Epilepsy surgery utilization: who, when, where, and why?

Using the most recent evidence, we provide an update on epilepsy surgery, focusing on its effectiveness, reasons for underutilization, considerations of candidacy and timing for referral for epilepsy surgery evaluation. The course of illness of epilepsy is being characterized. Well conducted studies describe the patterns of seizure remission and relapse with medical therapy and also in response to epilepsy surgery. Epilepsy surgery is highly effective in selected patients with drug-resistant epilepsy (DRE). The risk-benefit of epilepsy surgery is well known and consistent around the world. However, epilepsy surgery remains underutilized. A randomized controlled trial and Clinical Practice Guidelines (CPGs) supporting epilepsy surgery have had no discernible impact on referral rates for epilepsy surgery evaluation. Criteria and guidelines are being developed for identifying patients who need to be referred for epilepsy surgery evaluation. Quality indicators for epilepsy care now also include the need to consider surgical candidacy every 3 years in DRE. New developments in imaging and neurophysiology promise to help clinicians identify and treat patients more accurately. Surgery is effective but underused. Comprehensive interventions to translate evidence to practice in epilepsy surgery are urgently needed.