|Ahead of print publication
Outcomes after acute inpatient rehabilitation following epilepsy surgery: A case series
David Sherwood1, Alan Tran1, Benjamin Gill2, Benjamin Westerhaus1, Alexandra Arickx1, Patrick Landazuri3, Sarah Eickmeyer1
1 Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
2 Department of Physical Medicine and Rehabilitation, University of Missouri Medical Center, Columbia, MO, USA
3 Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
|Date of Submission||13-Sep-2020|
|Date of Decision||09-Oct-2020|
|Date of Acceptance||09-Oct-2020|
|Date of Web Publication||22-Feb-2021|
Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, 2201 Children's Way, Suite 1318, Nashville, TN 37212
Source of Support: None, Conflict of Interest: None
Objective: To describe functional outcomes following discharge from an acute inpatient rehabilitation facility (IRF) in patients following epilepsy surgery, comparing laser interstitial thermal therapy (LITT) versus surgical resection for epilepsy. Design: Retrospective case series. Setting: Academic tertiary hospital. Participants: Eight patients who received LITT (n = 3) or surgical resection (n = 5) for epilepsy. Interventions: Acute inpatient rehabilitation. Main Outcome Measures: Functional independence measure (FIM), seizure incidence, discharge destination. Level of Evidence: IV. Results: The epilepsy cohort demonstrated a FIM change of 38.88 (vs. national average 29.55), average length of stay (LOS) of 15.13 days (vs. 13.38 days), and LOS efficiency was 3.4 (vs. 2.68). No patients in the epilepsy cohort were discharged to acute care hospital compared to a national average of 9.82%. Eighty-seven percent in the epilepsy cohort discharged to home (vs. 77%) and 12.5% to skilled nursing facility (vs. 11.90%). Between the subset who received LITT and those who received surgical resection, there was no statistically significant change in mean total FIM change (43.7 vs. 36), FIM efficiency (5.3 vs. 2.2), or FIM change in subset measures of memory (0.5 vs. 0.25) or problem solving (0 vs. 0.8). There was no statistical significance between groups in adverse events, including seizure. Conclusions: Outcome measures in this population appear to be consistent with national outcome measures for other IRF diagnoses. This suggests that acute inpatient rehabilitation should be considered after patients undergo surgical intervention for epilepsy. However, a larger sample size and controlled studies are necessary before generalizations can be made. In addition, no statistically significant functional difference was seen between patients who underwent LITT or surgical resection.
Keywords: Epilepsy, Neurosurgery, Acute Inpatient Rehabilitation
|How to cite this URL:|
Sherwood D, Tran A, Gill B, Westerhaus B, Arickx A, Landazuri P, Eickmeyer S. Outcomes after acute inpatient rehabilitation following epilepsy surgery: A case series. J Int Soc Phys Rehabil Med [Epub ahead of print] [cited 2021 Apr 14]. Available from: https://www.jisprm.org/preprintarticle.asp?id=309890
| Introduction|| |
Drug-resistant epilepsy (DRE) occurs in approximately 30% of patients and is defined as the failure of two appropriately selected and dosed antiepileptic drugs (AEDs). For drug-resistant patients, surgical therapy should be considered according to the guidelines published and endorsed by multiple professional societies which are based in part on randomized controlled trials in temporal lobe epilepsy.,, Despite this strong level of evidence demonstrating the efficacy and safety of epilepsy surgery, both patients and physicians remain apprehensive regarding epilepsy surgery. As such, there has long been interest in minimally invasive surgical techniques that could remove less brain matter. One technique that has found recent increased use is laser interstitial thermal therapy (LITT). This technique involves insertion of a probe allowing targeted laser delivery into the cortex of interest via a single burr hole. A recent pooled analysis of temporal lobe epilepsy patients undergoing LITT therapy found that 58% achieved Engel I, meaning free of disabling seizures, outcome at 2 years. Thus, patients are often now presented with multiple surgical options with ultimate selection based on patient-specific characteristics and preferences.
Epilepsy has been associated with multiple performance deficits, including cognitive, psychomotor, and mood impairments.,,,, Most studies examining rehabilitation interventions for epilepsy focus on cognitive rehabilitation, which has shown benefit.,, Cognitive rehabilitation and prehabilitation have been shown to be helpful for DRE before and after surgery for epilepsy., With respect to patients with refractory epilepsy, less is known about postsurgical outcomes after comprehensive interdisciplinary rehabilitation in an acute inpatient rehabilitation facility (IRF) involving multiple therapy disciplines and physician oversight. A review of the literature found a single study relevant to IRF outcomes in the postsurgical epilepsy population. Thorbecke et al. evaluated the effects of an inpatient rehabilitation program on employment rate 2 years after surgery for refractory temporal lobe epilepsy and found a statistically significant increase in employment rate in the IRF group compared to the control group (P = 0.008). However, there is otherwise minimal research on the more immediate functional effects of IRF for patients with refractory epilepsy, specifically those who have received surgical resection or LITT.
The primary aim of this case series was to examine functional outcomes of DRE patients after surgical intervention who required IRF care when compared with national IRF outcomes. The secondary aim was to perform a subgroup analysis of functional outcomes comparing LITT and surgical resection.
| Methods|| |
This was a single-center, retrospective, nonconsecutive case series at a large academic medical center from January 2014 to January 2020. Of note, the hospital system began collecting data for the LITT cohort in April 2015, while the resection cohort started in January 2014. IRB approval for the project was obtained in December 2018 (Study 00143289). A secure registry was used by the Epilepsy Division with the Department of Neurology for every epilepsy surgery performed at this center during the study period.
The medical record numbers of those in the registry were cross-checked by a single investigator to assess for a rehabilitation encounter within the health-care system immediately following the time of the surgical intervention (DS). Those that were present on the registry and had a rehabilitation encounter created within the healthcare system postoperatively were included in the case series.
Data abstracted from the electronic medical record included functional independence measures (FIM), Montreal Cognitive Assessment (MoCA) and Saint Louis University Mental Status exam (SLUMS) total scores, admission length, seizure free days, acute care discharge, readmission within 30 days of discharge, and disposition at discharge. The FIM consists of 18 items that assess functional performance of activities of daily livings, mobility, and cognition/communication on a 1–7 scale and is gathered in IRF facilities as a standardized outcome measure. The MoCA (range, 1–30) and SLUMS (range, 1–30) are brief screening tools to assess cognition with cutoffs for mild, moderate, and severe cognitive impairment., Data regarding the type of intervention and location of the surgery and Engel Epilepsy Surgery Outcome Scale were pulled directly from the registry or from individual chart review when not in the registry. The Engel Epilepsy Surgery Outcome Scale, or Engel score, is used to classify postoperative outcomes for epilepsy surgery, consisting of Class 1, free of disabling seizures; Class 2, rare disabling seizures; Class 3, worthwhile improvement; and Class 4, no worthwhile improvement. Deidentified data were securely stored in an institutional database. A single investigator was responsible for data collection and storage. Charts were reviewed twice by at least two separate investigators to evaluate for errors or omissions in collection.
National IRF data were provided by the Uniform Data System for Medical Rehabilitation via UDSPRO Central software portal. For the sake of comparison, average outcome scores reported nationally for all diagnoses by participating IRFs were extracted during the dates of data collection (2015–2020). As there were no advanced metrics to extract from the dataset, only averages were provided via the USPRO Central for our analysis.
The statistical package of Microsoft Excel (Microsoft Corporation, Redmond, WA, USA) was used to perform all statistical analyses. A t-test assuming unequal variances was performed to compare each of the outcome measures for LITT to the outcome measures for resection following a square root transformation to normalize the data distribution. Fisher's exact test was performed to compare LITT to resection with regard to seizures. For all analyses, statistical significance was assumed for two-tailed P values of P < 0.05.
| Results|| |
There were eight total patients that completed an IRF stay following either LITT (n = 3) or surgical resection (n = 5) between January 2014 and January 2020. The mean age of patients at the time of procedure was 44.38 years. Seven (87.5%) of 8 patients were female. Within the LITT group, the mean age was 48.33 years with all females (n = 3). Within the resection group, the mean age was 42 years with 80% (n = 4) of females and 20% (n = 1) of males. The patients' surgery type, surgical outcome, and time since surgery are detailed in [Table 1].
|Table 1: Subjects' surgery type, surgical outcome and time since surgery to 4/2020|
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Comorbidities in the LITT group included anxiety, idiopathic thrombocytopenic purpura, Grave's disease, essential hypertension, Vitamin B12 deficiency, anemia, coronary artery disease, gastroesophageal reflux, cerebral aneurysm, and major depressive disorder. Comorbidities in the resection group included anxiety, hypertension, osteoarthritis, rheumatoid arthritis, history of transient ischemic attack, cognitive developmental delay, gastroesophageal reflux disease, generalized headaches, hyperlipidemia, sleep apnea, Vitamin D deficiency, pituitary gland enlargement, Asperger's syndrome, depression, diabetes mellitus, hypothyroidism, cerebral venous thrombosis, and stroke.
Epilepsy compared to other inpatient rehabilitation facility diagnoses
IRF national UDS data for all diagnoses dated between January 2015 and 2020 were collected and reported as an average for comparison to the epilepsy cohort, as shown in [Table 2]. Admission and discharge FIM scores and overall FIM change were comparable between groups. Problem solving and memory FIM scores also improved in both groups. Average length of stay (LOS) and LOS efficiency were similar between groups. Compared to the national cohort, the epilepsy group had fewer patients urgently discharged to the acute care hospital and comparable community discharges.
|Table 2: National inpatient rehabilitation facility functional outcomes compared to epilepsy cohort during 2015-2020|
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Laser interstitial thermal therapy compared to resection
[Table 3] compares the subgroups who received LITT (n = 3) and resection (n = 5). There were no statistical differences between groups for any of the outcomes measured. Both groups made improvements in overall FIM and the subscores of problem solving and memory. LOS was longer in the resection group (16.2 days) compared to the LITT group (9.7 days), but this was not significant.
|Table 3: Functional outcomes after inpatient rehabilitation facility for laser interstitial thermal therapy and resection subgroups|
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All patients in the LITT group (n = 3) were discharged home. While a single patient in the LITT group 33% (n = 1) discharged home with home health.. Eighty percent (n = 4) of the resection group discharged home, and 20% of the resection group (n = 1) discharged to skilled nursing facility. There were no acute care discharges or readmissions within thirty days for either epilepsy group.
Two patients in the LITT group had MoCA total scores on admission of 16 and 8, indicating moderate cognitive impairment. The remaining patients in the LITT group had a SLUMS test score of 22, consistent with mild cognitive impairment. For the resection group, three patients had MoCA testing on admission, with scores of 20 (mild cognitive impairment) and 11 and 12 (both indicating moderate cognitive impairment). One patient in the resection group scores 18 on the SLUMS, consistent with significant cognitive impairment. Cognitive testing was not available for the remaining two resection patients.
Two participants, both in the resection group, experienced postsurgical seizures when at acute inpatient rehabilitation. These seizures were managed by a consulting neurology service with recommendations to adjust current AED regimen. Neither patient required readmission to acute care for further management.
| Discussion|| |
The benefits of acute inpatient rehabilitation for DRE patients following epilepsy surgery have not been extensively studied based on our review of the literature. This case series examined the functional outcomes for postsurgical epilepsy patients after acute inpatient rehabilitation, with a subset analysis to evaluate for any differences between LITT and surgical resection. When comparing the outcomes of this patient population in our study to those of the national average, it can be noted that patients with refractory epilepsy after surgery make positive FIM change, discharge home, and sustain relatively few complications regardless of interventional method.
Overall, our cohort outcomes are similar to nationally reported IRF outcomes for FIM measures of problem solving, memory, total change, and efficiency.
Total FIM change and FIM efficiency were similar to national IRF data and comparable between surgical groups. These findings potentially show the value of rehabilitation in promoting functional gains in refractory epilepsy patients after surgical intervention. By demonstrating these outcomes, we are helping to expand the value of IRF for any insurers who might question the cost and medical necessity, who might otherwise deny the IRF stay for this diagnosis. However, larger studies should be conducted before generalizations can be made. We hope that this early literature serves to spark interest in researchers to develop larger scale projects to demonstrate the value across institutions.
Within the subset analysis of this patient population, FIM outcomes for LITT andsurgical resection were similar. The data from this study suggest that there is no significant difference in functional outcomes following discharge from IRF in patients receiving surgical intervention for refractory epilepsy, regardless of procedure. There was also no difference between surgical groups for the occurrence of postoperative seizures. This suggests that the need for inpatient rehabilitation can coexist with excellent epilepsy outcomes, as three patients had Engel I outcome and two additional patients had Engel II outcome.
Inpatient rehabilitation has been shown to reduce disability for many conditions on a wide range of both standardized and nonstandardized assessment tools. The IRF compliance threshold states that 60% of patients admitted to IRF must have one of the thirteen qualified medical conditions as outlined by the Centers for Medicare and Medicaid Services (CMS).
All patients in the LITT group (n = 3) were discharged home. While a single patient in the LITT group 33% (n = 1) discharged home with home health.
As a compliant diagnosis with acceptable functional outcomes, this suggests rehabilitation after surgical intervention for refractory epilepsy is a beneficial means to optimize functional outcomes.
Limitations of the study
Due to the small sample size, the data are neither generalizable nor statistically significant. Larger studies are needed to truly demonstrate whether a difference in outcomes exists. Missing data, specifically cognitive scores on the SLUMS and MoCA for two subjects, further complicate outcome assessment. Despite the small sample size, this information might be useful for a clinician looking to expand their IRF case mix into new diagnostic populations.
Four different neurosurgeons had patients who matriculated from their respective intervention (LITT or resection) to acute inpatient rehabilitation. Each neurosurgeon had a different amount of training, number of interventions performed, exposure to LITT intervention, and preference for either surgical resection or LITT. This case series consisted of multiple different anatomical sites for intervention. Varied localization brings varied risk profiles based on the surgery performed. Alternatively, different surgeons and anatomic sites could be a strength and make the findings more generalizable.
Finally, while the averages between national IRF outcome data and the epilepsy cohort appear similar, larger conclusions should not be made from this data. Given that these are just mean values without access to the entire national IRF outcome dataset, it would be imprudent to make generalizations or statistical inferences based solely on these averages. With the recent change from FIM to CMS Quality Indicators, future studies will have to use a different outcome tool.
| Conclusions|| |
Our study adds to the small amount of research regarding acute inpatient rehabilitation after surgical intervention for patients with refractory epilepsy. This study examined functional outcomes for the postsurgical epilepsy population and compared it to overall outcomes after IRF. Patients made positive FIM change and discharged home consistent with national IRF averages while suffering few complications. Moreover, there was no statistical difference in functional outcomes following discharge from IRF between LITT and resection patients.
Ultimately, outcome measures in our cohort appear to be consistent with national outcome measures of other IRF diagnoses. These findings suggest that the postsurgical epilepsy patient population may be appropriate for acute inpatient rehabilitation intervention.
This novel patient population for IRF is a potential source of patients who will succeed in our unique level of care. Epilepsy surgery programs may continue to grow as access to newer technologies such as laser ablation continues. As epilepsy surgery programs grow, it would be reasonable to accommodate this expanding patient population and ensure they receive the best level of care. However, controlled studies and larger sample sizes are needed to further generalize our findings.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]