What stops patients in SG from getting surgery for drug-resistant epilepsy?

Many people with drug-resistant epilepsy (DRE) in Singapore do not consider surgery because of the overestimated risk of the surgical procedure and the perception that seizures are nondisabling, according to a local cross-sectional survey study.

Of the 66 patients (mean age 47.9 years, 63.6 percent female, 81.8 percent Chinese) who completed the survey, 74.2 percent were aware of surgery as an option for the treatment of epilepsy, and these respondents were more likely to have undergraduate or postgraduate degrees (p=0.007). [Epilepsia Open 2025;doi:10.1002/epi4.70128]

Notably, 71.2 percent of the respondents said epilepsy surgery was moderately or very dangerous, with 83.3 percent overestimating the risk of serious side effects from surgery to be more than 10 percent. Close to half (47.0 percent) believed that epilepsy surgery was more dangerous than uncontrolled seizures, and 69.7 percent expressed that the procedure should be considered a “last resort.”

On the other hand, the respondents who had undergone epilepsy surgery did not think the procedure was as dangerous as the others did (p=0.006), with none overestimating its risk (p<0.001). Nevertheless, despite their experience, these respondents still believed that epilepsy surgery should be a last-resort option (p=0.357) and was no less dangerous than living with uncontrolled seizures (p=0.202). Half (50.0 percent) of the respondents who had undergone epilepsy surgery saw seizures as nondisabling as opposed to only 15 percent of patients who had never had surgery, although this difference did not reach statistical significance (p=0.068).

Even among respondents who were candidates for epilepsy surgery but were uninterested (24.2 percent), the most cited reason for their disinterest was a perception of high surgical risk (68.8 percent).

For most respondents (74.2 percent) overall, seizure freedom was the most important goal. However, only 57.6 percent responded affirmatively (somewhat agree or strongly agree) to the notion of undergoing surgery when presented with the hypothetical situation of guaranteed lifelong postoperative seizure-freedom, with or without antiseizure medications, and no resulting damage to the brain (ie, “guaranteed successful surgery”).

The most common concerns surrounding epilepsy surgery were the potential development of a new health issue after the procedure (65.2 percent), perioperative complications (62.1 percent), and cost (50.0 percent). There were 47.0 percent of respondents who expressed preference for trial of alternative medicine over epilepsy surgery, and 65.2 percent said they would participate in research studies testing new nonsurgical treatment.

“These data suggest the presence of a strong aversion to epilepsy surgery among Singaporean patients with DRE. This aversion may be partially attributable to a lack of knowledge, leading to an overestimation of surgical risks,” said lead author Dr Zhibin Tan of the National Neuroscience Institute (NNI) at Singapore General Hospital and colleagues.

To overcome these issues, Tan and colleagues suggested launching public campaigns to correct misinformation about the risks of epilepsy surgery, specifically targeting patients with lower educational achievement. These efforts should leverage the strong foundation of trust healthcare providers in Singapore have with their patients and be accompanied by subsidies, they added. In the survey, nearly all respondents (93.9 percent) said they trusted their healthcare providers, and none expressed any mistrust at all.

The authors also highlighted the significant support for alternative medicine and investigational nonsurgical treatment of epilepsy as preferred alternatives to surgery. “This is a potentially useful finding for Asian countries such as Singapore, where there are ongoing efforts to integrate traditional and alternative medicine into national health programs. [J Integr Med 2025;23:36-45; https://str.sg/iovYt]

“For instance, Singapore might consider exploring acupuncture for patients who declined surgery, since acupuncture has been associated with modestly reduced seizure frequency and improved quality of life when combined with Western pharmacological treatment of epilepsy,” they said. [Epilepsy Behav 2021;122:108213; Front Neurosci 2023;17:1203231]

Additional studies are needed to evaluate physician-related and system-related barriers to epilepsy surgery, which can also vary by region and country, they added.