Surgery

Surgery

More than one million people in the United States suffer from epilepsy. Their lives are filled with uncertainty and restrictions because they never know a seizure will strike. People who have seizures are denied the opportunity to enjoy simple pleasures like driving a car.

Today, epilepsy surgery provides patients hope for a brighter future. Advances in diagnostic and surgical approaches have greatly improved the outcomes of epilepsy surgery and more people are leading seizure-free lives.

Many patients who suffer from simple and complex partial epilepsy uncontrolled on medications can benefit from surgery. Yet many do not receive this treatment due to misconceptions about the procedure.

The Epilepsy Program staff believes that all patients should have the opportunity to learn whether surgery might help. Headed by our neurosurgical director, Ian B. Ross, M.D., EBMP's surgical program leads the way in outstanding surgical outcomes making our program one of the bes in the world. Together, team members-neurologists, neurosurgeons, nurses, neuropsychologists, psychologists, and technicians- bring patients the most effective care in the safest and most comfortable environment.

Surgical Evaluation
Five phases of evaluation and treatment are required for a patient to be considered for surgery:

Initial Encounter
 During an in-depth evaluation of each patient, Epilepsy Program physicians explore several non-surgical options for treatment of seizures.

Phase I-Telemetry Monitoring
If the physician needs further testing to determine the patient's seizure type or if the patient is a candidate for surgery, Phase I telemetry is required. This requires a stay in the hospital. During this time, electrodes attached to the scalp and wires inserted in to the cheek areas (sphenoidal electrodes) transmit the patient's EEG to a small amplifier worn by the patient. When seizures do not occur, physicians induce them by withdrawing medication and depriving the patient of sleep. Recording typical seizures (ictal recordings) on EEG and videotape is the single most important goal of Phase I. The location of the EEG seizure onset reveals the focal source of the seizures in most patients. If the patient is a candidate for surgery and the physician obtains sufficient data during Phase I to determine seizure type and to pinpoint the source of the seizures, the patient then proceeds to Phase III (surgery). If there is not sufficient data the patient may be given the option of a medical or dietary regimen to control their seizures, or they may be referred to Phase II. After Phase I, the team reviews the patient's results from their stay in the hospital to determine what will be best for that patient. This process may take a while.

Phase III - Intracranial Telemtery Monitoring
For surgery candidates, this is necessary if physicians need to evaluate deeper areas of the brain to find the source(s) of the seizures. This is required in about 20% of patients. Grids are placed over lateral seizure areas or depth electrodes are surgically implanted deep in to the brain, near the area which is likely producing seizures. The grid electrodes are used when seizures arise near those areas that govern language and movement. The patient remains in the hospital for about three week or until enough data is captured to determine where the seizures are originating from. Monitoring is similar to Phase I, except that the patient's movements are more restricted and there may be some discomfort associated with the intracranial placement of the electrodes. As in Phase I, physicians continuously monitor the patient. Most Phase II patients can proceed to surgery.  Patients with depth electrodes require about 1 month for their scalp to heal before surgery. Patients with grids have their surgery when the grid is removed at a second craniotomy.

Phase III ' Surgery
Neurosurgeons remove the small portions of damaged brain that cause the seizures. Based on the findings of Phases I and II, physicians determine which of several possible procedures will be most successful. The most common procedure is anterior temporal lobectomy, or removal of a section of the anterior temporal lobe and the deep structure (hippocampus). This is the source of seizures in most epilepsy patients evaluated for surgery. Approximately 83 percent of patients undergoing temporal lobectomy eventually become free of seizures. All surgical procedures require close medical follow-up and may involve risks and complications. Patients generally return to normal activities within three to four weeks and to full functioning, including work, within three months.

Phase IV ' Long Term Follow-Up
The Epilepsy Program has a long term commitment to patients after surgery. Their progress is followed closely for one year and once annually throughout their lifetime. Psychosocial counseling and cognitive (memory) and vocational rehabilitation help patients in their transition to a more active life.

Outcomes

More than 83 percent of patients undergoing termporal resections are seizure-free and the conditions of more than 97 percent are markedly improved. In frontal lobe epilepsy, seizures are markedly reduced in more than 85 percent of patients undergoing resections.

Cost Effectiveness of Epilepsy Surgery

As the figures show above, epilepsy surgery has been shown to be highly effective and further studies show that over the lifetime of the patient epilepsy surgery is cost effective. According to a consumer price index estimate update from a study performed at the National Institutes of Health task force on epilepsy in 1970, intractable epilepsy in the United States costs $450,000 per patient due to inability to work, lost income, underemployment, nursing home placement, chronic care facilities, etc. Of this amount $150,000 is spent on direct medical care over the life of the patient. The average cost of epilepsy surgery in the United States including all patients with both complex and simple problems is about $40,000-$50,000. Therefore, even including the most complex patients who have the more expensive evaluations, epilepsy surgery still is very cost effective in the long term.