The Safety & Efficacy Of Epilepsy Surgery - Luke Tomycz, The Epilepsy Institute of New Jersey, USA
Learn about epilepsy surgery and potential benefits and risks - from epilepsy neurosurgeon of the Epilepsy Institute of New Jersey: Luke Tomycz. Available via video and podcast!
Reported by Torie Robinson | Edited and produced by Pete Allen
Podcast:
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00:00 Luke Tomycz
“I always tell my patients that repeated seizure activity is bad for the brain. Now there's a spectrum. I do have kids who have frequent seizures and don't seem to be having significant cognitive decline. But for the most part, kids who are having frequent seizures - and I bring up kids in particular because a child's brain is still very much plastic and forming and developing new neuronal connections.”
00:26 Torie Robinson
Fellow homo sapiens! Welcome back to Epilepsy Sparks Insights.
Now the topic of epilespy surgery is a huge one- one that I find quite exciting - as someone who’s had surgery as a treatment for their epilepsy. So, in In our special 3-part series, we cover:
The safety and efficacy/effectiveness of epilepsy surgery
How we measure epilepsy surgery success, and the the question
Why Aren’t Patients that need epilepsy surgery, getting it?”
And this is all with epilepsy neurosurgeon Luke Tomycz from the Epilepsy Institute of New Jersey!
A quick one - please don’t forget to like, comment and subscribe. Your comment and like will help spread awareness and understanding of the epilepsies around the world.
Now, onto our star of the week, Luke Tomycz
01:09 Luke Tomycz
My name's Luke Tomycz. I'm a paediatric neurosurgeon by training, but now my practice basically specialises in paediatric and adult epilepsy care. And I'm the chief of paediatric epilepsy at Sanzari Children's Hospital at Hackensack, in Hackensack, New Jersey. And yeah, so that's basically who I am and what my practice consists of.
01:33 Torie Robinson
And what lead you to become not just a neurosurgeon but one that specialises in epilepsy surgery?
01:38 Luke Tomycz
I wasn't exposed to a whole lot of epilepsy surgery in residency, but then I did my fellowship with a neurosurgeon named Jeff Ojemann in Seattle Children's Hospital and he had a very busy epilepsy practice. So that was really where I first, I would say, got very interested in epilepsy care. And then I took a job, my first job, out of training in Austin, Texas, and again, I had a senior partner there who was doing close to 100 epilepsy surgeries a year. He had quite a busy practice. And so between my time in Seattle and my time in Austin, I became very interested. Finally I moved to New Jersey and at that point I was quite interested in epilepsy and realised it was really under, it was a need that wasn't being met appropriately by the medical community. I think I recognised that there was a need, that there were a number of patients who needed this kind of treatment. And so we began the task of building multidisciplinary epilepsy here in New Jersey.
02:48 Torie Robinson
Actually that leads us to the next question: Multidisciplinary care. When it comes to epilepsy surgery or surgery of any kind, but in this case epilepsy surgery: it's not just yourself that plays a part, right, you must have a team of, like a Multidisciplinary team of others who contribute in the work, identification of needs, etc, is that right?
03:07 Luke Tomycz
That's absolutely right. Yeah, there, you know, a lot of things in neurosurgery: let's say if you're doing spine surgery and a patient comes to you and they have a disc herniation, well, you're gonna take that disc herniation out if it's appropriate - and that's mostly a decision that you make by yourself as a surgeon.
03:25 Torie Robinson
Yep.
03:26 Luke Tomycz
But in epilepsy surgery, it's definitely a team effort. I don't operate on anybody without the green light of a epileptologist and without them having been conferenced in a group. And that group generally involves a number of surgeons who have a specialty in epilepsy care, a number of neurologists, epileptologists. There are, excuse me, there are typically neuropsychologists at that meeting, radiologists, sometimes pathologists. So, it's truly a big multidisciplinary group. MEG physicists is another group that are often involved. Or nuclear medicine specialists. So again, it's a big group and we sort of talk about all these pre-surgical studies. There are a number of pre-surgical studies that patients often get before they can even be considered for surgery and it takes a long time. And so it's a big discussion, it takes a long time.
04:26 Torie Robinson
Regarding surgery, people think “Oh, it's just, you know, you're slicing a bit of brain out and it's going to have this awful effect or this awful effect. Oh, well, if it does stop your seizures, that's great.” But what are the other impacts of surgery? And so what would you have to say to that?
04:46 Luke Tomycz
Well, so the way that I see my job and how I try to describe it to patients is: we're looking, again, mostly we're operating on patients with focal epilepsy - and let me just talk a little bit about this classification because I think it's important. We, you know, the International League Against Epilepsy a few years ago sort of did a reclassification of epilepsy. And basically, people are either having focal epilepsy (means that they have a normal brain but one little area in the brain is not quite normal and it's firing these abnormal seizures). Or they have generalised epilepsy, which means that we can't see a focal onset, we sort of see the whole brain kind of go off at once, so to speak, electrically. And, obviously, when it comes to surgery, we are mostly - now there are surgeries for patients with generalised epilepsy, including things like Vagal Nerve Stimulator and Callosotomy - but most of the surgeries that I'm doing when I have an intention to try to make the patient seizure free is on patients with focal epilepsy.
So now that I've made that clarification, I'll tell you a little bit about what I tell patients with focal epilepsy. I tell them our job is to find the abnormal area of brain and to take it out. And to do it without damaging areas of brain that have function, whether that function involves motor function, movement of your arms and legs, language function to make language and to comprehend language, and visual function. Now, I'll tell you, when it comes to epilepsy surgery, there's been, there was a recent Cochrane review sort of looking at, I think it was over 10,000 operated epilepsy patients, and they found that the risk of death (mortality) is less than 1%, significantly less than 1%, and the risk of major morbidity or major complications is around four to 5%. And most of those major morbidities were visual field cuts. And again, as we sort of talked about earlier, many of the visual field cuts are not, don't lead to a significant Quality of Life problem for the patient because many times they don't notice, for example; a quadrant visual field deficit post-surgically; but that was counted in that 4% major morbidity. So I think, you know, what I would tell patients and the purpose of this Cochrane review and the main message was that actually epilepsy surgery very rarely leads to serious complications for patients. But actually, if you look at some of the surveys of patients who are considering epilepsy surgery, there was one survey that we reviewed that said up to 50% of patients said that they thought death was a common outcome from epilepsy surgery. It's not at all, right? It would be very rare. And most, again, most busy epilepsy surgeons might have a death once every five years in a very rare circumstance. So it's a rare thing. But again, I think patients. worry about it, I think the overall thrust of that paper was that patients generally overestimate the risks of surgery and they underestimate the benefits. And so again, I think part of my job as a surgeon - I always tell people that I'm a part-time surgeon and I'm a part-time advocate - because a lot of what I'm doing is trying to educate patients and families, educate other healthcare practitioners (whether they be internists, paediatricians, or neurologists) to say that actually epilepsy surgery done appropriately should not lead to significant new deficits for our patients.
08:50 Torie Robinson
In many cases anyway, the earlier a patient has the surgery, if you know that they have refractory epilepsy, the drugs aren't doing anything, etc., then, in fact, not only could they potentially improve their life expectancy, but also save some brain tissue because for instance, you know, sclerosis or, you know, can actually worsen.
09:13 Luke Tomycz
I always tell my patients that repeated seizure activity is bad for the brain. Now there's a spectrum. I do have kids who have frequent seizures and don't seem to be having significant cognitive decline. But for the most part, kids who are having frequent seizures - and I bring up kids in particular because a child's brain is still very much plastic and forming and developing new neuronal connections.
09:40 Torie Robinson
Yeah.
09:41 Luke Tomycz
And so we know from animal models, we know from human studies that repeated seizure activity leads to neuronal loss, even in distant areas from where the seizures are happening! So, you know, I talk about each surgery as a small insult in the brain. Now, in some patients that can be quite consequential.
In other patients, as I mentioned, we don't see (thankfully) we don't see that rapid cognitive decline. But I would say most of the patients I operate on (and I'm thinking like 90%) I get a story of a child who is declining. They're not learning as well, they're not speaking as well. They had several words, but now they don't. They're tending toward a phenotype, an autistic phenotype in some cases. Memory, memory is another big thing. In children and adults, you see memory decline over time. You see a number of sort of behavioural problems, anxiety, depression. These things are all related to repeated seizure activity. And so, what we say is that once a patient is deemed drug resistant (so we see that we've tried them on two or three medicines, and they continue having seizures), they should be evaluated in a multidisciplinary hospital that can offer surgery as an option.
So I tell patients that we're operating on you for a few different reasons. We're operating on you because we want to stop seizures because repeated seizure activity is bad for the brain, but repeated seizure activity has a risk of lethality, right?
11:12 Torie Robinson
Exactly.
11:13 Luke Tomycz
So if you go to the American Epilepsy Society website, there's a statistic there that more patients or an equivalent amount of patients, at least as many patients die each year from epilepsy and epilepsy-related injuries as die of breast cancer. Now again, most people hear that and they're quite surprised because they see breast cancer as a fatal issue. They don't think of epilepsy as a potentially fatal issue. But certainly, you know, it's probably every year on CNN or on the mainstream news, you'll see a case of a young person otherwise healthy who has epilepsy who suddenly dies. And so, again, I always tell patients, I say, listen, I'm not trying to be alarmist. I'm not trying to tell you that if you don't get surgery, you're going to die from epilepsy. But I do think it is important to give them the data and to tell them that there is a certain annual risk, cumulative annual risk of death in patients who have uncontrolled epilepsy. And so yes, surgery ought to be part of the way to get patients to the goal of seizure freedom
12:24 Torie Robinson
Thank you to Luke for sharing with us his journey into epilepsy surgery as a profession as well as information into the safety of epilepsy surgery. Epilepsy surgery is a really big deal, and can also be a rather exciting, positively, life changing! Next week we shall talk about “How Do you Measure Epilepsy Surgery Success?! Is it via Engel Class? - so make sure that you join us! Again, if you haven’t already, don’t forget to like, comment, and subscribe, and see you next time!
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Dr. Luke Tomycz is a neurosurgeon living in New Jersey, board-certified by both the American Board of Neurosurgery (ABNS) and Pediatric Neurosurgery (ABPNS), specializing in the surgical treatment of complex epilepsy.
Hailing from Michigan, Luke finished first in his high school class before going to MIT to double-major in chemical engineering and biology with a minor in biomedical engineering. He was one of the few students in the country to be awarded a prestigious Dean's Full-Tuition Merit Scholarship to attend the University of Michigan Medical School where he was initially exposed to neurosurgery.
Following medical school, Luke performed 7 years of neurosurgical residency at Vanderbilt University Medical Center in Nashville, TN during which time he completed an in-folded neurointerventional fellowship. Finally, he spent an extra year of training with Dr. Jeff Ojemann at Seattle Children's Hospital where he was first exposed to a high-volume surgical epilepsy practice.
Having built one of the largest surgical epilepsy practices in the state, Luke is committed to the idea that all patients with DRE deserve a consultation with a surgeon to receive the latest information and hear all the options about surgical procedures that may help them or their family members who are living with epilepsy.
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Website: epilepsyinstitute.com
LinkedIn: luke-tomycz
Twitter: brainsurgeonlt
ResearchGate: Luke-Tomycz-2
TikTok: @epilepsyinstnj
The Epilepsy Podcast: https://open.spotify.com/show/2BFd1QGl0XskgeimS90UpC
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