Surgery may be better than drugs in epilepsy

Samena Chaudhry Birmingham

Surgery is more effective than drugs for treating epilepsy and should no longer be considered the treatment of last resort, according to the first clinical trial to compare the two approaches published recently in the New England Journal of Medicine (2001;345:315-8). Sixty four per cent of the patients who underwent the surgery were free of disabling seizures for the year after surgery, compared with only 8% of those receiving drug treatment. In addition, they were better able to participate in social activities, hold jobs, and lead satisfying lives.

However, four of the patients who had surgery had adverse effects. One developed a sensory abnormality in the thigh, one had an infection at the surgical site, and two had slight impairments of memory. One patient in the group receiving drugs died of unexplained causes.

Surgery for epilepsy has been around since the 1930s, long before clinical trials became the most important method of validating new drugs and medical procedures. Many researchers have felt the need to conduct a direct trial comparing surgery and drugs but felt ethically constrained. Because they believed in the superior efficacy of surgery, they were unwilling to randomly assign some eligible patients to receive only medications.

In the new study, however, Dr Samuel Wiebe and his colleagues were able to circumvent this ethical problem by taking advantage of the medical rationing that is the norm in Canada. Dr Wiebe obtained a special grant that allowed him to move some patients to the head of the queue so that they could get immediate surgery.

Wiebe and his colleagues identified 80 patients with a temporal lobe abnormality that made them good candidates for the procedure, then randomly assigned them to receive either surgery or medications. The patients were then followed for an average of about a year, at which time the patients receiving drugs became eligible for surgery through the normal course of events.

"What makes this study significant is that, for the first time, we have a strong prospective study that clearly shows the value of epilepsy surgery," said Dr Gregory L Barkley of the Henry Ford Comprehensive Epilepsy Program in Detroit. "The bottom line is that, if you've tried several drug combinations for a year to a year and a half, then you should think about surgery so that the patients can get on with their lives."

About three quarters of the people with epilepsy are able to control seizures with one or more of the two dozen medications now available. For many others, the brain abnormalities that trigger seizures are spread around the brain or are located in areas that have important functions. For them, the surgery, which removes part of the brain, could run the risk of impairing a vital function such as speech.

But that still leaves a large pool of patients for whom surgery could be lifesaving. Patients who have regular seizures are five times as likely to die as those who are able to control their seizures. "Epilepsy (with uncontrolled seizures) can have a devastating effect on people's lives," said Dr Richard B Kim of the University of California Irvine College of Medicine. "After the surgery many regain their lives," he said. "They are very satisfied with the results."



studentBMJ 2001;09:305-356 September ISSN 0966-6494