Abstract
Objective
Neurosurgery is a safe and effective form of treatment for select children with drug-resistant epilepsy. Still, there is concern that it remains underutilized, and that seizure freedom rates have not improved over time. We investigated referral and surgical practices, patient characteristics, and post-operative outcomes over the past two decades.
Methods
We performed a retrospective cohort study of children referred for epilepsy surgery at a tertiary center between 2000 and 2018. We extracted information from medical records and analyzed temporal trends using regression analyses.
Results
1,443 children were evaluated for surgery. Of these, 859 (402 females) underwent surgical resection or disconnection at a median age of 8.5 years (IQR=4.6-13.4). Excluding palliative procedures, 67% of patients were seizure-free and 15% were on no antiseizure medication at one-year follow-up. There was an annual increase in the number of referrals (7% [95% CI=5.3-8.6], p<0.001) and surgeries (4% [95% CI=2.9-5.6], p<0.001) over time. Duration of epilepsy and total number of different antiseizure medications trialed from epilepsy onset to surgery were, however, unchanged, and continued to exceed guidelines. Seizure freedom rates were overall also unchanged but showed improvement (OR 1.09 [95% CI=1.01-1.18], p=0.027) after adjustment for an observed increase in complex cases. Children who underwent surgery more recently were more likely to be off antiseizure medications post-operatively (OR 1.04 [95% CI=1.01-1.08], p=0.013). There was a 17% annual increase ([95% CI=8.4-28.4], p<0.001) in children identified to have a genetic cause of epilepsy, which was associated with poor outcome.
Significance
Children with drug-resistant epilepsy continue to be put forward for surgery late, despite national and international guidelines urging prompt referral. Seizure freedom rates have improved over the past decades, but only after adjustment for a concurrent increase in complex cases. Finally, genetic testing in epilepsy surgery patients has expanded considerably over time and shows promise in identifying patients in whom surgery is unlikely to be successful.
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