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Canadian Journal of Psychiatry. Revue... Dec 2023The anniversary of the publication of 'One Flew Over the Cuckoo's Nest' by Ken Kesey offers an opportunity for reflection on the use of neurosurgery in psychiatry. We...
The anniversary of the publication of 'One Flew Over the Cuckoo's Nest' by Ken Kesey offers an opportunity for reflection on the use of neurosurgery in psychiatry. We used a narrative, historical and dialectical method to deliver an account of the controversial subject. A balanced representation of the negative and positive aspects, acknowledging some of the questionable ethical practices while describing well-reasoned applications is provided. It includes neurosurgeons, psychiatrists who have embraced these procedures with unwarranted enthusiasm and those who have opposed. Neurosurgical techniques for the treatment of severe mental disorders have evolved from rudimentary procedures which were used to 'correct' unwanted behaviours associated with a wide range of severe mental disorders to more refined and selective approaches used as a last resort to treat specific mental health conditions. In the absence of specific aetiological models to guide ablative surgical targets, non-ablative, stimulatory techniques have more recently been developed to allow reversibility when surgical treatment fails to obtain a sizeable improvement in quality of life. The subject is concretely illustrated by two eloquent clinical images: one on a series of brain computed tomography scans carried out on a Canadian population of subjects, who underwent leukotomy decades ago, and the other more contemporary on an implantation surgery to epidural stimulation. Alongside technical advances in psychosurgery, a regulatory framework has gradually developed to ensure vigilance in the appropriateness of patients' selection. Nevertheless, harmonisation of protocols around the world is necessary to ensure consistency in obtaining and maintaining the highest possible ethical standards for the benefit of patients. If the neurosciences promise today, in their new, better framed, and reversible applications, to provide answers to unmet therapeutic needs, we still must remain attentive to drifts linked the introduction of intrusive technologies for purposes of domination or behaviour modification that would impede our individual freedom.
Topics: Humans; Animals; Psychosurgery; Diptera; Quality of Life; Canada; Mental Disorders
PubMed: 37424267
DOI: 10.1177/07067437231182658 -
Pediatric Neurosurgery 2023
Topics: Humans; Child; Psychosurgery; Epilepsy
PubMed: 37393898
DOI: 10.1159/000531755 -
Brain Sciences Jun 2023Science and philosophy have tried to understand the origin of emotions for centuries. However, only in the last 150 years have we started to try to understand them in a... (Review)
Review
Science and philosophy have tried to understand the origin of emotions for centuries. However, only in the last 150 years have we started to try to understand them in a neuroscientific scope. Emotions include physiological changes involving different systems, such as the endocrine or the musculoskeletal, but they also cause a conscious experience of those changes that are embedded in memory. In addition to the cortico-striato-thalamo-cortical circuit, which is the most important of the basal ganglia, the limbic system and prefrontal circuit are primarily involved in the process of emotion perceptions, thoughts, and memories. The purpose of this review is to describe the anatomy and physiology of the different brain structures involved in circuits that underlie emotions and behaviour, underlying the symptoms of certain psychiatric pathologies. These circuits are targeted during deep brain stimulation (DBS) and knowledge of them is mandatory to understand the clinical-physiological implications for the treatment. We summarize the main outcomes of DBS treatment in several psychiatric illness such as obsessive compulsive disorder, refractory depression, erethism and other conditions, aiming to understand the rationale for selecting these neural systems as targets for DBS.
PubMed: 37371421
DOI: 10.3390/brainsci13060943 -
Neurosurgical Review Jun 2023Neurosurgery is a therapeutic option for patients with refractory obsessive-compulsive disorder who do not respond to previous treatments. Although its efficacy in... (Review)
Review
Neurosurgery is a therapeutic option for patients with refractory obsessive-compulsive disorder who do not respond to previous treatments. Although its efficacy in reducing clinical symptomatology has been proven, few studies have analyzed its effects at the cognitive level. The aim of this systematic review was to describe the cognitive outcomes of functional neurosurgery in patients that went through capsulotomies or cingulotomies. PubMed, Medline, Scopus, PsycInfo, PsyArticles, and Web of Knowledge were searched for studies reporting cognitive outcomes in refractory obsessive-compulsive patients after capsulotomies and cingulotomies. The risk of bias was assessed with the Assessment Tool for Before-After (Pre-Post) Studies With No Control Group tool; 13 studies met inclusion criteria, including 205 refractory obsessive-compulsive disorder patients for both surgical procedures. Results showed a substantial number of studies that did report significant cognitive improvement after surgery, being this improvement specially related to memory and executive functions. The second-most frequent finding is the maintenance of cognitive performance (nor improvement or worsening). From a neuropsychological point of view, this outcome might be considered a success, given that it is accompanied by amelioration of obsessive-compulsive symptoms. Subtle cognitive adverse effects have also been reported. Neurosurgery procedures appear to be safe from a cognitive point of view. Methodological issues must be improved to draw clearer conclusions, but capsulotomies and cingulotomies constitute an effective alternative treatment for refractory obsessive-compulsive disorder patients.
Topics: Humans; Neurosurgery; Neurosurgical Procedures; Obsessive-Compulsive Disorder; Psychosurgery; Treatment Outcome; Cognition
PubMed: 37351641
DOI: 10.1007/s10143-023-02037-w -
Frontiers in Neuroscience 2023Limbic surgery is one of the most attractive and retaken fields of functional neurosurgery in the last two decades. Psychiatric surgery emerged from the incipient work... (Review)
Review
Limbic surgery is one of the most attractive and retaken fields of functional neurosurgery in the last two decades. Psychiatric surgery emerged from the incipient work of Moniz and Lima lesioning the prefrontal cortex in agitated patients. Since the onset of stereotactic and functional neurosurgery with Spiegel and Wycis, the treatment of mental diseases gave attention to refractory illnesses mainly with the use of thalamotomies. Neurosis and some psychotic symptoms were treated by them. Several indications when lesioning the brain were included: obsessive-compulsive disorder, depression, and aggressiveness among others with a diversity of targets. The indiscriminately use of anatomical sites without enough scientific evidence, and uncertainly defined criteria for selecting patients merged with a deficiency in ethical aspects, brought a lack of procedures for a long time: only select clinics allowed this surgery around the world from 1950 to the 1990s. In 1999, Nuttin et al. began a new chapter in limbic surgery with the use of Deep Brain Stimulation, based on the experience of pain, Parkinson's disease, and epilepsy. The efforts were focused on different targets to treat depression and obsessive-compulsive disorders. Nevertheless, other diseases were added to use neuromodulation. The goal of this article is to show the new opportunities to treat neuropsychiatric diseases.
PubMed: 37274213
DOI: 10.3389/fnins.2023.1167244 -
Brain Stimulation 2023Despite advances in the treatment of psychiatric diseases, currently available therapies do not provide sufficient and durable relief for as many as 30-40% of patients....
Future directions in psychiatric neurosurgery: Proceedings of the 2022 American Society for Stereotactic and Functional Neurosurgery meeting on surgical neuromodulation for psychiatric disorders.
OBJECTIVE
Despite advances in the treatment of psychiatric diseases, currently available therapies do not provide sufficient and durable relief for as many as 30-40% of patients. Neuromodulation, including deep brain stimulation (DBS), has emerged as a potential therapy for persistent disabling disease, however it has not yet gained widespread adoption. In 2016, the American Society for Stereotactic and Functional Neurosurgery (ASSFN) convened a meeting with leaders in the field to discuss a roadmap for the path forward. A follow-up meeting in 2022 aimed to review the current state of the field and to identify critical barriers and milestones for progress.
DESIGN
The ASSFN convened a meeting on June 3, 2022 in Atlanta, Georgia and included leaders from the fields of neurology, neurosurgery, and psychiatry along with colleagues from industry, government, ethics, and law. The goal was to review the current state of the field, assess for advances or setbacks in the interim six years, and suggest a future path forward. The participants focused on five areas of interest: interdisciplinary engagement, regulatory pathways and trial design, disease biomarkers, ethics of psychiatric surgery, and resource allocation/prioritization. The proceedings are summarized here.
CONCLUSION
The field of surgical psychiatry has made significant progress since our last expert meeting. Although weakness and threats to the development of novel surgical therapies exist, the identified strengths and opportunities promise to move the field through methodically rigorous and biologically-based approaches. The experts agree that ethics, law, patient engagement, and multidisciplinary teams will be critical to any potential growth in this area.
Topics: Humans; United States; Neurosurgery; Deep Brain Stimulation; Neurosurgical Procedures; Mental Disorders; Psychosurgery
PubMed: 37217075
DOI: 10.1016/j.brs.2023.05.011 -
BMC Anesthesiology May 2023To investigate the effects of ultrasound-guided erector spinae plane block (ESPB) on acute and chronic post-surgical pain in patients underwent video-assisted... (Randomized Controlled Trial)
Randomized Controlled Trial
Effects of ultrasound-guided erector spinae plane block on postoperative acute pain and chronic post-surgical pain in patients underwent video-assisted thoracoscopic lobectomy: a prospective randomized, controlled trial.
OBJECTIVE
To investigate the effects of ultrasound-guided erector spinae plane block (ESPB) on acute and chronic post-surgical pain in patients underwent video-assisted thoracoscopic lobectomy.
METHODS
A total of 94 patients, who underwent elective unilateral video-assisted thoracoscopic lobotomy from August 2021 to December 2021 were randomly divided into general anesthesia group (group A, n = 46) and ESPB combined with general anesthesia group (group B, n = 48) by computer. Patient controlled intravenous analgesia(PCIA) was performed in both groups after operation. The numerical rating scale(NRS) of rest and cough pain at post anesthesia care unit(PACU), 2 h, 6 h, 12 h, 24 and 48 h after operation, frequency of PCIA in 24 h after operation, frequency of rescue analgesia, patient satisfaction, adverse reactions and complications were recorded in the two groups. Incidence of chronic pain at 3 months and 6 months after operation, the effect of daily life and rating of chronic pain management measures were recorded in the two groups.
RESULTS
Compared with group A, rest and cough NRS score at 2 h, 6 h, 12 h, 24 and 48 h after surgery, frequency of PCIA use at 24 h after surgery, frequency of rescue analgesia were significantly decreased in group B (P < 0.05). There was no significant difference in NRS scores of rest and cough at PACU after operation between 2 groups after surgery at post anesthesia care unit (P > 0.05). There were no significant differences in the incidence of postoperative chronic pain between the 2 groups(P > 0.05);The effect of postoperative chronic pain on daily life and pain management measures in group B were significantly lower than those in group A(P < 0.05). Compared with group A, patients in group B had higher satisfaction degree, lower incidence of postoperative nausea and vomiting(PONV), and lower incidence of agitation during anesthesia recovery (P < 0.05). There were no pneumothorax, hematoma and toxicity of local anesthetic in the 2 groups.
CONCLUSION
Ultrasound-guided erector spinae plane block can significantly reduce acute post-surgical pain, can not reduce the incidence of chronic post-surgical pain, but can significantly reduce the severity of chronic pain in patients underwent video-assisted thoracoscopic lobectomy.
TRIAL REGISTRATION
ChiCTR2100050313,date of registration:26/08/2021.
Topics: Humans; Acute Pain; Chronic Pain; Cough; Prospective Studies; Psychosurgery; Thoracic Surgery, Video-Assisted; Anesthesia, Conduction; Pain, Postoperative; Analgesia, Patient-Controlled; Nerve Block; Ultrasonography, Interventional
PubMed: 37161305
DOI: 10.1186/s12871-023-02100-5 -
Neurology India 2023Psychiatric disorders are the hidden pandemic of the current century. Despite major advances in medical management, the options for treatment are still limited.... (Review)
Review
Psychiatric disorders are the hidden pandemic of the current century. Despite major advances in medical management, the options for treatment are still limited. Neurosurgical intervention is effective for certain refractory psychiatric illnesses and the options range from stimulation surgeries to precise disconnection procedures influencing the neuronal network. Literature regarding stereotactic radiosurgery (SRS) is now enriched with successful treatment of obsessive compulsive disorder, major depression disorder, and anorexia nervosa. These procedures by reducing compulsions, obsessions, depression, and anxiety, improve substantially the quality of life for patients with a good safety profile. It is a valid treatment alternative for a selected group of patients who otherwise have no therapeutic options for whom the neurosurgical intervention is the only hope. It is also cost effective and highly reproducible among specialists. These procedures are adjuvant to the medical and behavioural treatment of psychiatric disorders. In this study the Contemporary role of Stereotactic radiosurgery is reviewed starting with relevant history of psychosurgery followed by individual psychiatric disorders.
Topics: Humans; Radiosurgery; Quality of Life; Psychosurgery; Obsessive-Compulsive Disorder; Neurosurgical Procedures
PubMed: 37026332
DOI: 10.4103/0028-3886.373648 -
Personalized Medicine in Psychiatry 2023Major Depressive Disorder (MDD) and Obsessive-Compulsive Disorder (OCD) are common and potentially incapacitating conditions. Even when recognized and adequately...
Major Depressive Disorder (MDD) and Obsessive-Compulsive Disorder (OCD) are common and potentially incapacitating conditions. Even when recognized and adequately treated, in over a third of patients with these conditions the response to first-line pharmacological and psychotherapeutic measures is not satisfactory. After more assertive measures including pharmacological augmentation (and in the case of depression, transcranial magnetic stimulation, electroconvulsive therapy, or treatment with ketamine or esketamine), a significant number of individuals remain severely symptomatic. In these persons, different ablation and deep-brain stimulation (DBS) psychosurgical techniques have been employed. However, apart from the cost and potential morbidity associated with surgery, on average only about half of patients show adequate response, which limits the widespread application of these potentially life-saving interventions. Possible reasons are considered for the wide variation in outcomes across different series of patients with MDD or OCD exposed to ablative or DBS psychosurgery, including interindividual anatomical and etiological variability. Low-intensity focused ultrasound (LIFU) is an emerging technique that holds promise in its ability to achieve anatomically circumscribed, noninvasive, and reversible neuromodulation of deep brain structures. A possible role for LIFU in the personalized presurgical definition of neuromodulation targets in the individual patient is discussed, including a proposed roadmap for clinical trials addressed at testing whether this technique can help to improve psychosurgical outcomes.
PubMed: 36969502
DOI: 10.1016/j.pmip.2023.100100