Barriers to Referral for Epilepsy Surgery Evaluation

Summary and Comment |
January 21, 2015

Barriers to Referral for Epilepsy Surgery Evaluation

  1. Robert C. Knowlton, MD, MSPH

A large national survey in Canada reveals insights into neurologist-related barriers to referral for possible surgical treatment of drug-resistant seizure disorders.

  1. Robert C. Knowlton, MD, MSPH

Marked underuse of resective surgery for drug-resistant focal epilepsy has not changed in recent decades. Although substantial accumulated evidence has demonstrated safety and robust efficacy for surgical epilepsy treatment (N Engl J Med 2001; 345:311 and Neurology 2003; 60:538), only about 3000 patients completed surgery resection evaluations in 2013 in the U.S., compared with an estimated 4500 new patients with surgically amenable drug-resistant focal epilepsy per year and 130,000 to 280,000 existing candidates (Neurology 2012; 78:1200 and National Association of Epilepsy Centers 2013 survey results [unpublished]). To study one important possible cause for this remarkable lack of employing such a potent treatment option, researchers surveyed all practicing neurologists in Canada using a questionnaire to address several potential physician-related barriers to referral.

Responses were obtained from 54% (425) of 796 eligible participants. Although some bias appeared with respect to location, practice duration, and language preference, overall the sample represented a comprehensive spectrum of neurologists' background, practice characteristics, and experience. Only about half of the respondents answered questions correctly concerning what defines drug-resistant epilepsy and for whom and when surgical evaluation is indicated. More-recently graduated (year 2000 or later) neurologists were more likely to respond correctly. More than 75% of respondents considered “inadequate health care resources” to be the single greatest barrier to epilepsy surgery. Regardless of whether this resource limitation is specific to the Canadian health system, the authors conclude that a substantial knowledge gap remains regarding evidence-based indications for epilepsy surgery.


This thorough study provides some valuable insights into the problem of insufficient referral for epilepsy surgery evaluation. Yet it is only the beginning of understanding what is undoubtedly a multifactorial problem. Although not completely separate from neurologist-related barriers, the introduction of more than a dozen novel antiseizure medications since 1993 complicates treatment endeavors of well-intentioned practitioners. Patients may play an even larger role in prejudice against surgical treatment, as evidenced by the relatively large patient-driven response, including self-referral, for laser ablation therapy, which is perceived as minimally invasive. In addition, the vagal nerve stimulator — a minimally invasive treatment that provides only a modest chance at significant seizure control — is chosen even by many patients who are candidates for resective surgery with a high likelihood of a seizure-free or nearly seizure-free outcome.

Editor Disclosures at Time of Publication

  • Disclosures for Robert C. Knowlton, MD, MSPH at time of publication Consultant / Advisory board Upsher-Smith Laboratories, Inc.; University of Alabama at Birmingham, Dept. of Neurology Speaker’s bureau Eisai Grant / Research support NIH-NINDS Leadership positions in professional societies Southern Epilepsy & EEG Society (Treasurer)


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