Epilepsy surgery, delays and referral patterns - Are all your epilepsy patients controlled?

Rationale: Epilepsy surgery is a standard of care in the treatment of medically intractable epilepsy, but is underutilised. We describe the results of epilepsy surgery and the referral patterns at a referral epilepsy programme. Methods: We reviewed the outcome of epilepsy surgery performed at the University of South Florida and Tampa General Hospital epilepsy programme for the years 2000 and 2001. The typical presurgical evaluation included clinical evaluation, EEG-video monitoring, MRI with dedicated epilepsy protocol, PET, SPECT, neuropsychological testing and Wada testing. We used the Engel outcome classification, and focused on the referral information to determine how and when in the course of their illness patients arrive at a referral epilepsy centre. Results: In the 2-year period (2000-2001), a total of 36 epilepsy surgeries were performed. Twenty-nine temporal lobectomies, six extratemporal resections and one corpus callosotomy. Ages varied from 17 to 65 years. Overall results were: 30 (83%) seizure-free [class I], 5 (17%) rare seizures or almost seizure-free [class II] and 1 no improvement. Of the 29 temporal lobectomies, 27 (93%) are completely seizure-free [class I] and 2 (7%) are >90% improved [class II]. Duration of seizures before being seen at the epilepsy centre averaged 18 years (range 2-58 years). Twenty-two (61%) were sent by their neurologists, while 14 (39%) came self-referred without having discussed surgery with their neurologists. Five (14%) were specifically advised by their neurologist to not consider surgery. Two had participated in clinical trials of antiepileptic drugs (AEDs) before being seen at the epilepsy centre. Conclusions: Epilepsy surgery has high efficacy and very low morbidity. Yet, there continues to be a long delay in the referral of patients to the epilepsy centre, suggesting that surgery for epilepsy is underutilised.