Epilepsy surgery can be one of the most effective treatments for carefully selected people with drug-resistant epilepsy, yet access to it remains profoundly unequal around the world. The disparity is not limited to the operating theatre. A person must first be recognised as potentially having drug-resistant epilepsy, referred to a specialist service, undergo appropriate MRI and EEG investigations, reach a multidisciplinary epilepsy centre, complete presurgical assessment and then have access to neurosurgical expertise, postoperative care and long-term follow-up.
Any break in that chain can prevent surgery from ever being considered.
This means the global epilepsy surgery gap is not simply a shortage of neurosurgeons. It is a systems problem involving diagnosis, referral, imaging, neurophysiology, workforce, financing, geography, public awareness and health-policy priorities.
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Epilepsy surgery is not a last resort after endless medication trials
Drug-resistant epilepsy is generally defined by the International League Against Epilepsy as failure of adequate trials of two appropriately chosen and tolerated antiseizure medication regimens to achieve sustained seizure freedom. Once drug resistance is established, specialist evaluation should be considered rather than repeatedly cycling through medications with progressively lower chances of producing seizure freedom.
Current ILAE expert consensus recommends that referral for surgical evaluation should be offered promptly to appropriate people with drug-resistant epilepsy. Referral does not mean surgery will automatically happen. It means the person receives a specialist assessment to determine whether a surgical or other advanced treatment option is appropriate.
Globally, however, many people are never referred at all.
The burden of drug-resistant epilepsy is global
Around 50 million people worldwide live with epilepsy, and the majority live in low- and middle-income countries. Roughly one third of people with epilepsy may continue to have seizures despite appropriate medication treatment.
A global estimate published in the neurosurgical literature suggested that more than 10 million people may potentially have surgically treatable epilepsy, with more than a million new potentially surgical cases arising each year. The greatest burden falls disproportionately on regions that often have the fewest specialist epilepsy and neurosurgical resources.
The exact number of people who would ultimately be suitable for surgery is smaller than the number with drug-resistant epilepsy because candidacy depends on epilepsy type, lesion, seizure network, neurological risk and other factors. But the scale of unmet assessment need is still enormous.
Underuse exists even in high-income countries
Limited access to epilepsy surgery is not confined to poorer health systems. Studies from higher-income countries have repeatedly shown long delays between the development of drug-resistant epilepsy and referral to specialist epilepsy surgery services.
People may spend many years trying additional medication combinations before a surgical evaluation is discussed. Some are never told that surgery is an option. Others are referred only after decades of seizures.
The global problem therefore has two layers: under-referral in well-resourced systems and near-absence of comprehensive surgical pathways in many lower-resource settings.
Why the gap is wider in low- and middle-income countries
A 2019 scoping review of epilepsy surgery in low- and middle-income countries identified published surgical experience from only a minority of those countries. Programmes were more established in parts of Asia and Latin America, while other regions had little or no reported routine surgical activity.
The barriers described across the literature include shortages of neurologists, epileptologists, neurosurgeons, neuroradiologists, neuropsychologists and EEG technologists; limited access to video-EEG and epilepsy-protocol MRI; high out-of-pocket costs; long travel distances; weak referral systems; limited intensive-care capacity; and difficulty sustaining specialised equipment.
These problems are interconnected. A country cannot create equitable epilepsy surgery by training a surgeon alone if the diagnostic and referral pathway around that surgeon does not exist.
A surgical programme begins long before the operation
Presurgical evaluation typically combines several forms of evidence. These may include seizure history and semiology, prolonged video-EEG, structural MRI, neuropsychological assessment and multidisciplinary case review. Some patients also require PET, SPECT, MEG, functional MRI, language mapping or intracranial EEG such as SEEG.
A person therefore needs access to a network of services before the surgeon can decide whether an operation is both likely to help and acceptably safe.
This is why global access to EEG and global access to MRI are directly linked to the surgery gap. When the diagnostic infrastructure is missing, potential surgical candidates remain invisible.
Not every epilepsy surgery programme needs every technology
One of the most important lessons from global epilepsy surgery work is that programmes can be developed in stages. Some patients have relatively concordant findings: for example, a clear structural lesion, compatible seizure semiology and EEG findings pointing to the same region.
In appropriately selected cases, centres can begin with procedures that do not require the full technological infrastructure of the world’s largest tertiary programmes.
International reviews describe successful lower-resource programmes using carefully selected candidates, standardised pathways and collaboration with established epilepsy centres. This does not mean lowering safety standards. It means matching programme complexity to available expertise while developing capacity sustainably.
Temporal lobe surgery has been central to many lower-resource programmes
Historically, temporal lobe surgery has been among the most commonly reported epilepsy operations in low- and middle-income country series, particularly where mesial temporal sclerosis is clearly identified.
A systematic review and meta-analysis of surgery for medically intractable epilepsy in lower-resource countries found that, in published series of anterior temporal lobe surgery, seizure outcomes were broadly comparable with those reported from higher-income settings. These studies demonstrate that good outcomes are possible when selection, surgical technique and follow-up are appropriate.
The limitation is that published centres may represent stronger programmes and therefore should not be assumed to reflect every health system. Even so, the evidence challenges the idea that epilepsy surgery is inherently too complex to deliver safely outside wealthy countries.
The biggest barrier may be expertise, not equipment alone
Recent reviews of programme development in low- and middle-income countries repeatedly identify specialist expertise as one of the most important limiting factors. Epilepsy surgery requires a team that understands how to integrate sometimes conflicting evidence from MRI, EEG, seizure semiology and cognitive testing.
A technically excellent neurosurgeon cannot replace epileptology, neurophysiology or neuroradiology expertise. Likewise, expensive imaging equipment cannot replace the clinical judgement needed to select the right patient and the right procedure.
Workforce development must therefore include neurologists, paediatric neurologists, epileptologists, neurophysiologists, neurosurgeons, radiologists, neuropsychologists, specialist nurses, anaesthetists, rehabilitation staff and technical teams.
Training one person is not enough
Sustainable epilepsy surgery programmes depend on teams rather than isolated champions. A service can collapse if a single trained surgeon leaves, a neurophysiologist retires or an MRI protocol is no longer supported.
Long-term capacity building requires local training pathways, mentoring, multidisciplinary education and succession planning. The ILAE has specifically highlighted global shortages in epilepsy surgery education and the need to expand training opportunities for both neurologists and neurosurgeons.
International partnerships can help build local capacity
Several successful programmes have been developed through partnerships between newer centres and established epilepsy surgery units. These collaborations can provide case review, observerships, hands-on training, protocol development, teleconferencing and mentorship.
The strongest models aim to build independent local expertise rather than create permanent dependence on visiting teams.
Short-term surgical missions may help individual patients, but they cannot replace a sustainable local pathway capable of diagnosis, selection, surgery, complication management and follow-up.
Telemedicine can widen specialist reach
Digital EEG, MRI transfer and secure videoconferencing allow multidisciplinary teams to review cases across large distances. A centre without a full-time epilepsy neuroradiologist, for example, may be able to obtain specialist MRI review remotely.
Likewise, presurgical conferences can include experts from different countries without requiring every patient or clinician to travel internationally.
Telemedicine cannot perform the operation, but it can reduce the geographic concentration of expertise and support training, triage and complex decision-making.
Geography remains a major barrier
Epilepsy surgery programmes are usually concentrated in large urban tertiary centres. Patients living in rural or remote areas may need to make repeated journeys for consultations, MRI, EEG admission, neuropsychological testing, surgery and follow-up.
These journeys may require a family member to accompany the patient because seizures can make independent travel unsafe. The real cost therefore includes transport, accommodation, lost income and care responsibilities at home.
A programme can exist nationally while remaining practically inaccessible to people living far from it.
Cost can block referral before surgery is even discussed
Where healthcare costs are paid substantially out of pocket, families may never reach the presurgical stage. The expense may accumulate gradually through repeated clinic visits, EEG tests, imaging, travel and medication before an operation is even considered.
Some families may sell assets or borrow money to access advanced care. Others simply stop pursuing specialist assessment because the indirect costs are impossible to sustain.
This is why financial protection and universal health coverage are relevant to epilepsy surgery access. A theoretically available operation is not equitable if only wealthy families can reach it.
The cost question is more complex than ‘surgery is expensive’
Epilepsy surgery requires substantial upfront resources, but uncontrolled drug-resistant epilepsy also carries long-term costs. These can include repeated emergency care, injuries, hospital admissions, ongoing medication, unemployment, loss of education, caregiver time and premature mortality.
Health-economic studies in different settings have found that surgery can be cost-effective for appropriately selected patients, particularly when it produces long-term seizure freedom or major seizure reduction.
The global policy question is therefore not simply whether surgery costs money, but whether health systems can afford the cumulative consequences of leaving surgically remediable epilepsy untreated.
Children can lose important developmental time while waiting
In paediatric drug-resistant epilepsy, frequent seizures and epileptic activity can interfere with development, learning and behaviour. Some childhood epilepsies are associated with progressive developmental harm when seizures remain uncontrolled.
Delaying specialist evaluation for years can therefore have consequences beyond seizure frequency.
Paediatric epilepsy surgery also requires specialist expertise because developing brains, epilepsy syndromes and surgical risks differ from adult practice. In many countries, dedicated paediatric epilepsy surgery services are even scarcer than adult services.
Some operations aim for seizure freedom; others aim to reduce harm
Epilepsy surgery is not a single procedure. Resective and disconnective operations may aim to remove or isolate the seizure-generating network when it can be identified without unacceptable neurological loss.
Other procedures, such as corpus callosotomy in selected patients, may primarily reduce particularly dangerous seizure types rather than cure the epilepsy.
Neuromodulation approaches such as vagus nerve stimulation, deep brain stimulation and responsive neurostimulation can also be considered in some forms of drug-resistant epilepsy, but access to these technologies is highly unequal globally because they involve device cost, specialist implantation, programming and long-term maintenance.
Advanced technology can widen the gap further
SEEG, robotic stereotaxy, laser interstitial thermal therapy, intraoperative imaging and advanced functional mapping have expanded options in some centres. These technologies can be valuable, but they also require considerable capital investment, specialist expertise and maintenance.
A health system that lacks basic MRI or prolonged EEG cannot leap directly to the most technologically intensive model of epilepsy surgery.
Global programme development therefore needs a tiered approach: strengthen diagnosis and referral first, establish sustainable surgical pathways for appropriate cases, and add more complex technologies as expertise and infrastructure mature.
Surgery cannot be separated from pathology and postoperative care
Removed tissue may need neuropathological examination to clarify the underlying lesion, particularly in tumours, cortical dysplasia and inflammatory disorders. Patients also need monitoring for neurological deficits, infection, haemorrhage and other complications.
Long-term follow-up is equally important. Antiseizure medication is not necessarily stopped immediately after surgery, and decisions about reduction or withdrawal require specialist supervision. Some patients need neuropsychological rehabilitation, mental-health support or occupational and educational assistance.
A surgical service is therefore a long-term care pathway, not a single event.
Language and public understanding influence access
Families may decline referral because of fear that epilepsy surgery means removing a large part of the brain, causing paralysis or inevitably producing severe cognitive disability. In some communities, beliefs about epilepsy may also affect willingness to undergo neurological surgery.
Clear counselling is essential. Surgical risk is real and must never be minimised, but risk varies enormously according to the operation, brain region and individual patient. Evaluation exists precisely to weigh potential benefit against those risks.
Public education can therefore be part of closing the surgery gap.
Stigma can delay the entire pathway
Where epilepsy is heavily stigmatised, people may hide seizures, avoid medical care or rely exclusively on non-medical explanations and treatments. This can delay diagnosis by years.
A person who never reaches routine epilepsy treatment is unlikely to reach drug-resistance assessment, and someone who never reaches a specialist is unlikely to be considered for surgery.
The surgery gap therefore begins much earlier than the operating room.
Conflict and humanitarian emergencies can dismantle specialist programmes
Epilepsy surgery depends on stable tertiary healthcare infrastructure. Conflict can damage hospitals, interrupt electricity and imaging services, displace specialist staff and break medication supply chains.
Even established programmes can become inaccessible during war or political instability. Patients already partway through presurgical evaluation may lose continuity of care, while postoperative follow-up can disappear.
Because advanced epilepsy services are concentrated in a small number of centres, disruption to one hospital can affect an entire region.
Migration can interrupt surgical evaluation
People who move between countries may arrive with incomplete records, unavailable EEG data or MRI scans that cannot easily be transferred. Differences in referral criteria, insurance systems and waiting lists can force the presurgical process to begin again.
Continuity of digital medical records and cross-border communication therefore matter for complex epilepsy care as well as routine medication treatment.
Referral delay is itself part of the treatment gap
Measuring the number of epilepsy operations performed each year does not capture the full access problem. A health system may have a surgical centre but refer only a small fraction of eligible patients.
Useful measures therefore include the time from diagnosis of drug-resistant epilepsy to specialist referral, geographic distribution of referrals, completeness of presurgical investigations and the proportion of assessed patients who can actually proceed with recommended treatment.
The first step towards improving access is recognising where patients disappear from the pathway.
WHO policy increasingly treats epilepsy as a health-system priority
The World Health Organization’s Intersectoral Global Action Plan on epilepsy and other neurological disorders 2022–2031 calls for improved access to diagnosis, treatment and care across the full neurological pathway. WHO guidance also recognises surgery as a potentially beneficial option for people whose seizures respond poorly to medication.
For global epilepsy policy, that means closing the treatment gap cannot stop at making basic antiseizure medicines available. People with persistent seizures need pathways onward to specialist and advanced care.
What a realistic global strategy looks like
Closing the surgery gap does not mean placing a comprehensive epilepsy surgery centre in every hospital. A more realistic model is tiered regional care.
Primary and general services identify epilepsy and provide initial treatment. Specialist centres recognise drug resistance and perform appropriate EEG and MRI assessment. Regional comprehensive centres provide multidisciplinary presurgical evaluation and surgery. Highly complex cases can be referred nationally or internationally where necessary.
Digital image transfer, tele-EEG and remote multidisciplinary review can connect those levels.
What sustainable programmes need
Long-term epilepsy surgery capacity requires reliable referral criteria, affordable diagnostic testing, epilepsy-protocol MRI, prolonged video-EEG, multidisciplinary case conferences, trained neurosurgeons, anaesthesia and intensive-care support, neuropsychology, pathology, rehabilitation, data collection and postoperative follow-up.
It also requires governance and financing. Without protected funding, specialised programmes may depend on charitable donations, individual clinicians or short-lived projects and disappear when those supports end.
Global access improves when epilepsy surgery is treated as part of a national neurological service rather than as an exceptional luxury.
The central inequality
The science of epilepsy surgery is global, but access to it is not.
A person with drug-resistant focal epilepsy in one country may undergo epilepsy-protocol MRI, prolonged video-EEG, multidisciplinary review and potentially curative surgery. Another person with an almost identical epilepsy may spend decades cycling through medication because none of those services exists nearby.
The difference is not necessarily the biology of their epilepsy. It may simply be where they live.
What this page does — and does not — explain
This page is about worldwide access to epilepsy surgery and the health-system barriers that determine who reaches surgical assessment. The clinical process of deciding whether an individual is suitable for surgery is covered separately on Epilepsy Surgery and Presurgical Assessment. Advanced tests such as PET, SPECT, MEG and SEEG are covered on their own pages, while device-based treatments are covered under neurostimulation.
Sources
World Health Organization — Epilepsy fact sheet
WHO — Improving the lives of people with epilepsy: a technical brief
Watila et al. — Epilepsy surgery in low- and middle-income countries: a scoping review
Surgical outcomes for medically intractable epilepsy in low- and middle-income countries: systematic review and meta-analysis
Global volume of surgically treatable epilepsy: systematic review and meta-analysis
Outlines to Initiate Epilepsy Surgery in Low- and Middle-Income Countries
ILAE — Epilepsy surgery education and practice around the globe
Improving access to epilepsy surgery: global praxis, implementation science and policy frameworks
Challenges of establishing centres for surgical management of epilepsy in low- and middle-income countries
Evidence checked: September 2026.