Comparative Efficacy and Safety of Different Surgical Strategies for Refractory Obsessive-Compulsive Disorder: Evidence From Network Meta-Analysis

Why It Matters

The findings clarify that both DBS and capsulotomy are viable options for severe OCD, guiding clinicians toward personalized surgical strategies that balance efficacy with long‑term safety.

Key Takeaways

• DBS and capsulotomy achieve similar symptom reduction
• DBS carries fewer permanent neurological adverse events
• Ablative surgery offers quicker symptom relief without device maintenance
• Target selection influences response variability across patients
• Evidence confidence rated moderate‑to‑high using GRADE

Pulse Analysis

Refractory obsessive‑compulsive disorder remains a therapeutic dead‑end for many patients despite optimal pharmacotherapy and psychotherapy. Surgical neuromodulation—either lesion‑based capsulotomy or implantable deep brain stimulation—has emerged as the last line of defense. Capsulotomy, including gamma ventral and anterior limb approaches, creates permanent lesions that disrupt hyperactive cortico‑striatal circuits, while DBS delivers adjustable electrical currents to modulate the same pathways without destroying tissue. Both modalities target the reward and habit‑forming circuitry implicated in compulsive behaviors, yet they differ markedly in invasiveness, postoperative management, and reversibility.

The network meta‑analysis synthesized outcomes from over thirty peer‑reviewed trials, applying rigorous statistical models to compare multiple interventions simultaneously. Results indicated that response rates—defined as a ≥35% reduction in Y‑BOCS—hovered around 55% for DBS and 58% for capsulotomy, with no statistically significant superiority of one technique over the other. However, safety analyses revealed a distinct advantage for DBS: permanent neurological deficits occurred in less than 2% of DBS patients versus up to 7% in ablative cohorts, where transient side effects such as mood swings and temporary motor deficits were more common. The authors leveraged GRADE and CINeMA tools to rate the evidence, assigning moderate‑to‑high confidence to efficacy conclusions and lower confidence to long‑term safety due to heterogeneous follow‑up periods.

Clinicians interpreting these data must weigh the trade‑offs between immediate symptom control and the risk of irreversible tissue damage. For patients prioritizing reversibility and device programmability, DBS—particularly targeting the ventral capsule/ventral striatum—offers a compelling option. Conversely, individuals unsuitable for chronic implants may benefit from capsulotomy’s one‑time intervention despite its higher side‑effect profile. Ongoing trials exploring connectomic targeting and adaptive stimulation promise to refine patient selection, ultimately enhancing outcomes for the most severe OCD cases.