An Evaluation of Anterior Cingulotomy for Ongoing Pain

James Gillespie
Introduction
Psychosurgery, a form of brain surgery that destroys tissue in an effort to treat mental
illness, is unsurprisingly a controversial subject. In the wake of the disastrously overused
transorbital lobotomy several more focused procedures arose including the anterior cingulotomy.
This surgery had the somewhat unique application of serving as a treatment for intractable pain
in addition to several mental disorders. However it is not without its limitations and remains a
controversial procedure today. In this paper I will argue that this procedure is justified as a
treatment for severe pain among the terminally ill and ought to more often be offered as an
option for patients. In the case of non-terminal chronic pain this surgery should only be
performed on patients with a strong emotional aspect to their pain.

History
The first widely used psychosurgery was developed by Antonio Moniz, a Portuguese
physician, in the 1930s. In what he called a leucotomy he inserted an instrument called a
leucotome through a hole made in the skull and used it to cut tissue in the frontal lobe. The
operation sought to treat severe mental disorders by severing white matter tracts thought to be
involved in personality and behavior. This technique was adapted by American neurologist
Walter Freeman into the transorbital lobotomy in 1946. Unlike Monizs leucotomy, this
procedure went through the thin bone of the orbit, eliminating the need for surgery. As a result of
its ease and the lack of psychiatric medication at the time the transorbital lobotomy quickly
became commonplace. Approximately 40,000 people ultimately underwent the procedure, many

without severe disorders. Many others were residents of mental instructions operated on without
consent. The side effects of the lobotomy, including intellectual and emotional deficits as well as
death gradually became known. Soon public opinion changed and the lobotomy left as quickly as
it had arrived. In the modern United States the procedure remains an often cited example of
medicine gone out of control. However misused it may have been, some patients did see
significant relief of symptoms. With this in mind some research was done into alternative, more
precise surgeries. One of these was the anterior cingulotomy, which targets the fibers of the
cingulum within the anterior cingulate gyrus. Throughout its history it has been used to treat a
variety of mental disorders, but modern usage is mostly limited to chronic pain, OCD, and major
depressive disorder. It is unclear exactly how many anterior cingulotomies are performed each
year, but it is a fairly small number. The largest studies have fewer than 200 subjects over
multiple decades. This is likely due to alternatives in the form of modern drugs and the pall cast
on psychosurgeries by the lobotomy.

Role of the anterior cingulate and effects of lesions

The cingulate gyrus is a major component of the limbic system, which is involved in
emotion, learning, attention, and memory. It receives input from the neocortex and thalamus and
sends projections out via the cingulum. It is these projections that anterior cingulotomies seek to
sever. Specifically, by making a more anterior lesion, the hope is to sever fibers from the anterior
cingulate while sparing the rest. The anterior cingulate has been implicated in decision making,
reward, impulse control, emotion, and pain registering. Specifically it is believed to be a key
component of assigning emotional significance to pain. These functions make the anterior
cingulate a target for OCD, depression, and chronic pain treatments. By severing the projections

from this area in a pain patient it is hoped that the patient can be made to be more tolerant of
their pain. Unlike a lesion of the spinal cord or thalamocortical fibers, such a lesion should not
affect the patients ability to feel pain or touch. Rather the idea is they will not be bothered so
much by the pain. This is especially attractive in the case of long term pain that is either
unresponsive or only responsive to strong opioids.

Side effects and risks

As may be apparent by its multiple treatment usages, cingulotomies may have effects
beyond simply modifying pain behavior. Unfortunately relatively few studies have been done on
this procedure and of those fewer still looked into mental side effects. Thomas Ballantine, one of
the early pioneers of the surgery, did conduct some preliminary investigations. In one paper he
published with Dr. Wayne Hurt they were unable to document any unwanted changes in
intellect, memory, personality, or other psychological functions1. However another study by
Faillace et al. was able to observe some small behavioral changes with again no intellectual
impairment2. One thing that does seem clear is that the mental changes brought on by this
procedure are relatively minor compared to both earlier psychosurgeries and most psychiatric
drugs. Unlike the mental effects, physical risks and side effects are well understood and are fairly
typical for a brain surgery. There is always a risk of unforeseen damage or even death, but these
are very rare. Transient fever or headaches may occur in the first few days of recovery.

Limitations
While many patients have experienced significant improvement in life quality following
an anterior cingulotomy, many others have not. Ballantine observed a success rate of 67% for

some degree of improvement1. Meanwhile another neurosurgeon, Dr. Donald Wilson, was only
able to achieve pain relief in about half of his patients3. One explanation of this disparity both
between studies and between patients is selection criteria. A 1972 study Dr. Foltz out of the
University of Washington suggests that cingulotomies are useful for treating pain with a strong
emotional factor. When selecting for patients with this attribute they achieved improvement in
91% of patients, with 77% reaching either a good or excellent outcome4. This places a great
deal of importance upon proper diagnosis and patient selection, likely with psychiatric analysis.
Another limitation of the anterior cingulotomy is its long term success. In 1975 a study
investigating surgeries for pain looked into patients that had anterior cingulotomies. They found
that only about half of patients continued to experience relief until death5. However it should be
noted that these patients were not selected based upon the aforementioned emotional criteria and
there were only 21 of them. Ballantine observed much better sustained results with the exception
of progressive diseases (typically cancers)1.

Surgical modification of behavior

Despite their differences, the various psychosurgeries remain bound by their one common
thread they seek to modify behavior by damaging the brain. This distinguishes the cingulotomy
from other pain surgeries like nerve ablations that instead affect sensation. This is really unique
as far as surgery goes and falls much more in an area typically occupied by psychiatry. Ethically
this raises some concerns. First of all some may take issue with a procedure that detaches pain
from emotion. Will these patients become unconcerned with their own safety? Will they lose
some empathy for the pain of others? In addition the emotional nature of the pain that is most
effectively treated may cause some to wonder if surgery is the right method of treatment. Perhaps

talk therapy or lifestyle changes could also improve this pain in a way that is more conducive to
personal growth and more permanent. And strong pain medications may not be desirable for
patients, but they can always be stopped or dose modified. A surgery like this is a permanent,
deliberate change in a patients personality. With all of this in mind it is clear that surgery should
not be the first option. However this does not invalidate it as a treatment. Even when patients that
respond well to moderate medication or therapy are removed there is still a massive population
of pain patients. In each case the personality changes of the surgery must be weighed against the
potential pain relief, but that is a choice that patients ought to have the opportunity to make.

Consent
If it is agreed that this is a valid option, great care must be taken to ensure proper
informed consent is achieved. A permanent personality change should not be undertaken lightly.
This raises a problem because of the emotional distress many potential patients will be under. For
example depression and chronic pain are often associated. In fact, due to the emotional
connection, depressed pain patients may make some of the best candidates for cingulotomy. So,
to what extent can a depressed patient consent? This is an issue in any decision of course, but is
especially important here because of the irreversible nature of the surgery. It is my view that
informed consent can be given so long as the desire for the surgery is not being driven by
depression. This would likely necessitate considering past behavior and desires, which is likely
doable by using experience gained from the previous attempts at treating the patient nonsurgically. The psychiatric consult, while determining emotional connection with pain, can also
try to assess the impact of depression and ability to consent. Anterior cingulotomies in particular
have the advantage here of also being used as a treatment for major depressive disorder. It may

be possible to effectively kill two birds with one stone once consent is attained. Unfortunately
the situation is further compounded by the case of chronic pain due to an ongoing disease. If a
patient is dying from cancer they may be miserable as an appropriate reaction rather than as a
sign of pathological depression. I think that this case is similar to the application of physician
assisted suicide laws. In both cases patients seek to escape their suffering, albeit in different
ways. Thus the assisted suicide consent process can be co-opted for cingulotomy. The patient
must simply express the desire for the surgery on two separate occasions to ensure it has been
property considered. This will work in addition to the opinions of the patients doctors and
psychiatric consult.

Terminal patients with severe pain

Patients with terminal diagnoses make potentially excellent candidates for anterior
cingulotomies. It makes sense that pain associated with dying would have a strong emotional
component, meaning many of these patients are likely to have good outcomes. These patients are
also often taking powerful opioids in increasingly high doses in an effort to make their final
months comfortable. The unfortunate side effect of this is that they are effectively put in a stupor.
While their pain may be reduced, they certainly do not enjoy a fulfilling life in this state. Its no
wonder that some patients choose to avoid the medications and either endure the pain or end
their lives prematurely. Anterior cingulotomies provide an attractive alternative to this choice.
Should the surgery succeed it will allow these terminal patients to achieve relief from paincaused suffering while also allowing them to remain consciously sharp. This is important for
patients who want to spend meaningful time with loved ones or achieve some goals they value
before end of life. And terminal patients would have no concern for the potential decay of relief

over time. They only need relief for the next year or so following the surgery. Ordinarily a
patient discontinuing strong opioids, even if their pain problem was solved, would suffer severe
withdrawal. However cingulotomies have the incredible and convenient effect of also treating
narcotic withdrawal. Dr. Foltz also found that out of 19 addicted patients undergoing
cingulotomy for pain, 7 had only mild withdrawal symptoms and 11 had no withdrawal
symptoms at all. The remaining patient with normal withdrawal was attributed to an inadequate
lesion4. This has been supported by other studies directly aimed at treating addiction. Finally, the
ethical concern about permanent modification is not such an issue with terminal patients. In an
end of life scenario any treatment is permanent, so surgery is hardly different from medication.
And these patients may be much more willing to accept the risks of surgery than someone who
still expects to be around for decades. The primary goal of treating terminal patients is alleviating
suffering. Unlike most patients they dont need to go back to work or be concerned about health
outcomes years away. With all this in mind I think anterior cingulotomies ought to more readily
be offered to patients with impending terminal diagnoses as an option. Of course care must still
be taken to ensure informed consent is properly attained and that other options like therapy are
explored as well. Cingulotomies have a place in the increasingly interdisciplinary and patient
specific world of pain management.

Non-terminal chronic pain patients

Anterior cingulotomies can also be beneficial to patients with so called central pain.
Like pain from an ongoing disease this pain will continue over the long term, perhaps the
entirety of the patients life. Where the two differ is that chronic central pain is not due to any
observable tissue damage, thus the label of central. This chronic pain is thought to be a result

of some process in the central nervous system rather than peripheral nociception. As a result it
has a great potential to be significantly emotionally linked. Chronic pain therefor makes a good
target for both therapy and cingulotomy. However, because these patients will be living with the
aftermath of this surgery for decades, there are some additional concerns not present for terminal
patients. First of all, just as the pain arose without physical cause, it may depart in the same way.
Lifestyle changes, therapy, or even just time can sometimes solve cases of central pain. This
makes the invasive surgery with its risks and side effects potentially superfluous. There is also
the concern of the surgerys benefit potentially decaying over time. Unfortunately there is only
minimal data on whether or not this is a common problem. Therefore, until more research is
done, it should be considered a potential risk. Permanent personality modification is also a
potential issue. While the personality changes observed are not massive, they are present and
could be a concern to patients and family. Ultimately it seems clear that proper patient selection
is very important in this group. Good candidates must have a strong emotional connection to
pain, express informed consent, and have tried most alternatives. A major surgery like this should
be a kind of last resort. In the cases where such a point is reached however this procedure can be
a valuable option.

Patients not recommended

Non terminal patients with pain due to tissue damage do not make attractive candidates.
Research suggests that these patients are especially susceptible to loss of relief over time
following surgery. Research has not been done on this, but it logically follows that these patients
would have a relatively low emotional component to pain as well. Their pain is acute and likely
not a central focus of their life. Along with this, acute pain is expected to resolve as tissue heals.

It is therefore not desirable to subject patients to a permanent procedure for a temporary problem.
This may not apply to all acute pain patients; some diseases may cause pain for years without
being a threat to life. However when compared to the other categories mentioned so far this is a
fairly small population. And they still have a good chance of relief decay over time. Unlike
central pain, acute pain is also very often treatable with medication, which has the advantage of
being temporary. Drugs may also have their dosages changed to account for the place of the
specific patient at a specific point in their lives. Cingulotomies on the other hand are irreversible
and not patient specific procedures. As a major surgery they also carry greater risks than drug
treatment, which may be especially important to non-terminal patients. Even in the uncommon
case where acute pain has proven untreatable by medication, cingulotomy is still probably not
the preferred surgery. A procedure that severs afferent fibers carrying pain information would
likely prove a better solution. Either nerve ablation or a cut in the dorsolateral spinal cord could
treat pain without altering the patients self. It seems that organic pain in non-terminal patients
should rarely, if ever, be treated by anterior cingulotomy.

Confounding variables
Suffering caused by pain does not occur in a vacuum for anyone and neither do surgeries
that modify this. A great number of outside variables can influence impact of the pain and
success of cingulotomy as a treatment. The patients affect is especially important here. As has
been previously mentioned, depression is often associated with chronic pain or pain due to
terminal disease. And this can go both ways, with depression making pain worse or long term
pain leading to depression. This is very relevant for cingulotomy. On the one hand pain with a
high emotional component appears to be the most amenable to the surgery. But on the other

hand, if depression is the underlying problem, a cingulotomy may relieve pain without
addressing the root cause of suffering. Or a patient who develops depression post-surgery may be
at risk for relapsing into pain. Unfortunately, as far as I know, no research has been done on this.
A patients lifestyle can also have a great deal of impact upon pain. A patients diet, sleep,
exercise, job and many more attributes may all affect degree of pain and the effect it has upon
ones life. These factors may change by the week, month, or year. In this way a permanent
surgery is being used in conjunction with constantly fluctuating variables. And these lifestyle
factors are not independent they interact with each other and with the patients affect. A stressed
patient may also not sleep enough and an unemployed patient may have less to occupy their
mind from the pain. So it should be noted when considering surgery that the state of the patient
when he or she is evaluated is not a representation of a static person. What may look like a
desirable candidate one day may seem much less so a month later. And likewise a reduction in
suffering may not always be a consequence of the surgery.

Additional research
One thing that seems clear from researching this procedure is that there is very little data
on it. Likely in part due to the fear of psychosurgeries inspired by the lobotomy, the vast majority
of research on anterior cingulotomies was done in the 1970s. Since that time our understanding
of the brain has improved by leaps and bounds, as has our technology used to study it. Looking
back on these 40 year old studies it seems almost tragic how limited they are. And even during
their greatest use, anterior cingulotomies were fairly uncommon. Many studies had less than 50
subjects, with some even less than 10. And they had a great deal of variance in terms of patient
selection and outcome evaluation. All of this makes it difficult to draw solid conclusions from

the data. Now this is not to suggest that these studies were not useful, in fact they made a great
first step into investigating a potentially useful procedure. The problem is that research never
really progressed far beyond this first step. If this procedure becomes popular enough to collect
decent sized cohorts then hopefully it can be further understood and more accurately applied.

Conclusion
The anterior cingulotomy, along with other psychosurgeries, has fallen out of favor in the
past few decades. However it still has a potential use in the treatment of pain which should not
be ignored. This procedure hinges upon modifying the emotional aspect of pain through a lesion
of the anterior cingulate gyrus. Its success rate rests heavily upon selecting patients with a strong
emotional attribute in their pain. It makes an attractive option for terminal patients who are in a
unique place to reap the full benefits of the surgery while avoiding many of its drawbacks. Non
terminal chronic pain patients may also benefit, but such a surgery should not be performed too
readily due to its nature as a permanent behavior modifier. Pain-related suffering is linked to
many variables which much be considered holistically when selecting and evaluating candidates.
If anterior cingulotomies are to be more often utilized then further research must be done to fill
in the crucial gaps in our knowledge on the subject. This procedure has the potential to relieve a
great deal of suffering and it worth consideration.

References
1. Hurt RW, Ballantine HT Jr. Stereotactic anterior cingulate lesions for persistent pain: a
report on 68 cases. Clin Neurosurg 1974;21:334351.
http://www.ncbi.nlm.nih.gov/pubmed/4370936
2. Faillace LA, Allen RP, McQueen JD, Northrup B. Cognitive deficits from bilateral
cingulotomy for intractable pain in man. Dis Nerv Syst 1971;32:171175.
http://www.ncbi.nlm.nih.gov/pubmed/4929083
3. Wilson DH, Chang AE. Bilateral anterior cingulectomy for the relief of intractable pain:
report on 23 patients. Confin Neurol 1974;36:6168.
http://www.ncbi.nlm.nih.gov/pubmed/4824974
4. Foltz EL, White LE . The role of rostral cingulumotomy in pain relief. International
Journal of Neurology 1968;6(3):353-73. http://www.ncbi.nlm.nih.gov/pubmed/5759640
5. Voris HC, Whisler WW. Results of stereotaxic surgery for intractable pain. Confin
Neurol. 1975;37(1-3):86-96. http://www.ncbi.nlm.nih.gov/pubmed/1093800

See Also
Bouckoms AF (1989) Psychosurgery for pain. In: Wall PD, Melzack R, eds., Textbook of Pain.
Edinburgh: Churchill Livingstone, 868-81.
Christmas et al.. (2004). Neurosurgery for mental disorders. Advances in Psychiatric Treatment,
10, 189-199.
Mashour, G.A.; Walker, E.E.; Martuza, R.L. (2005). "Psychosurgery: past, present and future".
Brain Research Review 48 (3): 40918