Bilateral cingulate incision for treatment of obsessive-compulsive disorder and depression

Bilateral buckling incision is a brain surgery and is considered the last resort for patients with obsessive-compulsive disorder (OCD). It is also used to treat major depression and occasional chronic pain for people who have not yet obtained relief from any other form of treatment.

The surgery targets two parts of the brain:

  • The cingulate gyrus helps regulate mood and pain
  • The frontal lobe, whose functions include reasoning, impulse control, and judgment

Surgical procedures in psychiatry are controversial, and unless all other treatment options have been exhausted, most doctors will not perform bilateral cingulate incisions. In fact, many neurosurgeons need to obtain the consent of the patient and close family members before performing the operation.

In 1947, American physiologist John Farquhar Fulton first proposed bilateral cingulate incision as an alternative to lobectomy.

The basic principles of bilateral cingulate incision

The cingulate gyrus plays a unique role in the brain, linking experiences and feelings with pleasant or unpleasant memories. Among other things, it causes an emotional response to pain and associates this response with one or more of our senses (sight, smell, taste, touch, sound). The cingulate gyrus also completes the circuit to the caudate nucleus in another part of the brain. The function of the caudate nucleus is to form a habit.

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I believe that by disrupting these circuits, the connection between painful emotions and habitual behavior will also be disrupted.

How to perform surgery

When performing a bilateral cingulate incision, magnetic resonance imaging (MRI) is used to guide electrodes or a gamma knife (targeted radiation device) to the cingulate gyrus. There, the surgeon will perform a half-inch cut or burn to break the circuit.

It takes about four days to recover from the operation.Side effects are usually mild, and some people experience headaches, nausea, and vomiting within a few days after surgery. Surgery may also trigger seizures in some people, although this usually occurs in people with a history of epilepsy.

Some people complain of becoming indifferent after the operation, while others experience memory decline.These are uncommon side effects, but surgical candidates need to consider the potential risks.

Effectiveness of bilateral cingulate incision

Although bilateral cingulate incision can improve some patients with obsessive-compulsive disorder, it is by no means a panacea. A review of clinical studies in 2016 concluded that 41% of patients undergoing bilateral cingulate incisions responded to the procedure, 14% had short-term side effects, and 5% had serious side effects.

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Bilateral cingulate incision seems to be the least effective for patients with refractory obsessive-compulsive disorder. People who have little response to at least two different selective serotonin reuptake inhibitor (SSRI) drugs are diagnosed with refractory obsessive-compulsive disorder. It is also considered to be less useful for people with manifestations of more serious diseases, including hoarding related to obsessive-compulsive disorder.

Bilateral cingulate incision is also used to treat chronic intractable pain (pain that cannot be treated by any known method). A systematic review of the study showed that the procedure resulted in significant pain relief for more than 60% of patients up to a year after the procedure.Among them, more than half said that they no longer need painkillers.

Although some studies recommend bilateral cingiotomies for patients with refractory bipolar disorder, the studies so far are inconclusive. Therefore, it is currently not recognized as a means of biphasic therapy.