Bilateral cingulotomy is a form of psychosurgery, introduced in 1948 as an alternative to

lobotomy A lobotomy () or leucotomy is a discredited form of Neurosurgery, neurosurgical treatment for mental disorder, psychiatric disorder or neurological disorder (e.g. epilepsy, Depression in childhood and adolescence, depression) that involves sev ...

. Today, it is mainly used in the treatment of depression and obsessive-compulsive disorder. In the early years of the twenty-first century, it was used in Russia to treat

addiction Addiction is a neuropsychological disorder characterized by a persistent and intense urge to use a drug or engage in a behavior that produces natural reward, despite substantial harm and other negative consequences. Repetitive drug use can ...

.A. Carter and W. Hall 2012 ''Addiction neuroethics: the promises and perils of neuroscience research on addiction''. Cambridge University Press: 188-9. It is also used in the treatment of chronic pain. The objective of this procedure is the severing of the supracallosal fibres of the cingulum bundle, which pass through the anterior cingulate gyrus.

History

Cingulotomy was introduced in the 1940s as an alternative to standard pre-frontal leucotomy/lobotomy in the hope of alleviating symptoms of mental illness whilst reducing the undesirable effects of the standard operation (personality changes, etc.). It was suggested by American physiologist John Farquhar Fulton who, at a meeting of the Society of British Neurosurgeons in 1947, said "were it feasible, cingulotomy in man would seem an appropriate place for limited leucotomy". This was derived from the hypothesis of James Papez who thought that the cingulum was a major component of an anatomic circuit believed to play a significant role in emotion.S Corkin (1980) A prospective study of cingulotomy. In ES Valenstein (ed) ''The psychosurgery debate: scientific, legal, and ethical perspectives''. San Francisco, WH Freeman and Co: 164-204 The first reports of the use of cingulotomy on psychiatric patients came from J le Beau in Paris, Hugh Cairns in Oxford, and Kenneth Livingston in Oregon.

Target

Bilateral cingulotomy targets the

anterior cingulate cortex In human brains, the anterior cingulate cortex (ACC) is the frontal part of the cingulate cortex that resembles a "collar" surrounding the frontal part of the corpus callosum. It consists of Brodmann areas 24, 32, and 33. It is involved ...

, which is a part of the

limbic system The limbic system, also known as the paleomammalian cortex, is a set of brain structures located on both sides of the thalamus, immediately beneath the medial temporal lobe of the cerebrum primarily in the forebrain.Schacter, Daniel L. 2012. ''P ...

. This system is responsible for the integration of feelings and emotion in the human

cortex Cortex or cortical may refer to: Biology * Cortex (anatomy), the outermost layer of an organ ** Cerebral cortex, the outer layer of the vertebrate cerebrum, part of which is the ''forebrain'' *** Motor cortex, the regions of the cerebral cortex i ...

. It consists of the

cingulate gyrus The cingulate cortex is a part of the brain situated in the medial aspect of the cerebral cortex. The cingulate cortex includes the entire cingulate gyrus, which lies immediately above the corpus callosum, and the continuation of this in the cin ...

parahippocampal gyrus The parahippocampal gyrus (or hippocampal gyrus') is a grey matter cortical region, a gyrus of the brain that surrounds the hippocampus and is part of the limbic system. The region plays an important role in memory encoding and retrieval. It ha ...

amygdala The amygdala (; : amygdalae or amygdalas; also '; Latin from Greek language, Greek, , ', 'almond', 'tonsil') is a paired nucleus (neuroanatomy), nuclear complex present in the Cerebral hemisphere, cerebral hemispheres of vertebrates. It is c ...

, and the

hippocampal formation The hippocampal formation is a compound structure in the medial temporal lobe of the brain. It forms a c-shaped bulge on the floor of the inferior horn of the lateral ventricle. Typically, the hippocampal formation is said to included the dent ...

.Kandel E., Schwartz J., Jessel T., .. (2000). Principles of Neural Science.4th edition, McGraw-Hill, New York, 853-857. Studies in patients who were subject to bilateral cingulotomy, involving

fMRI Functional magnetic resonance imaging or functional MRI (fMRI) measures brain activity by detecting changes associated with blood flow. This technique relies on the fact that cerebral blood flow and neuronal activation are coupled. When an area o ...

analyses, showed that the anterior cingulate cortex has a key role in

cognitive Cognition is the "mental action or process of acquiring knowledge and understanding through thought, experience, and the senses". It encompasses all aspects of intellectual functions and processes such as: perception, attention, thought, ...

control and is highly likely to be involved in the control of attentional response, whereas the

dorsal Dorsal (from Latin ''dorsum'' ‘back’) may refer to: * Dorsal (anatomy), an anatomical term of location referring to the back or upper side of an organism or parts of an organism * Dorsal, positioned on top of an aircraft's fuselage The fus ...

part of that region of the brain was not identified to be involved in such a process, although this is still under dispute. The function of the dorsal part of the cingulate cortex was connected to the sorting out and processing of conflicting information signals. In addition,

neuroimaging Neuroimaging is the use of quantitative (computational) techniques to study the neuroanatomy, structure and function of the central nervous system, developed as an objective way of scientifically studying the healthy human brain in a non-invasive ...

studies also indicated that the anterior cingulate cortex participates in the modulation of cortical regions that are of higher order, as well as sensory processing areas. These findings have also been confirmed by

stereotactic Stereotactic surgery is a minimally invasive form of surgery, surgical intervention that makes use of a three-dimensional coordinates, coordinate system to locate small targets inside the body and to perform on them some action such as ablation, ...

microelectrode analysis of single cortical

neurons A neuron (American English), neurone (British English), or nerve cell, is an membrane potential#Cell excitability, excitable cell (biology), cell that fires electric signals called action potentials across a neural network (biology), neural net ...

in a study, which involved nine patients undergoing bilateral cingulotomy. The study investigated the effect of performing attention demanding tasks on the activity of 36 neurons located in the anterior cingulate cortex. Upon analyzing the results of the study, it was concluded that the anterior cingulate cortex is indeed involved in the modification of

tasks that require attention, based on the fact that there was a change in the basal firing rate of neurons in that region during simulation of such tasks. Neuroimaging also uncovered different sub-regions in the anterior cingulate cortex itself, based on their function. These studies showed that the caudal part of the anterior cingulate cortex plays a more important function in cognitive activities that involve attention, salience, interference and response competition. These results, combined with electrophysiological investigation of the function of neurons in the anterior cingulate cortex, have provided insights that can be used in the improvement of cingulotomy performed on patients treated for

obsessive–compulsive disorder Obsessive–compulsive disorder (OCD) is a mental disorder in which an individual has intrusive thoughts (an ''obsession'') and feels the need to perform certain routines (''Compulsive behavior, compulsions'') repeatedly to relieve the dis ...

(OCD). The basis behind this idea is the fact that a variation of certain tasks, emotional Stroop tasks (ES), which have been particularly identified as exerting effects in OCD patients, activate neurons in the more

rostral Rostral may refer to: Anatomy * Rostral (anatomical term), situated toward the oral or nasal region * Rostral bone, in ceratopsian dinosaurs * Rostral organ, of certain fish * Rostral scale The rostral scale, or rostral, in snakes and other sca ...

part of the anterior cingulate cortex. Thus, theoretically, if bilateral cingulotomy is performed in such a patient in the rostral anterior cingulate cortex, better results should be obtained. Moreover, OCD has been associated with a malformation of the

basal ganglia The basal ganglia (BG) or basal nuclei are a group of subcortical Nucleus (neuroanatomy), nuclei found in the brains of vertebrates. In humans and other primates, differences exist, primarily in the division of the globus pallidus into externa ...

.Kandel E., Schwartz J., Jessel T., .. (2000). Principles of Neural Science.4th edition, McGraw-Hill, New York, 1223-1224. The function of this part of the human brain has been mapped to be composed of fiber tracks associated with numerous parallel cortico-striato-thalamocortical circuits (CSTC), which are involved in sensorimotor, motor, oculomotor as well as the

processes that are manifested by the

.Leckman. (2000). Tic Disorder. Neuropsychopharmacology: The Fifth Generation of Progress This pathway involves

GABAergic In molecular biology and physiology, something is GABAergic or GABAnergic if it pertains to or affects the neurotransmitter gamma-aminobutyric acid (GABA). For example, a synapse is GABAergic if it uses GABA as its neurotransmitter, and a GABAergic ...

inhibitory An inhibitory postsynaptic potential (IPSP) is a kind of synaptic potential that makes a Chemical synapse, postsynaptic neuron less likely to generate an action potential.Purves et al. Neuroscience. 4th ed. Sunderland (MA): Sinauer Associates, Inc ...

projections that serve as one of the means of communication between the different structures involved. It has been hypothesized that some forms of OCD are a result of disinhibition of one or several of the circuits that operate in the CSTC. This is also indicated by a finding that showed a significant decrease in intracortical inhibition in OCD patients. Thus,

lesions A lesion is any damage or abnormal change in the tissue of an organism, usually caused by injury or diseases. The term ''Lesion'' is derived from the Latin meaning "injury". Lesions may occur in both plants and animals. Types There is no de ...

in the anterior cingulate cortex might contribute to the lessening of the disinhibition effect. This hypothesis has been confirmed by another study, which assessed the cortical inhibitory and excitatory mechanisms in OCD. The study measured the excitability of the

motor cortex The motor cortex is the region of the cerebral cortex involved in the planning, motor control, control, and execution of voluntary movements. The motor cortex is an area of the frontal lobe located in the posterior precentral gyrus immediately ...

, as well as intracortical inhibition in OCD patients and a control group of healthy individuals. The results showed a significant decrease in intracortical inhibition, which resulted in a slowdown of interstimulus intervals by 3 ms. In addition to its proximity to and association with the limbic system and the

in particular, which plays a key role in emotional experience, the anterior cingulate cortex shares afferent and efferent pathways with a number of thalamic nuclei as well as the

posterior cingulate The posterior cingulate cortex (PCC) is the caudal part of the cingulate cortex, located posterior to the anterior cingulate cortex. This is the upper part of the "limbic lobe". The cingulate cortex is made up of an area around the midline of the ...

and part of some parietal, frontal and supplementary motor cortex. All these underline the high likelihood that the anterior cingulate cortex must have some involvement in OCD. Functional

MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and rad ...

analyses of the anterior cingulate cortex have also led to the introduction of bilateral cingulotomy for the treatment of

chronic pain Chronic pain is pain that persists or recurs for longer than 3 months.https://icd.who.int/browse/2025-01/mms/en#1581976053 It is also known as gradual burning pain, electrical pain, throbbing pain, and nauseating pain. This type of pain is in cont ...

. Such application was introduced since the anterior cingulate cortex has been found to be related to the processing of

nociceptive In physiology, nociception , also nocioception; ) is the sensory nervous system's process of encoding noxious stimuli. It deals with a series of events and processes required for an organism to receive a painful stimulus, convert it to a molecular ...

information input. In particular, the role of the anterior cingulate cortex is in the interpretation of how a stimulus affects a person rather than its actual physical intensity.

Procedure

A book published in 1992 described how the operation was carried out at that time. In most cases the procedure started with the medical team taking a number of CT scan

X-ray An X-ray (also known in many languages as Röntgen radiation) is a form of high-energy electromagnetic radiation with a wavelength shorter than those of ultraviolet rays and longer than those of gamma rays. Roughly, X-rays have a wavelength ran ...

images of the brain of the patient. This step ensured that the exact target, the

cingulate cortex The cingulate cortex is a part of the brain situated in the medial aspect of the cerebral cortex. The cingulate cortex includes the entire cingulate gyrus, which lies immediately above the corpus callosum, and the continuation of this in the cin ...

, was mapped out, so that the surgeon could identify it. Burr holes were then created in the patient's

skull The skull, or cranium, is typically a bony enclosure around the brain of a vertebrate. In some fish, and amphibians, the skull is of cartilage. The skull is at the head end of the vertebrate. In the human, the skull comprises two prominent ...

using a drill.

Lesions A lesion is any damage or abnormal change in the tissue of an organism, usually caused by injury or diseases. The term ''Lesion'' is derived from the Latin meaning "injury". Lesions may occur in both plants and animals. Types There is no de ...

at the targeted tissue were made with the help of fine

electrodes An electrode is an electrical conductor used to make contact with a nonmetallic part of a circuit (e.g. a semiconductor, an electrolyte, a vacuum or a gas). In electrochemical cells, electrodes are essential parts that can consist of a variety ...

inserted at the right angle into the subject's brain based on plotting charts and making sure important

arteries An artery () is a blood vessel in humans and most other animals that takes oxygenated blood away from the heart in the systemic circulation to one or more parts of the body. Exceptions that carry deoxygenated blood are the pulmonary arteries in ...

and

blood vessels Blood vessels are the tubular structures of a circulatory system that transport blood throughout many animals’ bodies. Blood vessels transport blood cells, nutrients, and oxygen to most of the tissues of a body. They also take waste an ...

were intact. The electrode was placed in a probe, or a holder, with only its tip projecting. Upon the correct insertion of the holder into the brain tissue, air was injected and more scan images were taken. Then, after the medical team had made sure they were on the right track, the tip of the electrode was advanced to the plane of the cingulate where it was heated to 75-90 °C. Once the first lesion was created it served as a center around which several other

were created. In order to confirm whether lesions are made at the right place, scan images were taken postoperatively and analyzed.Joann Rodgers. (1992).Psychosurgery: Damaging the Brain to Save the Mind, HarperCollins, New York, 350-378, Recent technological advances, however, have made bilateral cingulotomy a more precise operation. For example, nowadays a neurosurgical team that performs the procedure can use an

to identify the location of the

anterior Standard anatomical terms of location are used to describe unambiguously the anatomy of humans and other animals. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position pro ...

and posterior

commissure A commissure () is the location at which two objects wikt:abut#Verb, abut or are joined. The term is used especially in the fields of anatomy and biology. * The most common usage of the term refers to the brain's commissures, of which there are at ...

s. This approach allows neurosurgeons to obtain a number of coronal images, which are then used to calculate the

coordinates of the target in the anterior cingulate cortex, where lesions need to be made. Moreover, the MRI enables more precise differentiation of the cell composition, and thus easily permits the identification of the grey matter in that region. This can then be further confirmed with the help of microelectrode recordings.

Side effects

Patients usually recover from this operation over a period of four days. However, there are cases of subjects being released from hospital after as few as 48 hours after the operation. The mild shorter postoperative complications that are most commonly related to bilateral cingulotomy are typical of head interventions and include but are not limited to

nausea Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. It can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the throat. Over 30 d ...

vomiting Vomiting (also known as emesis, puking and throwing up) is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose. Vomiting can be the result of ailments like food poisoning, gastroenteritis, pre ...

, and

headaches A headache, also known as cephalalgia, is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of depression in those with severe headaches. Head ...

. However, in some cases, patients exhibit

seizures A seizure is a sudden, brief disruption of brain activity caused by abnormal, excessive, or synchronous neuronal firing. Depending on the regions of the brain involved, seizures can lead to changes in movement, sensation, behavior, awareness, o ...

that sometimes appear up to two months after the surgical intervention. It has been questioned whether this is relevant and can be attributed to cingulotomy because such seizures were observed in patients who already had a history of this condition.

Case studies

A 2002 study conducted at the

Massachusetts General Hospital Massachusetts General Hospital (Mass General or MGH) is a teaching hospital located in the West End neighborhood of Boston, Massachusetts. It is the original and largest clinical education and research facility of Harvard Medical School/Harvar ...

analyzed the outcome of bilateral cingulotomy in 44 patients for the treatment of OCD in the period between 1965 and 1986. Patients were followed up over a long term and evaluated based on several criteria: 1) how many of them were responders after a period of six months, 2) how many cingulotomies a patient had undergone before the examination of the effectiveness of the procedure, 3) whether the patient showed any significant change after the most recent procedure, and 4) what the side effects related to the procedure were. The follow-up of the patients produced contradictory results, which indicated that bilateral cingulotomy is not the optimal treatment for OCD. Of the 44 patients, only 32% both fit the "responder" criteria and showed significant improvement compared to the other subjects. Another 14% exhibited some signs of improvement. Multiple cingulotomies correlated with a higher likelihood of continuing to respond to follow-up inquiries (6% more often fit the full "responder" criteria, 11% more often fit the partial "responder" criteria). However, the side effects associated with the procedure were numerous. Among the complaints that patients had after the surgery were

apathy Apathy, also referred to as indifference, is a lack of feeling, emotion, interest, or concern about something. It is a state of indifference, or the suppression of emotions such as concern, excitement, motivation, or passion. An apathetic i ...

and deficits in memory, although these were rarely reported. In addition, some subjects complained of some form of

urinary The human urinary system, also known as the urinary tract or renal system, consists of the kidneys, ureters, bladder, and the urethra. The purpose of the urinary system is to eliminate waste from the body, regulate blood volume and blood pressu ...

disturbance, ranging from

urinary retention Urinary retention is an inability to completely empty the bladder. Onset can be sudden or gradual. When of sudden onset, symptoms include an inability to urinate and lower abdominal pain. When of gradual onset, symptoms may include urinary incont ...

to incontinence.

Hydrocephalus Hydrocephalus is a condition in which cerebrospinal fluid (CSF) builds up within the brain, which can cause pressure to increase in the skull. Symptoms may vary according to age. Headaches and double vision are common. Elderly adults with n ...

(2%) and seizures (2%) were also observed. Bilateral cingulotomy has also been used in the treatment of chronic refractory pain. A systematic review of 11 studies encompassing 224 patients found that anterior cingulotomy led to significant pain relief in greater than 60% of patients post-operatively as well as at one year following the procedure. Of the included studies, one clinical study investigated the effect of bilateral cingulotomy for the treatment of

refractory In materials science, a refractory (or refractory material) is a material that is resistant to decomposition by heat or chemical attack and that retains its strength and rigidity at high temperatures. They are inorganic, non-metallic compound ...

. In this case, 23 patients who were subject to 28 cingulotomies in total were followed up. The analyses aimed at determining how much the pain of each individual was affected after the procedure with the help of a questionnaire. In addition, the examiners tried to evaluate the impacts on social and family relations of the participants in the study. Based on the data obtained, cingulotomy for treatment of chronic pain showed promising results. 72% reported improvement in the level of pain experienced, and 50% indicated that they no longer required painkillers after cingulotomy. More than half of the patients also claimed that the surgical procedure was beneficial and contributed to the improvement of their social interactions.

Notes

References

External links

MGH Psychiatric Neurosurgery Committee
{{DEFAULTSORT:Bilateral Cingulotomy Neurosurgical procedures Treatment of depression Treatment of obsessive–compulsive disorder