When Should a Patient Be Referred for Epilepsy Surgery Evaluation?

Summary and Comment |
October 23, 2012

When Should a Patient Be Referred for Epilepsy Surgery Evaluation?

  1. Robert C. Knowlton, MD, MSPH

A new Web-based tool is available to help clinicians decide when to refer a patient for evaluation.

  1. Robert C. Knowlton, MD, MSPH

Evidence suggests that the low rate of referral for epilepsy surgery evaluation is in part caused by clinicians' doubts about patient eligibility. To improve the rate of appropriate referrals, researchers have now developed and tested a Web-based decision-making tool.

A clinician panel that included epilepsy specialists and general neurologists surveyed the literature to identify eligibility criteria for entrance into epilepsy surgery studies, which they used to create a systematic, stepwise decision-making tool. The criteria were based on magnetic resonance imaging and electroencephalography findings, frequency of disabling seizures, presence of adverse effects related to antiepileptic drug (AED) use, and number of AEDs tried. The panel then used the tool to rate 2646 clinical scenarios as “appropriate,” “inappropriate,” or “uncertain” to refer the described patient for epilepsy surgery evaluation. The reviewers rated 62% of scenarios as inappropriate for surgery evaluation referral, 21% as appropriate, and 17% as uncertain. The reviewers disagreed in only 0.8% of cases, all of which involved either incomplete clinical investigations or nondisabling seizures. The Web-based tool is published at www.epilepsycases.com.

Comment

The panel developed this tool because of the persistent, frustrating absence of improvement in the relative number and timely referral of appropriate candidates for epilepsy surgery evaluation, despite decades of accumulating evidence and excellent guidelines supporting the efficacy and relatively low risks of epilepsy surgery. Astonishingly, time to surgical evaluation and treatment for adults remains approximately 20 years (CNS Spectr 2004; 9:136).

Regardless of any limitations in the data and methods used to develop this tool, it can aid in changing practice. Notably, the authors used only variables important in considering referral for epilepsy surgery evaluation, not the more extensive data points necessary for determining actual surgery candidacy. As the authors emphasize, the tool must be validated and, most importantly, updated as new pertinent knowledge becomes available. This should not be difficult, and the tool is easy to use. The challenge will be making target physicians aware of the tool and its importance.

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