In this paper, the authors performed a literature review and compared the results of anterior capsulotomy (AC) to those of deep brain stimulation (DBS) of the ventral capsule/ventral striatum for the treatment of obsessive-compulsive disorder (OCD).1 Capsulotomy has been in use for decades, whereas DBS for OCD is relatively new. The paper used the standard criteria for improvement, a Yale-Brown Obsessive-Compulsive Scale (YBOCS) score reduction of 35% or greater, and a YBOCS score of less than 8 for remission. The results demonstrate that the techniques are relatively comparable, with AC on average demonstrating a slightly greater effect compared to DBS. The authors argue that the adoption of DBS has more to do with patient and clinician preference than with greater clinical efficacy.
There are some limitations to the study that are worth noting. Virtually all of the papers included in the review were retrospective and open-label; hence the possibility of unintended bias exists. The papers in the review are not contemporaneous, with AC having the benefit of a much longer time to evolve. In addition, there are other ablative procedures, such as cingulotomy, that are not considered in the paper.
Nonetheless, the authors make an important point: specifically, that based on the available literature, ablative procedures may confer a clinical benefit similar to DBS. Moreover, ablative procedures are generally faster, more cost-effective, and require considerably less postoperative management, all of which are relevant factors given the current downward pressure on health care costs. Conversely, psychiatric neurosurgery has a checkered history in the popular mind, and the use of DBS, which is adjustable and reversible, makes it philosophically and ethically less challenging for providers and patients alike. Thus the use of DBS could lead more patients with medically intractable disease to benefit from surgical therapy. Ideally, there would be prospective randomized controlled trials to answer these questions definitively, but for the moment the controversy will continue.
Reference
Pepper J, , Hariz M, & Zrinzo L: Deep brain stimulation versus anterior capsulotomy for obsessive-compulsive disorder: a review of the literature. J Neurosurg [epub ahead of print January 30, 2015. DOI: 10.3171/2014.11.JNS132618]
