Capsulotomy for obsessive-compulsive disorder -: Long-term follow-up of 25 patients

Context: Capsulotomy is sometimes used as a treatment of last resort in severe and treatment- refractory cases of obsessive- compulsive disorder ( OCD). Objective: To evaluate the long- term efficacy and safety of capsulotomy in OCD. Design: Noncontrolled, long- term follow- up trial ( mean of 10.9 years after surgery). Setting: University hospital referral center. Patients: Twenty- five consecutive patients with OCD who underwent capsulotomy from 1988 to 2000. Intervention: Unilateral or bilateral capsulotomy. Lesions were created by means of radiofrequency heating ( thermocapsulotomy) or gamma radiation ( radiosurgery, gammacapsulotomy). Main Outcome Measure: Yale- Brown ObsessiveCompulsive Rating Scale ( Y- BOCS) score. Results: The mean Y- BOCS score was 34 preoperatively and 18 at long- term follow- up ( P <. 001). Response ( defined as >= 35% reduction at long- term follow- compared with baseline) was seen in 12 patients at long- term follow- up. Nine patients were in remission ( Y- BOCS score, 16) at long- term follow- up. Only 3 patients were in remission without adverse effects at longterm follow- up. Response rates did not differ significantly between surgical methods. A mean weight gain of 6 kg was reported in the first postoperative year. Ten patients were considered to have significant problems with executive functioning, apathy, or disinhibition. Six of these 10 patients had received high doses of radiation or had undergone multiple surgical procedures. Results of our magnetic resonance imaging analysis in 11 patients suggest that the OCD symptom reduction may be increased by reducing the lateral extension of the lesions, and a reduction in the medial and posterior extension may limit the risk of adverse effects ( ie, smaller lesions may produce better results). Conclusions: Capsulotomy is effective in reducing OCD symptoms. There is a substantial risk of adverse effects, and the risk may vary between surgical methods. Our findings suggest that smaller lesions are safer and that high radiation doses and multiple procedures should be avoided.