The current place of epilepsy surgery

Three randomized controlled trials demonstrate that surgical treatment is safe and effective for drug-resistant epilepsy (DRE), yet fewer than 1% of patients are referred for surgery. This is a review of recent trends in surgical referral for DRE, and advances in the field. Reasons for continued underutilization are discussed. Recent series indicate no increase in surgical referral for DRE over the past two decades. One study suggests that decreased referrals to major epilepsy centers can be accounted for by increased referrals to low-volume nonacademic hospitals where results are poorer, and complication rates higher. The increasing ability of high-resolution MRI to identify small neocortical lesions and an increase in pediatric surgeries, in part, explain a relative greater decrease in temporal lobe surgeries. Misconceptions continue to restrict referral. Consequently, advocacy for referral of all patients with DRE to epilepsy centers that offer specialized diagnosis and other alternative treatments, as well as psychosocial support, is recommended. Recent advances will continue to improve the safety and efficacy of surgical treatment and expand the types of patients who benefit from surgical intervention. Surgical treatment for epilepsy remains underutilized, in part because of persistent misconceptions. Rather than promote referral for surgery, it would be more appropriate to advocate that all patients with DRE deserve a consultation at a full-service epilepsy center that offers many options for eliminating or reducing disability.