Geschiedenis neurochirurgie en neurostimulatie
1891: Swiss psychiatrist Gottleib Burckhardt used ‘temporal topectomy’ on six patients who were probably suffering from schizophrenia. The procedure aimed to cut the connections between the frontal lobes and the rest of the brain.
1935: Portugese neurologist Egaz Moniz and Almeida Lima, a neurosurgeon, treated 20 institutionalised patients with psychiatric disorders that included mood disorders, schizophrenia, and panic. One third improved, one third got slightly better and one third showed no change.
1936: Walter Freeman, a US neurologist, teamed up with James Watts, a neurosurgeon. They adapted Moniz’s procedure and renamed it ‘bilateral frontal leucotomy’. The procedure became known as ‘lobotomy’. Freeman and Watts performed numerous lobotomies on patients in US psychiatric institutions.
1938: Bailey and Bremer (Belgium) discovered that electrical stimulation of the vagus nerve (VNS) in cats could desynchronise the EEG waveforms. There are probably no meaningful ‘clinical’ correlates – this reflects a decoupling of regional cortical EEG activity. It can occur with cigarette smoking, for example. Further experiments demonstrated that VNS could reduce epileptic activity.
1939-45:‘Psychosurgery’ spread rapidly in the USA and into Europe. It is estimated that upwards of 50,000 lobotomies were performed worldwide in the post-war period.
1946: Walter Freeman (USA) developed the ‘transorbital lobotomy’, involving the insertion of a tool through the thin orbital surface of the skull above the eyeball and into the frontal cortex. His choice of an ice-pick (used to break ice in kitchens) to perform the procedure led to this operation becoming known as the ‘ice-pick lobotomy’.
1954: Chlorpromazine – the first antipsychotic drug – became available in the USA following its development in France in 1952. For the first time, an alternative to psychosurgery, ECT, and insulin coma treatment for many chronically hospitalised, psychotic patients was available. Widespread use of chlorpromazine followed subsequently. Public attitudes to psychosurgery, although initially favourable, changed. Rates of psychosurgery subsequently declined worldwide.
1962: Anterior cingulotomy (ACING) was described by Foltz and White (USA) as a treatment for chronic pain.
1963: Robert Heath (USA) published studies of electrical self-stimulation of the human brain (DBS). He reported variable results. Many of the studies were more ‘proof of concept’ rather than long-term treatment studies, and so short-term mood or motor effects were described.
1964: Subcaudate tractotomy was developed by Geoffrey Knight in London.
1971: In the late 1960s/early 1970s, the procedures were used experimentally for the treatment of mood disorders and anxiety disorders. Anterior capsulotomy (ACAPS) was developed by the Swedish Lars Leksell (although it was first described by Jean Tailairach in 1949).
1973: Limbic leucotomy (a combination of subcaudate tractotomy lesions and cingulotomy lesions) was developed by Desmond Kelly in London.
1975: Implanted electrodes were tested as a treatment for anxiety in Australia. The implanted electrodes were used to test out stimulation of deep brain areas prior to lesioning (DBS).
1988: Reports were published of implanted electrodes being used to treat OCD in Sweden. Stimulation (DBS) was used intra-operatively, and about one third of people had some kind of benefit. However, they all went on to have ablative lesions.
1994: The first study reports were published from international trials of VNS for treatment refractory partial seizures. Since then, upwards of 35,000 patients have had VNS systems implanted worldwide as a treatment for epilepsy.
1995: The decreasing availability of radioactive Yttrium rods (used to create subcaudate tractotomy lesions) at the end of the Cold War led to a change in the method of lesion generation. However, the procedure was largely replaced by ACAPS and ACING.
1999: A team led by Bart Nuttin (Belgium) were the first to report improvements in OCD symptoms with stimulation of the anterior limb of the internal capsule, a similar target to that of anterior capsulotomy (DBS).
2000: USA reports published of mood improvements in patients with epilepsy treated by VNS led to it being investigated as a treatment for depression.
2005: The US Food and Drug Administration (FDA) approved VNS as an adjunctive treatment for chronic, treatment-refractory depression that has failed to respond to at least four antidepressant treatment trials.
2005 onwards: DBS was used to treat depression using a variety of targets.
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Neurosurgery and neuromodulation for mental disorder
CPD Online
Dr David Christmas, Professor Keith Matthews, Professor Douglas Steele and Mr Bob MacVicar
