Neurosurgical Treatment of Intractable Tourette’s Syndrome: A Scientific Clinical Review of Literatures

Abstract

Background

Tourette’s syndrome (TS) is an inherited neuropsychiatric disorder characterized by fluctuating motor and vocal tics that starts in childhood. Diagnostic criteria for TS include the presence of multiple motor tics and one or more vocal tics, both of which must exceed a year’s duration. Pharmacotherapy has been the mainstay of the treatment. However, some TS patients will not respond to conventional medications. They might develop residual debilitating symptoms. The current article examines the reported experience with neurosurgical treatment of intractable Tourette’s syndrome.

Design/Method

All articles and textbooks containing descriptions of Tourette’s syndrome and its surgical treatment were reviewed. All related articles in PubMed were searched using these words: Tourette’s syndrome, TS, Tourette, Gilles de la Tourette, tic, tics, surgical treatment of tic disorders, surgical intervention of Tourrete’s syndrome, ablative surgery in Tourette’s syndrome, stereotactic surgery of Tourette’s syndrome. Only articles published in English were reviewed. In total, 11 articles and 2 textbooks were found describing the experimental surgery of refractory Tourette’s syndrome. All data about patient’s history, surgical treatment, outcome and side effects were collected and reviewed.

Results

Intractable Tourette’s syndrome may represent a special subgroup of the tic range. A variety of experimental procedures have been performed in an attempt to treat intractable Tourette’s syndrome, including: 1) frontal lobe operation (i.e., frontal lobotomy and bimedial frontal leucotomy), 2) limbic system operation (i.e., anterior cingulotomy, limbic leucotomy), 3) a novel multisite operation (i.e., anterior cingulotomy combined with infrathalamic lesions), 4) thalamic operation (i.e., bilateral coagulation of rostral infrathalamic and medial thalamic nuclei), and 5) a cerebellar operation (i.e., bilateral cerebellar dentatomy). There are serious uncertainties regarding any experimental neurosurgical procedures. However, in the case of severe, intractable Tourette’s syndrome, these appropriate concerns must be weighed against the risks of conventional therapies, including tardive dyskinesia. Patients who suffer from severe Tourette’s syndrome, and are debilitated by their symptoms, and have failed an exhaustive range of conventional pharmacologic therapies could be candidates for an experimental treatment.

Conclusion

Case reports in the literature provide only anecdotal evidence supporting the efficacy and safety of neurosurgical treatment of Tourette’s syndrome. There is no convincing evidence showing that any particular neurosurgical procedure is best for Tourette’s syndrome. If experimental neurosurgery for Tourette’s syndrome is to continue, then guidelines should be developed regarding patient and operation selection. Also, accurate clinical measurement should be applied preoperatively and postoperatively to monitor long-term outcome.