Dorsal anterior cingulotomy and anterior capsulotomy for severe, refractory obsessive-compulsive disorder: a systematic review of observational studies

Lauren T. Brown Department of Neurological Surgery, Columbia University; and

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Charles B. Mikell Department of Neurological Surgery, Columbia University; and

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Brett E. Youngerman Department of Neurological Surgery, Columbia University; and

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Yuan Zhang Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York

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Guy M. McKhann II Department of Neurological Surgery, Columbia University; and

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Sameer A. Sheth Department of Neurological Surgery, Columbia University; and

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OBJECT

The object of this study was to perform a systematic review, according to Preferred Reporting Items of Systematic reviews and Meta-Analyses (PRISMA) and Agency for Healthcare Research and Quality (AHRQ) guidelines, of the clinical efficacy and adverse effect profile of dorsal anterior cingulotomy compared with anterior capsulotomy for the treatment of severe, refractory obsessive-compulsive disorder (OCD).

METHODS

The authors included studies comparing objective clinical measures before and after cingulotomy or capsulotomy (surgical and radiosurgical) in patients with OCD. Only papers reporting the most current follow-up data for each group of investigators were included. Studies reporting results on patients undergoing one or more procedures other than cingulotomy or capsulotomy were excluded. Case reports and studies with a mean follow-up shorter than 12 months were excluded. Clinical response was defined in terms of a change in the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score. The authors searched MEDLINE, PubMed, PsycINFO, Scopus, and Web of Knowledge through October 2013. English and non-English articles and abstracts were reviewed.

RESULTS

Ten studies involving 193 participants evaluated the length of follow-up, change in the Y-BOCS score, and postoperative adverse events (AEs) after cingulotomy (n = 2 studies, n = 81 participants) or capsulotomy (n = 8 studies, n = 112 participants). The average time to the last follow-up was 47 months for cingulotomy and 60 months for capsulotomy. The mean reduction in the Y-BOCS score at 12 months’ follow-up was 37% for cingulotomy and 55% for capsulotomy. At the last follow-up, the mean reduction in Y-BOCS score was 37% for cingulotomy and 57% for capsulotomy. The average full response rate to cingulotomy at the last follow-up was 41% (range 38%–47%, n = 2 studies, n = 51 participants), and to capsulotomy was 54% (range 37%–80%, n = 5 studies, n = 50 participants). The rate of transient AEs was 14.3% across cingulotomy studies (n = 116 procedures) and 56.2% across capsulotomy studies (n = 112 procedures). The rate of serious or permanent AEs was 5.2% across cingulotomy studies and 21.4% across capsulotomy studies.

CONCLUSIONS

This systematic review of the literature supports the efficacy of both dorsal anterior cingulotomy and anterior capsulotomy in this highly treatment-refractory population. The observational nature of available data limits the ability to directly compare these procedures. Controlled or head-to-head studies are necessary to identify differences in efficacy or AEs and may lead to the individualization of treatment recommendations.

ABBREVIATIONS

AE = adverse event; AHRQ = Agency for Healthcare Research and Quality; CBTC = cortico-basal ganglia-thalamocortical; dACC = dorsal anterior cingulate cortex; DBS = deep brain stimulation; LL = limbic leucotomy; MeSH = Medical Subject Headings; OCD = obsessive-compulsive disorder; OFC = orbitofrontal cortex; PRISMA = Preferred Reporting Items for Systematic reviews and Meta-Analyses; SCT = subcaudate tractotomy; Y-BOCS = Yale-Brown Obsessive Compulsive Scale.
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