La moderna psicocirugía: un nuevo enfoque de la neurocirugía en la enfermedad psiquiátrica

Abstract

To obtain an up to date review of the different possible surgical approaches in the management of certain psychiatric disorders that are refractory to conservative treatment (pharmacotherapy, psychotherapy, electroconvulsive therapy). In order to conduct this research we reviewed the work published by centres with the most experience in this type of surgery, mainly in North America and Europe, since its beginnings in the 1930s, with the controversy concerning prefrontal leucotomy, until the appearance of modern stereotactic techniques. We analyse the anatomophysiological bases, their main clinical indications, the surgical techniques used and their results, as well as perspectives for the future of this neurosurgical treatment. The most noteworthy progress in psychosurgery in recent years has been the combination of a more rigorous selection of patients and the higher degree of specificity with which treatment is performed on the brain structures involved in psychiatric disease. The most widely employed psychosurgical procedures at present are cingulotomy, anterior capsulotomy, subcaudate tractotomy, limbic leucotomy and postero medial hypothalamotomy, with favourable responses in about 35 70% of cases. The psychiatric diagnoses where the best results are to be found are obsessive compulsive disorder, chronic anxiety states and major depression. Current progress in neuroimaging techniques, increased neurophysiological knowledge and the revolutionary neuromodulation techniques, especially deep brain stimulation, offer an even more promising future for psychiatric neurosurgery.