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Summary

Bilateral cingulotomy is a neurosurgical procedure performed to alter the anterior cingulate region of the brain (present in the frontal lobe), which is responsible for emotional responses, memory, and the feeling of chronic pain

This procedure is done for the management of certain psychiatric disorders like OCD or chronic pain that does not resolve with medicines

Bilateral cingulotomy is performed under local anaesthesia, you will be awake during the procedure. A magnetic resonance imaging test is performed before the surgery to create a map of your brain. Although the surgery is considered safe, it is associated with a few complications such as bleeding, weight gain, confusion, and seizures.

  1. What is bilateral cingulotomy?
  2. Why is bilateral cingulotomy recommended?
  3. Who can and cannot get bilateral cingulotomy?
  4. What preparations are needed before bilateral cingulotomy?
  5. How is bilateral cingulotomy done?
  6. How to care for yourself after bilateral cingulotomy?
  7. What are the possible complications/risks of bilateral cingulotomy?
  8. When to follow up with your doctor after a bilateral cingulotomy?

Bilateral cingulotomy is a neurosurgical procedure that is done to manage certain psychiatric disorders including OCD and depression and chronic pain that does not subside with medications.

The anterior cingulate region in the brain is engaged in various functions such as emotion-based learning, emotional regulation, memory, and the feeling of chronic pain. Studies have shown that this region is involved in various mental health disorders. Reduced activity in the anterior cingulate region has been observed in individuals with post-traumatic stress disorder, schizophrenia, and depression, whereas increased activity has been observed in people with social anxiety.

Individuals experiencing chronic pain are usually treated with medicines and injections. However, if these treatment methods fail, the condition may become persistent. In such individuals and people with psychiatric diseases associated with the anterior cingulate region, bilateral cingulotomy is performed. 

The surgery involves alteration of this region to provide relief from pain and symptoms of the psychiatric conditions. It does not cure the underlying condition but merely provides symptomatic relief.

A neurosurgeon (a physician that specialises in the diagnosis and management of diseases of the central nervous system) will recommend this surgery if you have any of the following conditions:

  • Cancer-related pain that does not resolve with medications
  • Pain after a stroke
  • Obsessive-compulsive disorder: Symptoms of the condition include:
    • Fear of contamination
    • Thoughts about hurting oneself or others
    • Excessive cleaning or hand washing
    • A compulsion to arrange things in a perfect order
    • Compulsive counting
    • Need for objects to be symmetrical
    • Taboo or forbidden thoughts about religion, sex, etc.
  • Major depression that does not resolve with medications: Symptoms of major depression include:
    • Sense of despair
    • Profound sadness
    • Persistent and severe low mood
  • Atypical trigeminal neuralgia that causes constant facial pain with a burning sensation
  • Other unusual types of facial pain

This surgery is contraindicated in individuals with:

  • Sociopathic personality or some other personality disorders
  • Imaging tests that indicate organic lesion (area of damage) in the brain or impaired cognitive functions

You will need to visit the hospital a few days prior to the surgery for a preoperative assessment wherein the neurosurgeon will study your medical history and perform medical and imaging tests such as:

  • Blood tests
  • Urine tests
  • Pregnancy test
  • Magnetic resonance imaging (MRI): An MRI scan produces two-dimensional or three-dimensional detailed images of the brain
  • Computed tomography (CT): A CT scan creates two-dimensional pictures that can help diagnose brain damage and other disorders

Additionally, the surgeon will give you the following instructions to prepare for the surgery:

  • Stop smoking (if you do) to reduce the risk of complications in the surgery and to help you heal quickly afterwards.
  • Fast after midnight, the night prior to the surgery.
  • Take a shower and remove body piercings, nail polish, and make-up before arriving at the hospital on the day of the surgery.
  • Arrange for a family member, friend, or responsible adult to drive you home following the procedure.

Inform the surgeon of all the medicines that you take, including over-the-counter medications, vitamins, and supplements. He/she may ask you to discontinue blood thinners like aspirin, warfarin, and clopidogrel a few days prior to the surgery.

Tell the surgeon if you have a fever or other health issues in the days leading to the surgery. In such a case, your surgery may be postponed.

On the day of the surgery, you may be asked to sign an approval or consent form to grant permission for the procedure.

After you arrive at the hospital on the scheduled day of the surgery, the hospital staff will provide you with a hospital gown. They will start an intravenous (IV) line in your hand to supply essential fluids and medicines during the surgery and trim the hair over your scalp. You will be given a sedative through the IV line to help you relax, and local anaesthesia (numbing medicine) will be injected into your scalp.

The procedure may involve the following:

  • The surgeon will fix a stereotactic frame over your head and conduct an MRI test to create a map of your brain. The stereotactic head frame will provide target reference points and keep your head from moving.
  • After the scan, you will be moved to the operating theatre.
  • The neurosurgeon will make an incision (cut) on your scalp and drill small holes in your skull.
  • He/she will introduce an electrode (to monitor the electrical activity of the brain) in the targeted region of your brain under the guidance of an MRI.
  • Once the region is identified, this electrode will be used to create a wound in the target area on both sides of your brain.
  • Then, he/she will insert a tube into your skull to drain excess fluids and close the tissues and scalp over the operated area.

Following the procedure, you will have to stay at the hospital for a few days to recover. During the stay:

  • You will be taught some exercises and deep breathing exercises to prevent the formation of blood clots and chest infections.
  • You may experience fever, nausea, headache, and loss of bladder control. However, these will resolve within two days. 

Once you reach home, you will need the following care:

  • Keep the operated area dry and clean. You can wash your hair but gently pat dry the operated area after washing.
  • Avoid using ointments, lotions, and other products on the operated area. In addition, you should avoid using hair dryers for the initial two weeks and hair dyes for around 12 weeks.
  • You will be prescribed antibiotics and anti-seizure medications. Take them as directed.
  • Perform deep breathing and regular exercises that were taught to you in the hospital before discharge. 
  • Start with mild physical activity and gradually increase the intensity over the next few days.
  • While lifting objects, do not bend from your waist; instead, bend your knees while keeping your back straight.
  • Ask your surgeon before you resume driving.

When to see the doctor?

Contact the neurosurgeon at the earliest if you experience any of the following after the surgery:

This surgery is usually considered safe; however, it is associated with a few side effects including:

  • Bleeding
  • Rarely, transient spasticity (a condition that affects speech, muscle movement, and gait), hemiparesis (a condition that causes weakness on one side of the body) or confusion.
  • Transient problems emptying the bladder or bowel
  • Mild weight gain
  • Ataxia (disorders that affect speech, balance, and coordination)
  • Seizure
  • Decreased spontaneity and activity
  • Apathy

You will have a follow-up appointment in a week after surgery to get the stitches and drain removed. The surgeon will inform you about the subsequent follow-ups during this visit.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.

References

  1. Yen C-P, Kuan C-Y, Sheehan J, Kung S-S, Wang C-C, Liu C-K, et al. Impact of bilateral anterior cingulotomy on neurocognitive function in patients with intractable pain. J Clin Neurosci. 2009 Feb;16(2):214–219. PMID: 19101146.
  2. Doshi PK. Surgical treatment of obsessive compulsive disorders: current status. Indian J Psychiatry. 2009 Jul-Sep;51(3):216–221. PMID: 19881054.
  3. UCLA health [Internet]. University of California. Oakland. California. US; Cingulotomy
  4. National Institute of Mental Health [Internet]. National Institute of Health. US Department of Health and Human Services; Obsessive-Compulsive Disorder
  5. Lozano AM, Gildenberg PL, Tasker RR. Textbook of stereotactic and functional neurosurgery. 2nd ed. Springer; 2009. Chapter 172, cingulotomy for depression and OCD; p. 2887–2896
  6. Harvard Health Publishing: Harvard Medical School [Internet]. Harvard University, Cambridge. Massachusetts. USA; Major Depression
  7. American Association of Neurological Surgeons [Internet]. Illinois. US; Trigeminal Neuralgia
  8. National Health Service [Internet]. UK; Having an operation (surgery)
  9. National Institute of Neurological Disorders and Stroke [Internet[. National Institute of Health. US Department of Health and Human Services. US; Neurological Diagnostic Tests and Procedures Fact Sheet
  10. Johns Hopkins Medicine [Internet]. The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System; Burr Holes
  11. The Stroke Association [Internet]. Blackpool. UK; Blood-thinning medication and stroke
  12. Department of Neurosurgery: Washington University School of Medicine in St. Louis [Internet]. Washington University in St. Louis. US; Stereotactic Neurosurgical Procedures
  13. Viswanathan A, Harsh V, Pereira EAC, Aziz TZ. Cingulotomy for medically refractory cancer pain. Neurosurg Focus. 2013 Sep;35(3):E1. PMID: 23991812.
  14. Oxford University Hospitals [internet]: NHS Foundation Trust. National Health Service. U.K.; After cranial surgery
  15. Sawyer MM. Postanesthetic care. In: Duke JC, Keech BM, eds. Anesthesia Secrets. 5th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 28
  16. Ortega-Barnett J, Mohanty A, Desai SK, Patterson JT. Neurosurgery. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20th ed. Philadelphia, PA: Elsevier; 2017:chap 67

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