a century old.
The Swiss psychiatrist Gottlieb Burckhardt, in reporting the results of cortical excisions for psychiatric symptoms in 1891 , felt compelled to justify himself to his doubting colleagues:
Doctors are different by nature. One stands fast in the old principle: “primum non nocere”; the other states: “melius anceps remedium quam nullum.” I belong naturally to the second category…Every new surgical approach must first seek its special indications and contraindications and methods, and every path that leads to new victories is lined with the crosses of the dead. I do not believe that we should allow this to hold us back…
“First, do no harm,” the dictum of the Physician to leave the patient in no worse shape than initially encountered, versus “Better an unknown cure than nothing at all,” the desire to alleviate a patient’s suffering with a seemingly new “cure,” despite a lack of insight into the physiology of the disease in question. It is this fundamental struggle between the obligation of the physician to remain cautious and the desire to help those in need that define the efforts to intervene surgically on the mentally ill. Other therapies, including the surgical treatment for Parkinson’s disease, have successfully developed after a period of empiric surgical experimentation. However, the same will no longer be possible with psychosurgery, given the given its emotional connotation to the general public.
In 1935, a fateful meeting occurred. At the Second World Congress of Neurology in London, John Fulton and Carlyle Jacobsen presented their work showing behavioral changes in chimpanzees after ablation of frontal lobe areas. (Fig. 42.1)Fulton and Jacobsen made the observation that frontal lobe ablation could result in the lessening of “anxiety states” in chimpanzees. In attendance at that meeting was a Portuguese neurologist by the name of Egas Moniz and an American neuropsychiatrist by the name of Walter Freeman. (Figs. 42.2 and 42.3)
Drawing from Fulton and Jacobsen’s data, as well as synthesizing case reports of neurosurgeons operating on various frontal lobe lesions at the time, Egas Moniz formulated a bold plan: to sever the white matter bundles connecting frontal lobe regions with the rest of the brain, the frontal leucotomy. He convinced a young neurosurgeon in Libson, Almeida Lima, to undertake the procedure and a series of twenty patients commenced. (Fig. 42.4)
In 1936, Walter Freeman happened upon Moniz’s initial communications regarding frontal leucotomy in the journal Lisboa Medicina and brought the “Miracle of Moniz” to the United States, having convinced a neurosurgeon by the name of James Watts to help him in his endeavor. They modified the Moniz technique, abandoning the Moniz leucotome for a dull, flat knife known as a bistoury (Fig. 42.5) and, approached from the side rather than the top (Figs. 42.6 and 42.7) in an effort to streamline the procedure. The Moniz procedure, frontal leucotomy, became the Freeman-Watts technique, the prefrontal or standard lobotomy.
Yet this was not enough for Freeman. Drawing from an obscure report of an Italian psychiatrist, Amarro Fiamberti, Freeman developed the transorbital lobotomy, a procedure in which the frontal white matter is cut by a metal spike inserted through the thin bony orbit above the eye. Freeman’s initial choice to accomplish this procedure was the common ice pick.
Although Freeman, refined the common house tool into what he called a “transorbital leucotome,” he envisioned the procedure being able to be performed by any surgically untrained physician after the most minimal of instruction. “Every physician his own lobotomist.” In 1948, Freeman, with ice pick in hand, traveled across the country to fulfill what he considered to be an unanswered need (Fig. 42.8) . It did not take long for Watts to sever his ties with Freeman. Like other neurosurgeons, he was horrified at the ghastly treatment patients received under Freeman’s new procedure.
Yet “free” from his restrictive association with Watts, Freeman operated in earnest. Freeman and Watts recorded 625 operations between 1936 and 1948. By 1957, Freeman had lobotomized another 2400 patients. In one 12-day period, he operated on 225. Time magazine heralded the age of “mass lobotomies.”
“What are these terrible things I hear about you doing lobotomies in your office with an ice pick?” scolded John Fulton, whose animal work was the basis for lobotomy. “Why not use a shot gun?” Freeman calmly responded that his transorbital procedure was “much less traumatizing than a shotgun and almost as quick.” In the end, Freeman’s kind of psychiatric surgery was not stopped by the outrage of colleagues, but by the advent of chlorpromazine, which was approved by the Food and Drug Administration in 1954. The death knell for psychiatric neurosurgery had sounded, yet Freeman carried on his one-man war. On occasion, Freeman would dump shoeboxes crammed with letters from “grateful” lobotomized patients onto the desks of skeptical colleagues. They, however, remained unconvinced. Freeman died in 1972, at the age of seventy-six.
THE STEREOTACTIC ERA
Yet even as lobotomy was dying, psychiatric surgery was to be reborn as the herald of a new frontier in neurosurgical practice: the application of stereotaxis. In 1947, Wycis and Spiegel introduced the dorsomedial thalamotomy, the first subcortical stereotactic neurosurgical procedure performed on humans and the model on which modern psychiatric neurosurgical procedures are based. , The process of stereotaxis involves the definition of the brain as volume in a Cartesian three-dimensional space. This space can be referenced to a specific coordinate system. The process allowed, for the very first time in history, precise accuracy and the ability to reach subcortical structures with minimal disruption of brain tissue. These stereotactic techniques have been coupled with the latest developments in computer database, functional imaging, and physiological recording technology.
The four psychiatric neurosurgical procedures that benefited from these techniques are cingulotomy, capsulotomy, subcaudate tractotomy, and limbic leucotomy. Today, only cingulotomy, capsulotomy, and limbic leucotomy are practiced with any frequency. Many of the following studies of psychiatric neurosurgery do have significant flaws, most notably the inherent bias of a nonrandomized, nondouble-blind study. They do, however, suggest a viable means of treatment for a subset of patients who may have no other options. It is important to place these procedures in the context of the physiological systems previously described to make sense of their functional strategy. Ultimately, all of the following procedures seek to modulate the activity of the dorsolateral frontal, orbitofrontal, and cingulate cortices and their interactions with the basal ganglia and thalamus.
In 1967, Ballantine introduced the modern stereotactic procedure in which a thermocoagulative lesion, localized by air ventriculography, was made bilaterally in the anterior cingulate. The lesion is typically 2 to 2.5 cm from the tip of the frontal horns, 7 mm lateral from the midline, and 1 mm above the roof of the ventricles, bilaterally. Such a lesion would be expected to affect the cortico-striato-thalamo-cortical (CSTC) loops by interrupting reciprocal activity from the dorsal anterior cingulate cortex (ACC) to the orbitofrontal gyrus (OFC), amygdala, and hippocampus via the cingulum bundle. , The procedure performed today has been refined using the latest stereotactic equipment and imaging techniques. Stereotactic cingulotomy is the most reported neurosurgical procedure for psychiatric disease in the United States and Canada.
Historically, response rates for patients with obsessive-compulsive disorder (OCD)-like symptoms following cingulotomy were reported as high as 56%. However, the studies were hampered by investigational bias and lack of modern psychiatric assessment tools. In 2002, the most recent study of cingulotomy for OCD, 44 patients were studied prospectively using current methodologies and rigorous screening. At a mean of 32 months after one or more cingulotomies, 32% of the patients met conservative criteria for response and 14% were partial-responders. For major depression, the largest study reported a 68% response rate, with 42% of patients being reported as “recovered.” A more recent study, performed in the era of MRI guidance, corroborated these results with 60% of 34 patients with unipolar depression responding to treatment.
No deaths have been reported with an experience of 1000 cingulotomies performed at Massachusetts General Hospital, with clinical significant hemorrhage rate at 0.03 %. , Other adverse effects include seizures and hydrocephalus with rates similar to other stereotactic procedures. There have been no significant permanent behavioral or cognitive changes reported.16
Developed in Sweden by Lars Leksell and in France by Jean Talairach, anterior capsulotomy has been in use for refractory psychiatric illness since 1949. There are two forms of this procedure, both of which are stereotactic operations. One technique involves the use of radiofrequency and the other uses gamma radiation to make the lesion. In either case, the target area is between the anterior and middle third of the anterior limb of the internal capsule at the approximate level of the foramen of Monro. Specifically, the most commonly used target lays at 17 mm from the midline, 10 mm rostral to the anterior commissure, and 8 mm above the intercommissural line. The lesion is approximately 15 to 18 mm in length and 4 to 5 mm in width. , A recent study of gamma capsulotomy has a modified target that has evolved based on recent results. This modified target centers specifically around the ventral aspect of the anterior internal capsule.
Anterior capsulotomy probably exerts its effects on psychiatric symptoms by interrupting ventral fibers in the anterior internal capsule from the OFC and subgenual ACC to medial, dorsomedial and anterior thalamic nuclei.
Historically, response rates have been reported in the range of 48 to 78 %.16 Again, these studies were often retrospective and lacking in modern psychiatric assessment tools. Preliminary findings from an ongoing study of gamma capsulotomy utilizing modern response measures indicate a 27% response in patients receiving a single-shot bilateral lesion and 62% response rate in patients receiving two pairs of bilateral lesions.16
No deaths have been reported owing to capsulotomy itself. A single patient has been reported to have committed suicide in the perioperative period. Headaches, confusion, urinary incontinence, weight gain, and lethargy have all been reported with stereotactic thermocoagulative capsulotomy, although these adverse effects have been generally transient. In a sample of 200 thermocoagulative capsulotomy patients, no significant changes to behavior or cognition were measured. The Providence group’s experience with gamma capsulotomy has also found evidence of transient headaches and cerebral edema. Three of 31 patients had small, asymptomatic caudate infarctions. Although there were no group decrements in cognitive and personality testing, 1 of 31 patients developed a persistent mild frontal lobe syndrome manifested by apathy and amotivation.16