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  • Improved Utility of Neuroablation Over Deep Brain Stimulation in the Treatment of Obsessive Compulsive Disorder May Not Be Durable

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    Kevin K Kumar MD, PhD; Geoffrey Appelboom M.D. Ph.D.; Layton Lamsam BS; Nolan Williams; Mahendra T. Bhati; Sherman C. Stein MD; Casey H. Halpern MD

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    Meeting: Congress of Neurological Surgeons 2017 Annual Meeting

    Introduction: The advent of deep brain stimulation (DBS) technology has generated interest in its novel application for neurological and psychiatric conditions. Obsessive compulsive disorder (OCD) is the fourth most common mental disorder, resulting in lost income and decreased quality of life (QOL). Surgical treatment for medically-refractory OCD previously consisted of neuroablation (ABL) of targets in the OCD circuitry. Recent trials have examined the utility of DBS for OCD. However, no quantitative analysis directly comparing DBS to ABL has previously been performed.

    Methods: We completed a structured literature search from 1999-2016, identifying 57 clinical publications of DBS or ABL for OCD. A total of 519 cases were included in the analysis. We developed a decision-analytic model to compare the data from DBS and ABL. Specifically, we evaluated baseline demographics, utility based on percent decrease in the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), long-term outcomes, duration of follow up, and procedure complications.

    Results: There was no difference in age of OCD onset, age at treatment, percentage of female patients, and preoperative Y-BOCS score. Compared to ABL studies, there was a significantly longer duration of follow up (p= 0.002) in the identified DBS trials. Overall, ABL added significantly more units of utility 0.185 ± 0.005 than DBS 0.162 ± 0.006 (p < 0.001). Furthermore, ABL had significantly fewer complications than DBS (p<0.001). However, subgroup analyses revealed that DBS became more effective with time and DBS outcomes were superior to ABL at 5 years.

    Conclusions: Our metanalysis of OCD neurosurgical trials has revealed that ABL has higher short-term efficacy and fewer complications than DBS. While these data suggest that ABL is safer than DBS, under-reporting of ABL complications potentially confounds this finding. The temporal improvement in DBS efficacy and superior long-term DBS outcomes suggest that neuroplasticity and stimulator programming may ultimately determine the therapeutic benefit of DBS for OCD.

    Patient Care: Our research evaluates the outcomes and complications of two major neurosurgical techniques for obsessive compulsive disorder (OCD): neuroablation and deep brain stimulation. This work helps inform future studies exploring the safest and most effective neurosurgical treatment for patients suffering from OCD.

    Learning Objectives: By the conclusion of this session, participants should be able to: (1) understand the application of neuroablation and DBS for OCD, (2) appreciate the differences in utility, complications, and outcomes between neuroablation and DBS for OCD, and (3) identify the future areas of investigation into neurosurgical interventions for OCD.

    References: 1. Abramowitz, J.S., Taylor, S. and McKay, D., 2009. Obsessive-compulsive disorder. The Lancet, 374(9688), pp.491-499. 2. Brown, L.T., Mikell, C.B., Youngerman, B.E., Zhang, Y., McKhann, G.M. and Sheth, S.A., 2016. Dorsal anterior cingulotomy and anterior capsulotomy for severe, refractory obsessive-compulsive disorder: a systematic review of observational studies. Journal of neurosurgery, 124(1), pp.77-89.

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