Perils and progress in epilepsy surgery utilization: Twenty-five years later

More than 25 years have passed since the first randomized controlled trial (RCT) established that surgery is superior to continued anti-seizure medication (ASM) for drug-resistant temporal lobe epilepsy, and nearly as long since a joint practice parameter urged that appropriate surgical candidates be referred to a specialized center for evaluation-guidance that subsequent consensus has since broadened to all patients with drug-resistant epilepsy. Despite Class I evidence and durable guidelines, epilepsy surgery remains one of the most underutilized effective interventions in medicine: fewer than 1% of potentially eligible patients are referred, and those who are referred reach a center on average two decades after seizure onset. This critical review, framed primarily around U.S. data and supplemented by a dedicated assessment of the global picture, examines the scope and burden of drug-resistant epilepsy (DRE), the foundational evidence and guideline history, and the magnitude, patterns, and causes of persistent underutilization, including a distinct discussion of pediatric care and of disparities by race, insurance, and geography. We then turn to grounds for optimism. Surgical candidacy has materially expanded through minimally invasive approaches to both monitoring (stereo-electroencephalography) and treatment (laser interstitial thermal therapy and neuromodulation), and indications have broadened to include selected generalized and multifocal epilepsies through thalamic neuromodulation. Contemporary International League Against Epilepsy (ILAE) recommendations go further still, extending referral even to selected patients who are seizure-free on medication but harbor a surgically accessible lesion. We also raise a counterbalancing concern: the welcome diffusion of minimally invasive options should not eclipse resective and disconnective surgery, which remain the only potentially curative options validated by RCTs. We conclude that, 25 years on, underutilization persists as a major and partly remediable problem, and we offer recommendations for closing the surgical gap.