Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA.
Epilepsy Curr. 2013 Sep;13(5):198-204. doi: 10.5698/1535-7597-13.5.198.
Surgical treatment for epilepsy has made tremendous strides in the past few decades as a result of advances in neurodiagnostics-particularly structural and functional neuroimaging-and improved surgical techniques. This has not only resulted in better outcomes with respect to epileptic seizures and quality of life, and reduced surgical morbidity and mortality, but it has also increased the population of patients now considered as surgical candidates, particularly in the pediatric age range, and enhanced cost-effectiveness sufficient to make surgical treatment available to countries with limited resources. Yet surgical treatment for epilepsy remains arguably the most underutilized of all accepted medical interventions. In the United States, less than 1% of patients with pharmacoresistant epilepsy are referred to epilepsy centers. Although the number of epilepsy surgery centers has increased appreciably over the past two decades, the number of therapeutic surgical procedures performed for epilepsy has not increased at all. For patients who are referred, the average delay from onset of epilepsy to surgery is more than 20 years-too late for many to avoid a lifetime of disability or premature death. Not only has there been no consistent message to convince neurologists and primary care physicians to refer patients for surgery, but the increase in epilepsy surgery centers in the United States has appeared to result in a divergence of approaches to surgical treatment. Efforts are still needed to further improve the safety and efficacy of surgical treatment, including the identification of biomarkers that can reliably determine the extent of the epileptogenic region; however, the greatest benefits would derive from increasing access for potential surgical candidates to epilepsy surgery facilities. Information is needed to determine why appropriate surgical referrals are not being made. Consensus conferences are necessary to resolve controversies that still exist regarding presurgical evaluation and surgical approaches. Standards should be established for certifying epilepsy centers as recommended by the Institute of Medicine's report on epilepsy. Finally, the epilepsy community should not be promoting epilepsy surgery per se but instead emphasize that epilepsy centers do more than epilepsy surgery, promoting the message: All patients with disabling pharmacoresistant seizures deserve evaluation by specialists at epilepsy centers who can provide a variety of advanced diagnostic and therapeutic services.
由于神经诊断学的进步，尤其是结构和功能神经影像学的进步，以及手术技术的改进，过去几十年中，癫痫的外科治疗取得了巨大进展。这不仅提高了癫痫发作和生活质量的治疗效果，降低了手术发病率和死亡率，而且还增加了现在被认为是手术候选者的患者群体，尤其是在儿科年龄段，并且提高了成本效益，足以使手术治疗可用于资源有限的国家。然而，癫痫的外科治疗仍然是所有公认的医疗干预措施中利用率最低的。在美国，只有不到 1%的耐药性癫痫患者被转诊到癫痫中心。尽管过去二十年中癫痫手术中心的数量显著增加，但癫痫治疗性手术的数量并未增加。对于被转诊的患者，从癫痫发作到手术的平均延迟时间超过 20 年-对于许多人来说，避免终生残疾或过早死亡已经太晚了。不仅没有一致的信息来说服神经科医生和初级保健医生将患者转介进行手术，而且美国癫痫手术中心的增加似乎导致了手术治疗方法的分歧。仍需要努力进一步提高手术治疗的安全性和有效性，包括确定可靠地确定致痫区范围的生物标志物；但是，最大的收益将来自为潜在的手术候选者增加获得癫痫手术设施的机会。需要了解为什么没有进行适当的手术转诊。共识会议对于解决关于术前评估和手术方法仍然存在的争议是必要的。应该按照医学研究所关于癫痫的报告建议，为认证癫痫中心制定标准。最后，癫痫社区本身不应推广癫痫手术，而应强调癫痫中心不仅仅进行癫痫手术，而是传递这样一个信息：所有患有致残性耐药性癫痫发作的患者都应在癫痫中心的专家处进行评估，这些专家可以提供各种先进的诊断和治疗服务。
