Neurosurgery for intractable psychiatric conditions has seen a resurgence with the increasing use of deep brain stimulation (DBS). Although DBS promises reversible neuromodulation and has become more popular than older lesioning methods, lesioning might still be preferred in specific cases. Here, we review the evidence for DBS and lesions in the treatment of intractable neuropsychiatric conditions and consider the factors that favour the continued use of lesioning procedures in appropriately selected cases. Broadly, systemic factors including comparative effectiveness, cost, and ethical arguments support an ongoing role for lesioning. Such a role is also supported by practical considerations including patient experiences of this type of therapy, the relative intensity of follow-up care, access to sparse or specialised follow-up care, and relative infection risk. Overall, we argue that neurosurgical lesion procedures remain an important alternative to DBS and their continued availability is necessary to fulfil the imperatives of mental health parity and enhance access to effective mental health treatments. Nonetheless, the efficacy of DBS and recent advances in closed-loop stimulation and remote programming might provide solutions to some of the challenges associated with wider use of electrical neuromodulation. Concerns about the scarcity of high-level evidence for the efficacy of lesioning procedures as well as the potential irreversible adverse effects of lesioning remain to be addressed.

中文翻译：

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病变在精神神经外科中的持久价值


随着深部脑刺激 （DBS） 的日益普及，针对顽固性精神疾病的神经外科已经复苏。尽管 DBS 有望实现可逆的神经调控，并且比旧的病变方法更受欢迎，但在特定情况下，病变可能仍然是首选。在这里，我们回顾了 DBS 和病变治疗顽固性神经精神疾病的证据，并考虑了在适当选择的病例中支持继续使用病变手术的因素。从广义上讲，包括比较有效性、成本和伦理论点在内的系统性因素支持病变的持续作用。这种作用也得到了实际考虑的支持，包括患者对这种治疗的体验、随访护理的相对强度、获得稀疏或专门的随访护理的机会以及相对感染风险。总体而言，我们认为神经外科病变手术仍然是 DBS 的重要替代方案，它们的持续可用性对于满足心理健康平等的必要条件和增加获得有效心理健康治疗的机会是必要的。尽管如此，DBS 的功效以及闭环刺激和远程编程的最新进展可能会为与更广泛使用神经调控相关的一些挑战提供解决方案。对病变手术疗效的高水平证据缺乏以及病变的潜在不可逆不良反应的担忧仍有待解决。