The evolution of epilepsy surgery over 30 years: A retrospective review of a level 4 comprehensive pediatric epilepsy program.

INTRODUCTION Epilepsy is a common pediatric neurologic disorder, and its surgical management has increased over time. To characterize longitudinal changes in patient selection, surgical approach and outcomes, we report a 30-year retrospective review at a high-volume level 4 epilepsy center.

Methods

Consecutive epilepsy surgeries from 1989 to 2018 were analyzed and grouped into early (1989-2003) and late (2004-2018) 15-year eras. Demographic, clinical, radiographic, surgical, and 2-year Engel outcome data were collected and analyzed. Multivariable logistic regression assessed independent associations between era, patient characteristics, imaging findings, surgical procedures, and seizure outcomes.

Results

Of 1241 surgical records, 1128 pediatric cases were included (415 early, 713 late; 55.50% male). Patients in the late era were older at surgery (10.27 vs. 8.53 years, p < .001), and repeat surgery was more common (p < .001). Focal (OR 1.72, p = .005) and cerebral insult related (OR 2.74, p < .001) MRI abnormalities were more frequently treated in the late era. Hemispherectomies, lobectomies and corpus callosotomies were performed less often (all p ≤ .001), while focal and multilobar resections remained stable (p > .05). Use of invasive monitoring and electrical stimulation mapping declined over time (p < .001). Seizure freedom rates were stable, however, ≥ 90% seizure reduction was more common in the late era (OR 1.60, p = .038).

Conclusion

Over three decades, pediatric epilepsy surgical volume increased, surgery shifted towards older patients, with reduced extensive resection and reduced reliance on invasive monitoring. Despite these changes, seizure freedom rates remained stable, with improved near-complete seizure control in the later era.