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Central Modulation of Pain
Published in Peter Kam, Ian Power, Michael J. Cousins, Philip J. Siddal, Principles of Physiology for the Anaesthetist, 2020
Peter Kam, Ian Power, Michael J. Cousins, Philip J. Siddal
The somatosensory cortex is important for the localization and sensation of pain. Functional magnetic resonance imaging studies have showed that a large brain network is activated during acute pain. These include the primary somatosensory cortex and secondary somatosensory cortex with the adjacent insula region, anterior cingulate cortex, ventromedial prefrontal cortex and thalamus. These regions of the brain form the ‘pain matrix’. The functions of these cortical areas are summarized in Table 70.2. The anterior cingulate cortex and the prefrontal cortex directly feedback to the PAG, which activates the descending anti-nociceptive pathways. Damage to the prefrontal cortex reduces the ability to evaluate the severity of pain. Cingulotomy decreases the emotional aspects of pain.
Treatment of Chronic Fatigue Syndrome
Published in Jay A. Goldstein, Chronic Fatigue Syndromes, 2020
Much of our understanding of the role of the limbic system in pain derives from the use of limbic surgery in the treatment of intractable pain. To summarize the results of the last 50 years: the best results have been obtained with bilateral anterior cingulotomy in a patient who is anxious and/or depressed and in whom antidepressant and/or anticonvulsant medication is maintained. Cingulotomy may help patients when deep brain stimulation does not. Somatoform disorders, personality disorders, and primary substance abuse were among the exclusionary criteria for such surgery at Massachusetts General Hospital in 1987.141
Neurosurgery: Functional neurosurgery
Published in Hemanshu Prabhakar, Charu Mahajan, Indu Kapoor, Essentials of Geriatric Neuroanesthesia, 2019
Suparna Bharadwaj, Christine Dy-Valdez, Jason Chui
Functional neurosurgery encompasses a variety of surgical interventions that are designed to alter the physiological activity of the central nervous system for functional neurological disorders. Many of these chronic neurological disorders that were once thought to be untreatable are now being successfully managed surgically (Table 11.1). Historically, the surgical principles of functional neurosurgery were to lesion the brain structures, thereby removing abnormal neuronal circuits. Typical examples of these procedures are thalamotomy, pallidotomy, and cingulotomy. However, these lesioning procedures were irreversible and were associated with severe permanent side effects. As such, there was interest in developing a neuromodulation technique that aims to achieve the same functional outcome as lesioning procedures but with less morbidity.
Ablative brain surgery: an overview
Published in International Journal of Hyperthermia, 2019
Andrea Franzini, Shayan Moosa, Domenico Servello, Isabella Small, Francesco DiMeco, Zhiyuan Xu, William Jeffrey Elias, Angelo Franzini, Francesco Prada
Anterior cingulotomy (ACT) involves lesioning of the dorsal anterior cingulate cortex and anterior cingulate bundle. These fibers carry information from the cingulate cortex to the orbitofrontal cortex and limbic system [68,71]. ACT was introduced as an open technique, which was associated with significant mortality and morbidity [73,83]. However, after the adaptation of stereotactic techniques, it was demonstrated to be a safe and effective procedure in a large number of patients with psychiatric illness, to the point that it was the procedure of choice for OCD and MDD patients in North America for more than 30 years [69,73,83]. A recent literature review of the SRS and RF ACT observational studies for OCD reported a full response rate (>35% Y-BOCS reduction) in 41% of patients, with transient and permanent adverse events rates of 14.3% and 5.2%, respectively [71]. When patients with MDD undergoing ACT are considered, a literature review showed an improvement of standardized outcomes ranging from 39–65% [70].
Incisionless MR-guided focused ultrasound: technical considerations and current therapeutic approaches in psychiatric disorders
Published in Expert Review of Neurotherapeutics, 2020
Thomas Kinfe, Andreas Stadlbauer, Klemens Winder, Rene Hurlemann, Michael Buchfelder
Cingulotomy (dorsal anterior cingulotomy) and capsulotomy, both have been applied in a sufficient numbers of OCD trials. Banks et al retrospectively determined neuroanatomical features in OCD patients treated with cingulotomy in order to explore potential predictive characteristics and to extract phenotype-based inter-individual variability. Using voxel-based morphometry (VBM) and diffusion tensor imaging (probalistic DTI), they found that decreased gray matter in the dorsal anterior cingulate cortex and increased right-sided connectivity (hemispheric asymmetry) significantly correlated with higher responder rate indicating an intra- and inter-individual variability relevant for cingulotomy outcome [53,54]. In addition to invasive lesioning approaches (RFA) of the anterior cingulate cortex, noninvasive GKRS has been used to perform capsulotomy for OCD suffers refractory to pharmacological and behavioral therapies. Similar to invasive ablative procedures and deep brain stimulation, the fronto-striatal circuits (fiber tracts) between the orbito-frontal cortex, the dorsal anterior cingulate cortex and subcortical networks has been largely the intended target. For instance, Rasmussen and coworkers prospectively evaluated the impact of Gamma Knife ventral capsulotomy and observed significant and sustained improvements (defined as ≥ 35% reduction in YBOCS) in 56% of treated OCD patients observed over a time period of 3 years. Of note, in a meta-analysis comparing capsulotomy with VS/VC-DBS, the responder rate was higher in the lesioning group versus the DBS treated cohort [55]. So far, a broad range of procedures (invasive (RFA) and noninvasive (GKRS) cingulotomy/capsulotomy; VS/VC-DBS) demonstrated clinical improvement in refractory OCD, however, comparative data and a structured framework how to systematically evaluate theses different therapy options has not been established.
Legal Regulation of Psychosurgery: A Fifty-State Survey
Published in Journal of Legal Medicine, 2019
Roland Nadler, Jennifer A. Chandler
A final search targeted several specifically named medical procedures of potential relevance (items 6, 7, 8, and 9 in Table 1). “Cingulotomy” appears in the text of two regulations, both of which are medical insurance provisions containing large lists of named procedures, with no further substantive relevance for our purposes.17