“You are not alone! 10-15% of people suffer from depression. There is an effective treatment for depression available, even for severely depressed patients….

Lesion Procedures

Ablative surgery to treat mental illnesses is one of the therapies that has expanded more rapidly and widely as a non-pharmacological therapy. Throughout the decades many targets, approaches and techniques have been tried, with diverse and sometimes contradictory outcomes. Although the effects on mood gained the attention of medical community, due to the growing prevalence and socioeconomic burden, often no objective measurement of the effects was performed and probably misdiagnosed patients were included into the studies.

Jean Talairach, based on the leucotomy work, got the idea to disconnect front thalamic fibers e.g. fibers running between the subgenual anterior cingulate cortex and the orbitofrontal cortex and the medial, anterior and dorsomedial thalamic nuclei. The procedure represented, in that way, a restricted lobotomy procedure and was performed stereo tactically by electrocoagulation between the anterior and mid third of the anterior limb of the internal capsule at the level of the interventricular foramen. Lars Leksell propagated this procedure in Sweden where the procedure also have been performed with the gamma knife.

During the course of years, the target got more refined. Additional information suggested that the ventral part of the internal capsule was surrounded by functionally active an important areas like bed nucleus of stria terminals, nucleus accumbens, ventral striatum etc. Nuttin et. al showed that the initial Capsulotomy target can be further modified to move posteriorly and ventrally to achieve better outcomes. The current strategy is to use stereotactic techniques to make a lesion in the VC/VS area.

Results There is no age limit for the surgery but Capsulotomy below the age of 20 has not been reported. The anterior Capsulotomy has been reported to be especially effective against obsessive compulsive disorder with a long lasting improvement among 48–78%. Side effects are generally few and shortlift consisting of headache, confusion, urinary incontinence and weight gain. The most prevalent side effect is tiredness and lack of initiative. This lethargia, although generally transient, has been reported to last for several weeks or months and at least in some case may result in a persistent mild apathy or dominant frontal lobe syndrome.

Cingulectomy (cingulotomy)

In 1967, Ballantine described the first stereotactic anterior cingulotomy for psychiatric disorders including depression, after the publication of reports by Foltz and White, who by that time had carried out stereotactic cingulotomies in patients with untreatable pain. The stereotactic neurosurgical technique was applied for the first time in patients by Spiegel and Wycis in 1947. It was a milestone in neurosurgery because specific deep targets could be reached through one burr-hole by using internal cerebral landmarks. Ballantine reported an improvement in 77% of operated patients with comorbid fear and depression. Other studies showed an improvement between 44% and 92% with personality changes, epilepsy, weight gain and urine incontinence as the most reported side effects.  Cingulotomy is more commonly used for treating depression than OCD.