Deep Brain Stimulation Between 1947 and 1987: The Untold Story
Deep Brain Stimulation Between 1947 and 1987: The Untold Story
Deep brain stimulation (DBS) is the most rapidly expanding field in neurosurgery. Movement disorders are well-established indications for DBS, and a number of other neurological and psychiatric indications are currently being investigated.
Numerous contemporary opinions, reviews, and viewpoints on DBS fail to provide a comprehensive account of how this method came into being. Misconceptions in the narrative history of DBS conveyed by the wealth of literature published over the last 2 decades can be summarized as follows: Deep brain stimulation was invented in 1987. The utility of high-frequency stimulation was also discovered in 1987. Lesional surgery preceded DBS. Deep brain stimulation was first used in the treatment of movement disorders and was subsequently used in the treatment of psychiatric and behavioral disorders. Reports of nonmotor effects of subthalamic nucleus DBS prompted its use in psychiatric illness. Early surgical interventions for psychiatric illness failed to adopt a multidisciplinary approach; neurosurgeons often worked "in isolation" from other medical specialists. The involvement of neuro-ethicists and multidisciplinary teams are novel standards introduced in the modern practice of DBS for mental illness that are essential in avoiding the unethical behavior of bygone eras.
In this paper, the authors examined each of these messages in the light of literature published since 1947 and formed the following conclusions. Chronic stimulation of subcortical structures was first used in the early 1950s, very soon after the introduction of human stereotaxy. Studies and debate on the stimulation frequency most likely to achieve desirable results and avoid side effects date back to the early days of DBS; several authors advocated the use of "high" frequency, although the exact frequency was not always specified. Ablative surgery and electrical stimulation developed in parallel, practically since the introduction of human stereotactic surgery. The first applications of both ablative surgery and chronic subcortical stimulation were in psychiatry, not in movement disorders. The renaissance of DBS in surgical treatment of psychiatric illness in 1999 had little to do with nonmotor effects of subthalamic nucleus DBS but involved high-frequency stimulation of the very same brain targets previously used in ablative surgery. Pioneers in functional neurosurgery mostly worked in multidisciplinary groups, including when treating psychiatric illness; those "acting in isolation" were not neurosurgeons. Ethical concerns have indeed been addressed in the past, by neurosurgeons and others. Some of the questionable behavior in surgery for psychiatric illness, including the bygone era of DBS, was at the hands of nonneurosurgeons. These practices have been deemed as "dubious and precarious by yesterday's standards."
Treating obsessive-compulsive disorder. Options include medication, psychotherapy, surgery, and deep brain stimulation.
THE HARVARD MENTAL HEALTH LETTER, MARCH 2009
Deep brain stimulation is probably the most rapidly expanding field in neurosurgery. Parkinson disease, essential tremor, and dystonia are well-established, evidence-based indications for DBS, and a number of other neurological and psychiatric indications are currently being investigated.
There is no doubt that the modern form of DBS was heralded by the neurosurgeon/neurologist team of Benabid and Pollak and their colleagues in Grenoble, France, through their 1987 publication on thalamic DBS contralateral to thalamotomy in patients with tremor. Subsequently, DBS virtually replaced thalamotomy as a first-hand procedure for tremor. The introduction of subthalamic nucleus (STN) DBS in 1993 by the same group, and the documentation of the safety and efficacy of this method applied bilaterally, including its potential for reducing the dose of dopaminergic medications in patients with advanced PD, eventually gave the coup de grâce to posteroventral pallidotomy, which was the preferred surgical procedure for PD in the 1990s. The nondestructive, that is, the nonablative feature of DBS, its adaptability and virtual reversibility, combined with its potential for conducting in vivo research on subcortical structures and basal ganglia functions, have attracted the interest of clinicians from several other specialties as well as that of neuroscientists, historians, and ethicists.
Common beliefs conveyed by contemporary literature on DBS include the following: DBS was "invented by Benabid and coworkers;" the observation that high-frequency stimulation often mimics the clinical effects of lesional surgery was first made in 1987; DBS was initially developed for movement disorders and has only recently been applied in neuropsychiatry; it was the observation of psychiatric side effects after STN DBS in patients with PD that prompted DBS trials for psychiatric disorders; and early proponents of surgical intervention for psychiatric illness failed to adopt a multidisciplinary approach with neurosurgeons often working "in isolation" from other specialists.
The aim of the present review was to look for the seeds of what was to become one of the most rapidly expanding and most promising techniques in the field of functional stereotactic neurosurgery, and to establish if some of the contemporary claims related to the history of DBS can be substantiated.
Abstract and Introduction
Abstract
Deep brain stimulation (DBS) is the most rapidly expanding field in neurosurgery. Movement disorders are well-established indications for DBS, and a number of other neurological and psychiatric indications are currently being investigated.
Numerous contemporary opinions, reviews, and viewpoints on DBS fail to provide a comprehensive account of how this method came into being. Misconceptions in the narrative history of DBS conveyed by the wealth of literature published over the last 2 decades can be summarized as follows: Deep brain stimulation was invented in 1987. The utility of high-frequency stimulation was also discovered in 1987. Lesional surgery preceded DBS. Deep brain stimulation was first used in the treatment of movement disorders and was subsequently used in the treatment of psychiatric and behavioral disorders. Reports of nonmotor effects of subthalamic nucleus DBS prompted its use in psychiatric illness. Early surgical interventions for psychiatric illness failed to adopt a multidisciplinary approach; neurosurgeons often worked "in isolation" from other medical specialists. The involvement of neuro-ethicists and multidisciplinary teams are novel standards introduced in the modern practice of DBS for mental illness that are essential in avoiding the unethical behavior of bygone eras.
In this paper, the authors examined each of these messages in the light of literature published since 1947 and formed the following conclusions. Chronic stimulation of subcortical structures was first used in the early 1950s, very soon after the introduction of human stereotaxy. Studies and debate on the stimulation frequency most likely to achieve desirable results and avoid side effects date back to the early days of DBS; several authors advocated the use of "high" frequency, although the exact frequency was not always specified. Ablative surgery and electrical stimulation developed in parallel, practically since the introduction of human stereotactic surgery. The first applications of both ablative surgery and chronic subcortical stimulation were in psychiatry, not in movement disorders. The renaissance of DBS in surgical treatment of psychiatric illness in 1999 had little to do with nonmotor effects of subthalamic nucleus DBS but involved high-frequency stimulation of the very same brain targets previously used in ablative surgery. Pioneers in functional neurosurgery mostly worked in multidisciplinary groups, including when treating psychiatric illness; those "acting in isolation" were not neurosurgeons. Ethical concerns have indeed been addressed in the past, by neurosurgeons and others. Some of the questionable behavior in surgery for psychiatric illness, including the bygone era of DBS, was at the hands of nonneurosurgeons. These practices have been deemed as "dubious and precarious by yesterday's standards."
Introduction
Treating obsessive-compulsive disorder. Options include medication, psychotherapy, surgery, and deep brain stimulation.
THE HARVARD MENTAL HEALTH LETTER, MARCH 2009
Deep brain stimulation is probably the most rapidly expanding field in neurosurgery. Parkinson disease, essential tremor, and dystonia are well-established, evidence-based indications for DBS, and a number of other neurological and psychiatric indications are currently being investigated.
There is no doubt that the modern form of DBS was heralded by the neurosurgeon/neurologist team of Benabid and Pollak and their colleagues in Grenoble, France, through their 1987 publication on thalamic DBS contralateral to thalamotomy in patients with tremor. Subsequently, DBS virtually replaced thalamotomy as a first-hand procedure for tremor. The introduction of subthalamic nucleus (STN) DBS in 1993 by the same group, and the documentation of the safety and efficacy of this method applied bilaterally, including its potential for reducing the dose of dopaminergic medications in patients with advanced PD, eventually gave the coup de grâce to posteroventral pallidotomy, which was the preferred surgical procedure for PD in the 1990s. The nondestructive, that is, the nonablative feature of DBS, its adaptability and virtual reversibility, combined with its potential for conducting in vivo research on subcortical structures and basal ganglia functions, have attracted the interest of clinicians from several other specialties as well as that of neuroscientists, historians, and ethicists.
Common beliefs conveyed by contemporary literature on DBS include the following: DBS was "invented by Benabid and coworkers;" the observation that high-frequency stimulation often mimics the clinical effects of lesional surgery was first made in 1987; DBS was initially developed for movement disorders and has only recently been applied in neuropsychiatry; it was the observation of psychiatric side effects after STN DBS in patients with PD that prompted DBS trials for psychiatric disorders; and early proponents of surgical intervention for psychiatric illness failed to adopt a multidisciplinary approach with neurosurgeons often working "in isolation" from other specialists.
The aim of the present review was to look for the seeds of what was to become one of the most rapidly expanding and most promising techniques in the field of functional stereotactic neurosurgery, and to establish if some of the contemporary claims related to the history of DBS can be substantiated.
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