FUNCTIONAL NEUROSURGERY
2O
G. Rees Cosgrove, MD, FRCS (C), and Scott L. Rauch, MD
Since its introduction as a treatment for severe
mental illness in 1936, psychosurgery at various
times has been enthusiastically embraced and flatly
rejected by both the medical profession and society
at large. Currently, the accepted therapeutic ap-
proach to most psychiatric disease involves a
combination of well-supervised psychotherapy,
pharmacotherapy, and, in some instances, electro-
convulsive therapy. Despite these modern treat-
ment methods, however, many patients fail to re-
spond adequately and remain severely disabled.
In these patients, surgical intervention might be
considered appropriate if the therapeutic result and
overall level of functioning could be improved.
In this article, we will explore the historical back-
ground of psychosurgery and discuss the anatomic
and physiologic basis for such procedures. Guide-
lines for the appropriate selection of surgical candi-
dates will be presented and the four most common
psychosurgical procedures practiced today will be
described. Finally, overall experience, including in-
dications, results, and complications for each pro-
cedure, will be reviewed and compared.
HISTORICAL PERSPECTIVE
Although trephination performed by ancient civ-
ilizations may represent the earliest form of surgical
intervention for psychiatric disease, the first use
of psychosurgery in modern times was reported by
Burckhardt in 1891.8He described bilateral cortical
excision with mixed results in the treatment of six
demented and aggressive patients. Following this
report, several other neurosurgical procedures
were attempted for the treatment of the mentally
ill.27In 1935, Fulton and Jacobsen20presented their
early experience with primate behavior following
From Massachusetts General Hospital and Harvard Medic:a1 School, Boston, Massachusetts
NEUROSURGERY CLINICS OF NORTH AMERICA
VOLUME 6 . NUMBER 1 JANUARY 1995
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PSYCHOSURGERY
ablation of the frontal cortices. They observed that
the lobectomized animals demonstrated less exper-
imental neurosis to task failures, although they
were also less able to complete the tasks success-
fully. These observations prompted Egas M ~ n i z , ~ ~
the inventor of cerebral angiography, to perform
prefrontal leukotomies by injection of absolute al-
cohol, with the help of his neurosurgical colleague,
Almeida Lima. They reported that 14 of 20 severely
ill institutionalized patients showed worthwhile
improvement after operation and coined the
phrase psychosurgey to describe this intervention.
At that time, few satisfactory treatment options
existed and the asylums for the insane were over-
flowing with the chronic mentally ill. Therefore,
despite the lack of objective data and long-term
follow-up, an enthusiastic response was obtained
from the medical community, resulting in Moniz
receiving the 1949 Nobel Prize in Medicine and
Physiology.
One of the most enthusiastic proponents of the
procedure was Walter Freeman, a neuropsychia-
trist, and within a few months of Moniz's publica-
tion, Freeman performed the first prefrontal lobot-
omy in the United States with the neurosurgical
help of James Watts.17The Freeman-Watts prefron-
tal lobotomy was performed through bilateral bur
holes placed in the inferior frontal region at the
level of the coronal suture. This disconnection pro-
cedure was carried out with a specially designed
calibrated leukotome that was inserted blindly, ad-
vanced to the midline, and swept back and forth
to interrupt the white matter tracts in the frontal
lobes surgically. In reporting their results in 1942
on the first 200 patients, Freeman and Watts18were
favorably impressed, although they did admit a
significant complication rate, including frontal lobe
syndrome, seizures, apathy, decreased attention,
167
168 COSGROVE & RAUCH
and inappropriate behavior. Despite these side-
effects, prefrontal lobotomy became widely per-
formed throughout the United States, largely
because of the lack of satisfactory therapeutic alter-
natives and the promotional zeal of Freeman
himself.
Tooth and Newtodo reviewed 10,365 standard
prefrontal lobotomy operations performed be-
tween 1943 and 1954 and confirmed that the rate
of improvement was about 70%, but also reported
a 6% mortality, 1%epilepsy rate, and 1.5%marked
disinhibition. These complications prompted Ful-
ton19 and others to call for a less radical and more
specific approach to the surgery. By the late 1940s
more precise open surgical procedures were de-
scribed, including bilateral inferior l e ~ k o t o m y , ~ ~rior thalamic nuclei, cingulate gyri, and their inter-
bimedial l e ~ k o t o m ~and
, ' ~ orbital gyms under-
cutting.57Cerebral topectomies 51 and anterior cin-
gulectomies36,64 were also proposed and carried
out during the same period. At the same time,
Freeman16 described a new technique of transor-
bital leukotomy which involved inserting a small
right-angled instrument under the eyelid, pushing
it through the bony orbit into the frontal orbital
cortex, and severing the thalamofrontal radiations
with a sweeping motion. This so-called "ice pick
procedure" could be performed quickly and with
minimal anesthesia, which led to its ready accep-
tance and widespread use. The broad and some-
what indiscriminate application of this particular
technique contributed to the subsequent decline of
pyschosurgery.
The next major advance in the neurosurgical
treatment of psychiatric illness occurred with the
introduction of stereotactic techniques to create
well-localized and discrete lesions in-specific target
sites. Stereotactic anterior cingulotomy was first
reported by Foltz and White in 196215and subcau-
date tractotomy was carried out in England by
Knight in 1964.32 Lars Leksel17,25 described his ex-
perience with anterior capsulotomy soon thereaf-
ter, and Kelley et a131 reported limbic leukotomy
(subcaudate tractotomy and cingulotomy com-
bined) in 1973. Isolated reports of hypothalamot-
omy, l2 bilateral amygdal~tomy,~~ and thalamot-
omyw also can be found during this same time
period.
With the introduction of chlorpromazinein 1954,
satisfactory medical management of psychiatric ill-
ness became possible. The availability of effective
drug therapy, in combination with the side-effects
of surgical intervention and its excessive use in the
preceding decades, led to the sudden and almost
complete disappearance of pyschosurgery for men-
tal illness. Newer and even more specific psy-
chotrophic medications have been developed, but
there remains a small percentage of patients with
treatment-refractorypsychiatric disease that might
be considered for surgcal treatment. Because of
the ethical, legal, and social implications of psycho-
surgery, however, only a limited number of surgi-
cal procedures are carried out at a handful of medi-
cal centers in the world today.
ANATOMIC AND PHYSIOLOGIC
RATIONALE FOR PSYCHOSURGERY
In 1937, a year after Moniz reported his initial
experience with prefrontal lobotomy, P a p e pub-~~~
lished a paper in which he postulated that a rever-
berating circuit in the brain might be responsible
for emotion, anxiety, and memory. The compo-
nents of this circuit consisted of the hypothalamus,
septa1 area, hippocampus, mamillary bodies, ante-
connections. These structures comprise the rudi-
mentary limbic system of the human brain, which
was subsequently expanded by M ~ L e a in n ~1952
~ to
incorporate the orbital frontal, insular, and anterior
temporal cortices; the amygdala; and the dor-
somedial thalamic nuclei (paralimbic structures).
Neurosurgical interventions for psychiatric disor-
ders have all been directed at various targets within
this system, and therefore some have proposed
the term limbic system surgery as an alternative to
psychosurgery.
Although the neuroanatomic and neurochemi-
cal basis of emotion in health and disease re-
mains undefined, there is evidence that this
system and its interconnections with the cortico-
striato-thalamic circuits play a central role in
the pathophysiology of major affective illness,
obsessive-compulsive disorder, and other anxiety
disorders.44, 47 Electrical stimulation of specific
areas within the limbic system, i.e., the anterior
cingulum, has been shown in humans to alter both
autonomic responses and anxiety level^.^^,^^ Stimu-
lation of the hypothalamus in animals produces
autonomic, endocrine, and complex motor effects,
which suggest that the hypothalamus integrates
and coordinates the behavioral expression of emo-
tional states.26,53 The Papez circuit represents the
direct conduit to the hypothalamus. Paralimbic
structures form the link between heteromodal cor-
tex and the limbic system proper.40Thus, the lim-
bic system appears strategically located to mediate
and interconnect somatic and visceral stimuli with
higher cortical functions and in this way may add
emotional coloring to the psychic process.48 It is
intuitively appealing, therefore, to believe that psy-
chiatric disorders that are characterizedby affective
and cognitive manifestations (e.g., depression, ob-
sessive-compulsive disorder [OCD], and other
anxiety disorders) might reflect a final common
pathway of limbic dysregulation. Contemporary
neurobiologic models of anxiety and affective dis-
orders also emphasize the fundamental role of the
limbic system and its related structures.lO,22, 44, 47
Data from neuropyschologic, neurosurgical,
physiologic, and neuroimaging studies have also

converged to implicate a circuit composed of
orbitofrontal cortex, striatum, thalamus, and an-
terior cin ulate cortex in the pathophysiology
of 0CD.g 28, 44, 55 This frontal-striatal-pallido-
thalamic-frontal loop, which has been so well char-
acterized for its control of motor function, may well
be involved in some features of OCD, as many
similarities exist between OCD and the pathology
seen in Sydenham's chorea, von Economo's dis-
ease, focal striatal abnormalities, and Tourette's
syndrome. Anatomic imaging with MRI has sug-
gested focal abnormalities in these striatal areas63
and smaller caudate nuclei in patients with OCD.38 dacy requires that criteria for severity, chronicity,
Functional neuroimaging research also has sug-
gested that abnormal activity in the lateral frontal
cortex is a correlate of the depressive state in con-
cert with the presumed role of the limbic s ~ s t e m . ~ toms without significant remission, although
Neurochemical models suggest that the affective
and anxiety disorders may be mediated via mono-
aminergic systems. In particular, the serotonergic
system has received emphasis with respect to
OCD. Because of the diffuse nature of the monoam-
inergic projections and their role as neuromodula-
tors, however, these models are not particularly
instructive in terms of the functional neuroanat-
omy relevant to different neurosurgical treatments
as they are currently employed. Although the exact
neuroanatomic and neurochemical mechanisms
underlying depression, OCD, and other anxiety
states remain unclear, it is believed that the basal
ganglia, limbic system, and the frontal cortex play
a principal role in the pathophysiology of these
diseases.
SELECTION OF PATIENTS
Only patients with severe, chronic, disabling,
and treatment-refractory psychiatric illness should
be considered for surgical intervention. Chronicity
in this context refers to the enduring nature of the
illness without extended periods of symptomatic
relief. Moreover, the severity of the patient's illness
must be manifest both in terms of subjective dis-
tress and a decrement in psychosocial functioning.
In many cases, the chronicity of the illness may be
less important than the severity of the illness. The
illness must prove to be refractory to systematic
trials of pharmacologic, psychologic, and, when
appropriate, electroconvulsive therapy prior to
considering neurosurgical intervention. As in all
medical decisions, the potential benefit from such
an intervention must be balanced against the risks
imposed by surgery.
The major psychiatric diagnostic groups as de-
fined by the Diagnostic and Statistical Manual of
Mental Disorders, Third Edition, Revised (DSM-
IIIR) that might benefit from surgical intervention
include (1) obsessive-compulsive disorder and
(2) major affective disorder (i.e., major depression
or bipolar disorder).' In many instances patients
PSYCHOSURGERY 169
present with mixed disorders combining symp-
toms of anxiety, depression, and OCD, and these
patients remain candidates for surgery. Schizo-
phrenia is not currently considered an indication
for surgery. A history of personality disorder, sub-
stance abuse, or other axis I1 symptomatology is
often a relative contraindication to surgery. In rare
instances only, patients with severe violent out-
bursts and the potential for serious injury or self-
mutilation might be considered for bilateral amyg-
dalotomy, thalamotomy, or hypothalamotomy.
Thoughtful assessment of psychosurgical candi-
disability, and treatment refractoriness be formal-
ized to establish guidelines. In this regard, chronic-
ity would require at least 1year of enduring symp-
practically speaking confirmation of treatment re-
fractoriness usually requires more than 5 years of
illness prior to surgery. Severity is usually mea-
sured using validated clinical research instruments
corresponding to specific indicators such as a Yale-
Brown Obsessive Compulsive Scale (YBOCS)score
of greater than 20 for OCD or a Beck Depression
Inventory (BDI) score greater than 30. Disability
may be reflected, for instance, by a Global Assess-
ment of Function (GAF) score of less than 50.
In order to determine that their psychiatric illness
is refractory to treatment despite appropriate care,
all vatients must be referred for sureical
1 " interven-
tion by their treating psychiatrist. The referring
psychiatrist must demonstrate an ongoing commit-
ment to the vatient and the evaluation vrocess and
~ ~
must also agree to be responsible for postoperative
management. Detailed questionnaires that docu-
ment the extent and severitv of the illness. as well
as a thorough account of th; diagnostic and thera-
peutic history, must be provided by the psychia-
trist. The specifics of pharmacologic trials should
include the agents used, dose, duration, response,
and the reason for discontinuation for any subopti-
mal trial. Adequate trials of electroconvulsive ther-
apy or behavorial therapy must also be demon-
strated when clinically appropriate.
The patient and the family must also agree to
participate completely in the evaluation process as
well as the postoperative psychiatric treatment pro-
gram. In general, only adult patients (older than
18 years) who are able to render informed consent
and who express a genuine desire and commitment
to proceed with surgery are accepted. Obviously,
the surgery should only be performed to help a
sick patient and never for social or political reasons.
If the patient meets the above criteria, at our
institution they would undergo a more detailed
presurgical screening evaluation by an experi-
enced, multidisciplinary group of psychiatrists,
neurosurgeons, and neurologists (Cingulotomy
Assessment Committee). Thorough review of the
medical record is carried out to ensure that the
170 COSGROVE & RAUCH
illness is indeed refractory to an exhaustive array
of conventional therapies. The MassachusettsGen-
eral Hospital (MGH) evaluation also includes an
electroencephalogram (EEG), brain MRI, neuro-
psychologic testing, and independently conducted
clinical examinationsby a psychiatrist, neurologist,
and neurosurgeon in the outpatient setting. Elec-
trocardiogram and appropriate blood tests are ob-
tained to assess medical risks and to exclude or-
ganic etiologies for mental status abnormalities.
Validated clinical research instruments are em-
ployed to quantify psychiatric symptom severity.
There must be unanimous agreement that the pa-
tient satisfies selection criteria, that the surgery is
indicated, and that the requirements for informed
consent are fulfilled. A family member or close
relative must also understand the evaluation pro-
cess and the indications for, risks of, and alterna-
tives to surgery and agree to be available to provide
emotional support for the patient during the hospi-
talization.
SURGICAL APPROACHES
Although many methods have been used in the
neurosurgicaltreatment of psychiatric disease, four
procedures have evolved as the safest and most
effective. These are all performed bilaterally and
under stereotactic conditions to allow for precise
lesioning of target structures. They are (1) subcau-
date tractotomy, (2) anterior cingulotomy, (3) lim-
bic leukotomy, and (4) anterior capsulotomy. Each
procedure has differentindications, techniques, re-
sults, and complications which will be discussed
in the following sections.
Subcaudate Tractotomy
Subcaudate tractotomy was introduced by
Knight32in Great Britain in 1964 as one of the first
attempts to restrict the size of the surgical lesion
and therefore minimize the side-effects seen with
standard prefrontal lobotomy. The aim was to in-
terrupt white matter tracts between orbital cortex
and subcortical structures by placing a lesion in the
region of the substantia innominata just below the
head of the caudate nucleus. Surgical indications
included major depressive illness, OCD, and anxi-
ety states as well as a variety of other psychiatric
diagnoses.
The surgical procedure was performed by stereo-
tactic technique using bony landmarks and ventric-
ular outline. Target coordinates were calculated as
15 mm from the midline and approximately 10 to
11mm above the planum sphenoidale at the most
anterior part of the sella turcica. Lesions were cre-
ated using radioactive implantable yttrium-90
seeds. Lesionalvolumes were estimated at approxi-
mately 2 mL.
In patients with depression and OCD, total im-
provement or improvement with minimal symp-
toms was clinically observed in two thirds of the
patients.33The best review of the surgical results
for subcaudate tractotomy was presented by Gok-
tepe et a121in 1975. Using a five-point global scale
and rating scales for depression and anxiety, they
reviewed 208 patients with a mean follow-up of 2.5
years. Of the 134 patients available for structured
interview, good results were seen in 68% of pa-
tients suffereing from depression, 62.5% of pa-
tients with anxiety states, and 50% of patients with
obsessive neurosis. Patients with schizophrenia,
personality disorder, drug abuse, or alcohol abuse
did poorly. Some patients who had only temporary
benefit from the initial lesion had second lesions
created lateral to the first with good results seen
in approximately 50%. 4
The incidence of complications was small but
included postoperative seizures in 2.2% and unde-
sirable personality traits in 6.7%. Transient disinhi-
bition was common. Of the 25 patients who had
died at the time of review, 3 patients had commit-
ted suicide. One patient died from inadvertent de-
struction of the hypothalamus when a yttrium seed
migrated off target.21
Anterior Cingulotomy
Fulton19was the first to suggest that the anterior
cingulum would be an appropriate target for psy-
chosurgical intervention, and cingulotomy was ini-
tially carried out as an open p r ~ c e d u r eFoltz
. ~ ~ and
White15 reported their experience with stereotac-
tic cingulotomy for intractable pain and noted the
best results were in those patients with concurrent
anxiety-depressive states. Ballantine et a12 subse-
quently demonstrated the safety and effectiveness
of cingulotomy in a large number of patients, and it
has been the surgical procedure of choice in North
America over the last 30 years. Currently, the surgi-
cal indications are treatment-refractory major af-
fective disorder, chronic anxiety states, or OCD.
The procedure is still performed on occasion for
some patients with severe chronic pain.
Initially these procedures were carried out with
ventriculography, but over the past several years
this has been replaced by MRI-guided stereotactic
techniques. Target coordinates are calculated for a
point in the cingulum 7 mm from the midline and
20 to 25 mm posterior to the tip of the frontal horns.
Lesions are created by thermocoagulation, the
technical details of which have been well described
previously.3Intraoperative stimulation is not per-
formed routinely, but neurologic testing. is carried
out during lesioniq to ensure-that no ikpairment
of motor or sensorv function is incurred, esveciallv
' I
in the lower extremities. On the day after surgery,
a postoperative MRI scan is obtained to document
the placement and extent of the lesions (Fig. 1).

Figure 1. TI-weighted MR images of the cingulotomy lesions seen 24 hours postoperatively in A, the sagittal (left)
and 6, coronal (right)views.
Although the patient may experience an immedi-
ate reduction in anxiety, there is generally a delay
in the onset of beneficial effect on depression and
OCD. This latency may be as long as 6 to 12 weeks
and must be clearly explained to the patient and
referring psychiatrist. If there has been no response
to the initial cingulotomy after 3 to 6 months, then
reoperation and enlargement of the cingulotomy
lesion are considered.
The results of bilaterial cingulotomy in 198 pa-
tients suffering from a variety of psychiatric disor-
ders were reported retrospectively by Ballantine et
a1 in 1987.' With a mean follow-up of 8.6 years,
62% of patients with severe affective disorder were
found to have had worthwhile improvement. Simi-
larly, in patients with OCD, approximately 56%
were found to have undergone worthwhile im-
provement. In 14 patients suffering from non-
obsessive anxiety disorders, 50% were found to be
functionally well and 29% showed marked im-
provement. A recent retrospective study evaluat-
ing cingulotomy in 33 patients with refractory OCD
demonstrated that, using very strict criteria for suc-
cessful outcome, at least 25% to 30% of patients
benefited substantially from the procedure.29In a
prospective long-term follow-up study of 18 pa-
tients who underwent cingulotomy for intractable
OCD, 5 patients met very conservative criteria as
treatment responders and 2 others were considered
possible responders (Baer L, Rauch SL, and Ballan-
tine, et al, unpublished data). Overall, the entire
group improved significantly in terms of functional
status and no serious adverse effects were found.
PSYCHOSURGERY 171
This is the first study to demonstrate in a prospec-
tive way that cingulotomy is effective in OCD as
measured by standard psychiatric rating scales and
independent observers.
In over 800 cingulotomies performed at MGH
since 1962, there have been no deaths and no infec-
tions. Two acute subdural hematomas occurred
early in the series secondary to laceration of a corti-
cal artery at the time of introduction of ventricular
needles but only 1patient suffered permanent neu-
rologic impairment.3 An independent analysis of
34 patients who underwent cingulotomy demon-
strated no significant behavorial or intellectual
deficits as a result of the cingulate lesions them-
selves." They subsequently evaluated 57 patients
before and after cingulotomy and found no evi-
dence of lasting neurologic or behavorial deficits
after surgery. A comparison of preoperative and
postoperative Weschler IQ scores demonstrated
significant gains postoperatively. This improve-
ment was greatest in patients with chronic pain
and depression but negligible in those with the
diagnosis of schizophrenia.
Limbic Leukotomy
Limbic leukotomy was introduced by Kelley et
a131 in 1973 and combines subcaudate tractotomy
with anterior cingulotomy. This procedure was de-
signed to disconnect orbital-frontal-thalamic path-
ways with the former lesion and interrupt an im-
portant portion of the Papez circuit with the latter.
172 COSGROVE & RAUCH
Kelley reasoned that these two lesions might lead
to a better result for the symptoms of OCD than
either lesion alone. Indications for surgical inter-
vention included obsessional neurosis, anxiety
states, depression, and a variety of other psychiat-
ric diagnoses.
This procedure was carried out stereotactically
and three small (6-mm diameter) lesions were
placed in the lower medial quadrant of each frontal
lobe and two lesions in each cingulate gyrus. Le-
sions were created using either a cryoprobe or with
thermocoagulation.Intraoperative stimulationwas
carried out, and, if pronounced autonomic re-
sponses were observed, this was thought to pro-
vide physiologic proof of correct location.
Using the same five-point scale described in the
study by Goktepe et a1,2166 patients were assessed
preoperatively and postoperatively (mean 16 mo).
In patients with obsessional neurosis, 89% were
clinically improved; in chronic anxiety, 66% were
improved; in depression, 78%were improved; and
in a small number of schizophrenics, over 80%
were improved.43Kelley30later reported that in 49
patients with OCD, 84%were improved 20 months
after surgery. They also noted that postoperative
symptom improvement was not immediate, with a
fluctuating but progressive reduction of symptoms
over the first postoperative year.
Although many patients complain of lethargy,
confusion, and lack of sphincter control in the early
postoperative period, persistent complications are
rare. No patients developed seizures postopera-
tively, one patient suffered severe memory loss
due to improper lesion placement, and 12% of pa-
tients complained of persistent lethargy. Measure-
ments of IQ showed slight improvement postoper-
atively.
Anterior Capsulotomy
Although Talairach et a159were the first to de-
scribe anterior capsulotomy, Leksell et a17popular-
ized the procedure for patients with a variety of
psychiatric disorders. The aim was to interrupt pre-
sumed frontothalamic connections in the anterior
limb of the internal capsule where they pass be-
tween the head of the caudate nucleus and the
putamen. Clinical indications for capsulotomy ini-
tially included schizophrenia, depression, chronic
anxiety states, and obsessional neurosis.
The exact target coordinates as described by Lek-
sell are in the anterior one third of the anterior limb
of the internal capsule 5 mm behind the tip of the
frontal horns, 20 mm lateral to the midline at the
level of the intercommissuralplane. Intraoperative
electrical stimulation has not been helpful in terms
of determining optimal placement of lesions within
the capsule. Lesions were created by thermocoagu-
lation using a bipolar electrode system. Several
cases were also performed using the gamma
knife.7,41
In the first 116 patients operated on by Leksell,
50% of patients with obsessional neurosis and 48%
of depressed patients had a satisfactory response.
Only 20% of patients with anxiety neurosis and
14% with schizophrenia were improved.25In this
classification system, only patients who were free
of symptoms or markedly improved were judged
as having a satisfactory response. Of the patients
who were rated as worse after capsulotomy, 9 were
schizophrenics, 4 depressives, and 3 obsessives.
In another series of 35 patients with OCD who
underwent capsulotomy and were followed pro-
spectively by independent psychiatrists, 16 were
rated as free of symptoms and 9 were much im-
proved, for an overall satisfactory result of 70%.7
In a review of all cases of capsulotomy previously
reported in the literature, Mindus found sufficient
data to categorize outcome in 213 of 362 patients.
Of these, 137 (64%)were deemed to have a satisfac-
tory result (Mindus P et al, unpublished data.)
More recently Mindus and Nymad2 have fol-
lowed 24 patients prospectively with standardized
rating scales. Complications of the surgery in-
cluded transient episodes of confusion during the
first week in 19 of 22 patients available for follow-
up, and an occasional patient had nocturnal incon-
tinence. One patient was noted to have an intra-
cranial hemorrhage without neurologic sequelae,
and one patient suffered seizures. One patient
committed suicide in the postoperative phase and
8 patients suffered from depression requiring treat-
ment. Excessive fatigue was a complaint in 7 pa-
tients, 4 had poor memory, and 2 patients showed
slovenliness.Weight gain is common after capsulo-
tomy with an overall mean weight gain of about
10%. No evidence of cognitive dysfunction has
been reported in 200 capsulotomy patients studied
by a variety of psychometric tests.7,9,25,61Reopera-
tion was required in 2 patients who did not achieve
a satisfactory result, with only 1 improving after
the second operation. Burzacogsubjected 17 of his
85 patients to a second procedure to enlarge the
lesions, and half of these reoperations yielded satis-
factory results.
DISCUSSION
Much of the controversy surrounding the use
of psychosurgery may be attributed to its rather
indiscriminate application and the high incidence
of side-effects seen with the early procedures. Ste-
reotactic techniques have certainly minimized the
side-effects of surgery, but the issue of case selec-
tion remains a major consideration. Although ini-
tially any patient with a severe psychiatric illness
was once considered a candidate for surgical inter-
vention, it is now clear that the indications for
psychosurgery are more restrictive. There is gen-

era1 agreement among centers that patients with
major affective disorder, chronic anxiety states,
and OCD are the best candidates for surgery. It
can be safely concluded that schizophrenia is not
an indication for psychosurgery, although patients
with concomitant psychotic disorders and depres-
sion might still be helped with surgery and should
not be excluded. Personality disorders or psychoac-
tive substance use disorders are significant relative
contraindications to surgery. Appropriate selection
of patients for surgery remains a major issue and
the responsibility of the psychiatrist, guided by the
informed and expert opinions of the other mem-
bers of the psychosurgical team.
With currently available data, it is impossible to
determine whether there is one optimal surgical
technique or strategy. All procedures seem to be
well tolerated with minimal side-effects or compli-
cations when applied with the modern stereotactic
techniques. No matter which structure in the limbic
system is chosen for ablation, the clinical outcome
appears similar.
There are many obstacles that prevent a direct
comparison of results across centers. These include
diagnostic inaccuracies, nonstandarized presurgi-
cal evaluation tools, center bias, and varied out-
come assessment scales. In virtually all published
reports, however, some modification of the Pip-
pard Postoperative Rating Scale5' or equivalent has
been used to determine clinical outcome. The
Pippard scale rates outcome in five categories:
(1) symptom free, (2) much improved, some symp-
toms remaining, but no additional treatment nec-
essary, (3) slightly improved, (4) unchanged, and
(5) worse. Although comparisons are imperfect,
these scales appear to have some clinical valid-
it^.^^, 62 If categories 1 and 2 are considered satis-
factory outcomes, then, in patients with OCD,
subcaudate tractotomy was effective in 50%, cin-
gulotomy in 56%, limbic leukotomy in 61%, and
capsulotomy in 67%. In patients with major af-
fective disorder, subcaudate tractotomy was effec-
tive in 68%, cingulotomy in 65%,limbic leukotomy
in 78% and capsulotomy in 55%.
K ~ l l b e r gattempted
~~ to compare cingulotomy
and capsulotomy in the treatment of 26 patients
in a randomized fashion. Six of 13 capsulotomy
patients and 3 of 13 cingulotomy patients were
better, but transient deterioration in mental status
was much more marked after cavsulotomv than
after cingulotomy. Fodstad et all4reported a similar
experience but only studied 4 patients. Recently
two prospective studies attempted to evaluate the
efficacy of cingulotomy (Baer L, Rauch SL, Ballan-
tine HT, et al, unpublished data) and capsulotomy
(Mindus P, Rauch SL, Nyman H, et al, unpublished
data) in OCD. Using the best available research
methodologies and well-accepted rating scales of
disease and outcome, exhaustive preoperative and
postoperative evaluations were carried out. Of the
PSYCHOSURGERY 173
capsulotomy patients 45% had clear-cut improve-
ment, and of cingulotomy patients 39% were im-
proved.
Based on these methods of comparison, the clini-
cal superiority of any one procedure is not convinc-
ing. Although many centers claim advantages for
their specific surgical inter~ention,~~, 49, 62 we are
unable to determine whether one of the four major
psychosurgical procedures is superior to the oth-
ers. Cingulotomy is the treatment of choice in this
country, whereas in Europe capsulotomy and lim-
bic leukotomy are more prevalent. They all appear
roughly equivalent therapeutically, but cingulo-
tomy appears to be the safest of all procedures
currently performed in terms of unwanted side-
effects.
Regardless of the choice of procedure, surgical
failures should be investigated, and if the lesion
size or location is suboptimal, consideration should
be given to repeating the procedure. In 5 of the
24 patients in the Mindus and N ~ m a series, n ~ ~ a
significant correlation was found between neurora-
diologic ranking of a target site and the psychiatric
outcome, suggesting that the site and extent of
the lesion may be important factors influencing
outcome. Repeat surgery in capsulotomy patients
has been reported as 20%.34 At least 45% of patients
undergoing cingulotomy require repeat operation
with good results being salvaged in 50%.3,29 The
exact size or volume of tissue required for an effec-
tive outcome at each of the target sites has yet to
be determined.
The method used for creating the lesion itself
does not appear to influence results or complication
rates. There is some interest in the potential use
of external radiosurgical techniques for psychosur-
gery, but this remains controversial. Although ra-
diosurgery does not require introduction of a sub-
cortical electrode, it remains a surgical procedure
with a small but significant complication rate.58Lit-
tle is known about the exact dosimetry required
for satisfactory lesions,37and the latency to onset
of beneficial effect as radionecrosis develops may
not be reasonable for patients who are in a grave
psychiatric condition. In view of the proliferation
of radiosurgical centers and the inexperience of
these same groups with psychosurgery, the poten-
tial for misapplication of this technique is great.
While controversy exists regarding the exact
choice of surgical procedure to be employed, there
is unanimous agreement that the presurgical evalu-
ation be performed by committed multidisciplinary
teams with expertise and experience in the surgical
treatment of psychiatric illness. Although it is im-
possible to mandate uniformity across all centers,
diagnosis based upon the DSM classification
scheme is encouraged, and prospective trials em-
ploying standardized clinical instruments with
long-term follow-up are needed. Comparisons of
preoperative and postoperative functional status,
174 COSGROVE & RAUCH
i n addition to target psychiatric symptoms, remain
important parameters i n characterizing outcome.
All centers w i t h experience emphasize t h e impor-
tance of rehabilitation postoperatively a n d t h e n e e d
for ongoing psychiatric follow-up. The operation
is n o t a panacea a n d should b e considered a s only
o n e aspect i n t h e overall management of these pa-
tients. Despite t h e a d v e n t of n e w a n d effective
psychopharmacologic agents, teams i n centers em-
ploying this form of psychosurgery generally be-
lieve t h a t t h e procedure is useful. Caution m u s t b e
urged, however, regarding t h e surgical treatment
of psychiatric disease t o ensure t h a t t h e indiscrimi-
nate application of this form of therapy never
recurs.
CONCLUSIONS
The surgical treatment of psychiatric disease can
b e helpful i n certain patients w i t h severe, disa-
bling, a n d treatment-refractory major affective
disorders; obsessive-compulsive disorder; a n d
chronic anxiety states. Psychosurgical treatment
should only b e carried o u t b y a n expert multidisci-
plinary t e a m w i t h experience i n these disorders.
Surgery should b e considered a s o n e part of a n
entire treatment plan a n d m u s t b e followed b y a n
appropriate psychiatric rehabilitation program.
M a n y patients are greatly improved after surgery,
a n d t h e complications o r side-effects are few. Surgi-
cal intervention remains a n important therapeutic
option for disabling psychiatric disease a n d is prob-
ably underused.
ACKNOWLEDGMENT
We are indebted to H. Thomas Ballantine, Jr, MD, Ned
Cassem, MD, and Ida Giriunas, RN, for their insight,
experience and guidance and to Rosemary Dolan for her
expert secretarial assistance.
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