Objective:Surgery is an effective but costly treatment for many patients with drug resistant temporal lobe epilepsy (DR-TLE). We aim to evaluate whether, in the United States, 1) surgery is cost-effective compared to medical management for patients deemed surgical candidates, 2) surgical evaluation is cost-effective for DR-TLE patients in general.Methods:We use a semi-Markov model to assess the cost-effectiveness of surgery and surgical evaluation over a lifetime horizon. We use 2nd order Monte Carlo simulations to conduct probabilistic sensitivity analyses to estimate variation in model output. We adopt both healthcare and societal perspectives, including direct healthcare costs (e.g. surgery, AEDs) and indirect costs (e.g. lost earnings by patients and care providers.) We compare incremental cost-effectiveness ratio (ICER) to societal willingness-to-pay (∼$100,000 per Quality Adjusted Life Year) to determine whether surgery is cost-effective.Results:Epilepsy surgery is cost effective compared to medical management in surgically eligible patients by virtue of being cost saving ($328K vs. 423K) and more effective (16.6 QALY vs. 13.6 QALY) than medical management in the long run. Surgical evaluation is cost-effective in DR-TLE patients even if the probability of being deemed a surgical candidate is only 5%. From a societal perspective, surgery becomes cost effective within 3 years and 89% of simulations favor surgery over the lifetime horizon.Conclusion:For surgically eligible DR-TLE patients, surgery is cost-effective. For DR-TLE patients in general, referral for surgical evaluation (and possible subsequent surgery) is cost-effective. DR-TLE patients should be referred for surgical evaluation without hesitation on cost-effectiveness grounds.

Objective: The aim was to compare the outcomes of subdural electrode (SDE) implantations versus stereotactic electroencephalography (SEEG), the 2 predominant methods of intracranial electroencephalography (iEEG) performed in difficult-to-localize drug-resistant focal epilepsy. Methods: The Surgical Therapies Commission of the International League Against Epilepsy created an international registry of iEEG patients implanted between 2005 and 2019 with ≥1 year of follow-up. We used propensity score matching to control exposure selection bias and generate comparable cohorts. Study endpoints were: (1) likelihood of resection after iEEG; (2) seizure freedom at last follow-up; and (3) complications (composite of postoperative infection, symptomatic intracranial hemorrhage, or permanent neurological deficit).Results: Ten study sites from 7 countries and 3 continents contributed 2,012 patients, including 1,468 (73%) eligible for analysis (526 SDE and 942 SEEG), of whom 988 (67%) underwent subsequent resection. Propensity score matching improved covariate balance between exposure groups for all analyses. Propensity-matched patients who underwent SDE had higher odds of subsequent resective surgery (odds ratio [OR] = 1.4, 95% confidence interval [CI] 1.05, 1.84) and higher odds of complications (OR = 2.24, 95% CI 1.34, 3.74; unadjusted: 9.6% after SDE vs 3.3% after SEEG). Odds of seizure freedom in propensity-matched resected patients were 1.66 times higher (95% CI 1.21, 2.26) for SEEG compared with SDE (unadjusted: 55% seizure free after SEEG-guided resections vs 41% after SDE). Interpretation: In comparison to SEEG, SDE evaluations are more likely to lead to brain surgery in patients with drugresistant epilepsy but have more surgical complications and lower probability of seizure freedom. This comparativeeffectiveness study provides the highest feasible evidence level to guide decisions on iEEG.

BACKGROUND Previous reports have suggested an increasing rate of utilization of spinal fusions, but contemporary data have not been analyzed, and there has been little investigation of putative drivers of increased utilization. OBJECTIVE To investigate whether there is an ongoing trend of increased utilization of spinal fusions in recent data, and if there may be associations with an increasing proportion of elderly in the population, changing patterns of payer-types, and changing reimbursement rates. METHODS We analyze 7.1 million cases from the National Inpatient Sample between 1998 and 2014. We measure annual utilization per 100 000 persons and conduct trend analyses with subgroup analysis of the senior (65 + ) population. Spine surgery utilization is compared with nonspine surgical procedures (coronary artery bypass grafting, hernia repair, hip, and knee replacement). We assess trends in charges, payer type, Medicare reimbursement rates, and hospital type. RESULTS There was an 88% increase in the utilization rate of spinal fusion procedures from 1998 to 2014 (from 74 to 139 cases per 100 000 persons) with a significant upward trend (P < .001) that persisted in the 65 + subgroup (P < .001). An increasing proportion of spinal fusions is paid for by public payers, but per-procedure reimbursement for spinal fusions by Medicare has decreased recently (5% reduction from 2014 to 2016). CONCLUSION Utilization of spinal fusions continues to increase and is not explained by increased proportion of elderly in the population, increased utilization of surgeries across specialties, or increased Medicare reimbursement. In fact, increased utilization of spinal fusions temporally correlated with decreasing per-procedure Medicare reimbursement.

Objective Previous work has suggested that seizure outcome is the most important predictor of quality of life (QoL) after epilepsy surgery, but it is unknown which specific seizure outcome measure should be used in judging surgical success. We assess three different seizure outcome measures (relative seizure reduction, absolute seizure reduction, and seizure freedom [yes/no]) to investigate which measure best predicts postoperative QoL. Methods We prospectively surveyed patients at outpatient visits before and after epilepsy surgery (n = 550). The QoL measure was the Quality of Life in Epilepsy (QOLIE‐10) score at the patient's most recent office visit. We created multivariate regression models to predict postoperative QOLIE‐10, with a different seizure outcome measure in each model. We compared models using adjusted R2 values and Akaike information criteria (AIC). Results Our cohort had a high level of disease severity and complexity (17% repeat surgery, 39% extratemporal, and 18% nonlesional). For the cohort as a whole, mean absolute seizure frequency decreased from 1 per day to 0.1 per day (P < .001), and mean reduction was 73% (95% confidence interval [CI] 66%‐81%). Average improvement in QoL score was 5.3 (95% CI 4.1‐6.5) points. Of patients who reported an improvement in QoL, 27% had persistent seizures. Comparison of regression models to predict QoL showed that the worst model was provided when using “absolute seizure reduction,” but that models using “relative seizure reduction” and “seizure freedom (yes/no)” were equally strong. Significance In our high severity and complexity cohort, a substantial subset of patients (27%) reported improved QoL despite persistent seizures. Relative seizure reduction was at least as good a predictor of QoL as seizure freedom. A yes/no seizure freedom variable may be a suboptimal measure of surgical success, especially in high complexity cohorts.

Surgical management of medically intractable epilepsy was historically based on the premise of excising the presumed substrate of disease, that is, “the epileptogenic zone.” There was early interest in establishing the extent of resection of the temporal lobe that optimized postoperative reduction in seizure burden while preserving neurocognitive function. Studies approaching this question used varied methods of defining and measuring “extent,” complicating the task of distilling evidence‐based recommendations for surgical practice. A palpable shift in the paradigm of surgical epilepsy has gained traction and greatly altered not only the kind of studies being undertaken but the focus of inquiry itself. Key to this paradigm shift has been the increasingly well‐held notion that epilepsy, far from being a disease of a single problem focus, is rather a disease of a problem network. Where a former generation of investigators labored to find an optimal extent of resection, concentrating on magnetic resonance imaging–visible lesions and on standardization of the extent of resection (ie, “standard temporal lobectomy”), the modern strategy is more concerned with understanding network activation and its concordance with presurgical clinical and electrophysiological features and the organization of epileptic activity over time. The vital lessons of the early literature investigating optimal extent of resection, however, remain informative to the field, and it is worthwhile to contextualize them within the modern network‐focused paradigm. In this comprehensive review of the literature, we aim to recapitulate the major findings of the “optimal extent of resection” literature (focusing on both seizure control and neuropsychological outcomes) and distill wherever possible the consensus findings that may guide surgical approach to epileptic disease of the temporal lobe. We also review the particular implications of modern laser ablation techniques on the question of “optimal extent of resection” in temporal lobe epilepsy, and contextualize them as a marker of a shifting paradigm.

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Objective This study was undertaken to better understand the long‐term palliative and disease‐modifying effects of surgical resection beyond seizure freedom, including frequency reduction and both late recurrence and remission, in patients with drug‐resistant epilepsy. Methods This retrospective database‐driven cohort study included all patients with >9 years of follow‐up at a single high‐volume epilepsy center. We included patients who underwent lobectomy, multilobar resection, or lesionectomies for drug‐resistant epilepsy; we excluded patients who underwent hemispherectomies. Our main outcomes were (1) reduction in frequency of disabling seizures (at 6 months, each year up to 9 years postoperatively, and at last follow‐up), (2) achievement of seizure remission (>6 months, >1 year, and longest duration), and (3) seizure freedom at last follow‐up. Results We included 251 patients; 234 (93.2%) achieved 6 months and 232 (92.4%) experienced 1 year of seizure freedom. Of these, the average period of seizure freedom was 10.3 years. A total of 182 (72.5%) patients were seizure‐free at last follow‐up (defined as >1 year without seizures), with a median 11.9 years since remission. For patients not completely seizure‐free, the mean seizure frequency reduction at each time point was 76.2%, and ranged from 66.6% to 85.0%. Patients decreased their number of antiseizure medications on average by .58, and 53 (21.2%) patients were on no antiseizure medication at last follow‐up. Nearly half (47.1%) of those seizure‐free at last follow‐up were not seizure‐free immediately postoperatively. Significance Patients who continue to have seizures after resection often have considerable reductions in seizure frequency, and many are able to achieve seizure freedom in a delayed manner.

Objective: Compared to other seizure types, generalized tonic-clonic (GTC) seizures may be disproportionately related to increased morbidity, and reducing seizure frequency could translate into improvements across measures of morbidity in medically treated patients with drug-resistant epilepsy (DRE). The primary objective of this analysis was to quantify the burden of patients with DRE who experience GTC seizures (GTC+) compared to patients with DRE who do not experience GTC seizures (GTC−). Methods: Adult patients from the Cleveland Clinic Epilepsy Center-Neurological Institute from 2012-2016 with DRE with epilepsy for at least 1 year were eligible for inclusion and were divided into GTC ± groups based on whether the patient had experienced a GTC seizure in the year preceding the first visit. Epilepsy duration, comorbidities, antiepileptic drug use, patient-reported outcomes (PROs) and seizure type, frequency, and etiology were captured. Generalized linear models, negative binomial regression, logistic regression, and linear regression were used as appropriate for multivariate analyses. Results: A total of 379 patients met inclusion criteria and had data at 1-year followup after their baseline visit (192 GTC+ and 187 GTC−). Although DRE patients experiencing GTC seizures had fewer seizures per day over the preceding 6 months than those not experiencing GTC seizures, seizure severity and levels of depression and anxiety were greater. GTC+ patients who reported five or more seizures in the preceding 4 weeks had 82% lower odds (1−0.18 = 0.82) of working than patients with no seizures. Significance: Patients with DRE experience a significant burden and decreased quality of life. Multivariate analysis is necessary to understand the complex relationship between seizure type, frequency, and impact on health-related quality of life (HRQoL) and changes over time. Effective treatments to reduce the burden for DRE patients who experience GTC seizures continue to be needed.