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Salud mental

versão impressa ISSN 0185-3325


JIMENEZ PONCE, Fiacro et al. Introducción a la neurocirugía psiquiátrica. Salud Ment [online]. 2006, vol.29, n.1, pp.3-12. ISSN 0185-3325.

Recent background in neurosurgery for psychiatric disorders can be placed in the mid XIXth century. Buckhartd made partial resection of frontal cortex in 6 psychiatric patients, with successful results in 4 of them, but important side effects prevented the development of this scientific approach. In 1936 Egas Moniz and Almeida Lima performed a new neuro-psychiatric technique for treatment of several psychiatric disorders, named prefrontal lobotomy. Results of this treatment won Moniz a Nobel Prize in 1949, and encouraged Freeman and Watts to further develop this kind of surgery in United States of America.

Unfortunately, the knowledge about pathophysiology was not sufficient to make a precise indication of surgery in this patients. Between 1935 and 1950, nearly 20,000 surgeries were performed in doubtful conditions, showing important side effects. On the other hand, the emergency of new drugs for the treatment of psychiatric disorders along with the absence of regulation stopped development of "psychosurgery".

However, in 1946 Spiegel and Wacis started stereotactic age of neurosurgery, thus reducing risk and complication of this procedures. Nowadays, World Health Organization accepted four neurosurgery procedures for psychiatric disorders: cingulotomy, anterior capsulotomy, subcaudate tractotomy and limbic leucotomy (a combination of cingulotomy and subcaudate tractotomy). Best results for this kind of surgery are shown for affective disorders (major depression disorder, bipolar disorder, anxiety disorders) and obsessive compulsive disorder. Besides, in clinical research protocols the inclusion criteria for neurosurgical procedures in psychiatry have been well defined. Both patients' selection and medical team must be monitored by ethics committee. Currently, the requirements to consider a patient as a candidate for psychiatric neurosurgery are:

Clear psychiatric diagnosis in accordance to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM.IV-TR).

Evidence of refractivity (improved of symptoms inferior to 50%) to conventional treatments provided by two different psychiatrists.

A minimum of 5 years of evolution in symptoms.

The ethics committee must monitor surgical and research protocols in a case by case basis. The Committee will made sure that patient and relatives understand medic and psychiatric inclusion criteria.

Neurosurgical procedures will only be indicated when the patient is able to understand and accept any details presented to him or her in a formal Consent Form.

Neurosurgery psychiatric clinical teams should be integrated by:

Stereotactic neurosurgeons whose have experience in psychiatric neurosurgery, neuromodulation, radiosurgery and clinical issues.

A psychiatric team with ample experience in psychiatric conditions and research protocols.

In case both teams of specialists are not experienced enough in the field of psychiatric neurosurgery, they must look for technical advice from other neurosurgical psychiatric centers.

Psychiatric neurosurgery can only be performed to recover healthy conditions and relief suffering. These interventions must always be performed with the sole objective of improving patients quality of life and they must never be used for political, legal or social purposes.

Finally, Neuromodulation has shown to be a useful and safe tool in relief of psychiatric disorders. Neuromodulation's effects are reversible and they can adjusted to patient. Nowadays, Neuromodulation is being used in patients with major depression, obsessive compulsive disorder and Tourette's illness.

Palavras-chave : Psychosurgery; limbic system; neuromodulation; stereotactic; psychiatric disorders.

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