key: cord-0725310-3q6jibl8
authors: Knopf, Joshua D.; Kumar, Rahul; Barats, Michael; Klimo, Paul; Boop, Frederick A.; Michael, L. Madison; Martin, Jonathan E.; Bookland, Markus; Hersh, David S.
title: Neurosurgical operative videos: an analysis of an increasingly popular educational resource
date: 2020-09-02
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.08.187
sha: 24a70a0fb34723f0bc76c99ca970f319e1a86311
doc_id: 725310
cord_uid: 3q6jibl8

Objective Surgical education has increasingly relied upon electronic learning, and in particular, online operative videos have become a core resource within the field of neurosurgery. Here, we analyze the current forums for neurosurgical operative videos. Methods Operative videos from 5 sources were reviewed: (1) the NEUROSURGERY Journal YouTube channel; (2) the AANSNeurosurgery YouTube channel; (3) The Neurosurgical Atlas Operative Video Cases; (4) Operative Neurosurgery; and (5) Neurosurgical Focus: Video. Title, year of publication, senior author, institution, country, and subspecialty were documented for each video. Results A total of 1,233 videos demonstrating 1,247 surgeries were identified. Ten videos included >1 surgery; of those, there was a median of 2 surgeries (interquartile range, 2.0–2.5) per video. The most frequently represented subspecialties include vascular (48.3%), tumor (35.2%), and skull base surgery (27.5%), with almost 40% of videos depicting >1 category. Videos were submitted by authors from 28 countries, but 82.1% of the videos originated in the United States. Conclusion Neurosurgical operative videos have become increasingly common through a variety of online platforms. Future efforts may benefit from collecting videos from underrepresented regions and subspecialties, providing long-term follow-up data and demonstrating techniques for managing complications.

Surgical education has traditionally been built upon graduated "hands-on" operative experience, supplemented by textbooks, lectures, cadaver labs, and formal surgical courses.

However, the rapid pace of technology has opened other educational avenues, such as online lectures and courses, virtual dissections, and simulation training. The current COVID-19 pandemic has highlighted the importance, application, and adaptability of these electronic resources, as trainees have had less operative experience and may need to continue social distancing measures for a protracted period of time. [1] [2] [3] [4] [5] Operative videos represent another educational tool for trainees as well as for established surgeons. Operative videos in neurosurgery can be traced back to Gazi Yasargil's early recordings of his microsurgical cases; today, videos are simpler to record, store, and transmit in high definition (2D or 3D). As aptly stated by Robert Spetzler, "It is true that watching a brilliant surgeon's video will not make you one, but recognizing what is possible and seeing it done will inspire you to be a better surgeon and to achieve that goal." 6 To date, a number of operative video "libraries" have been collated and published. For the purpose of this analysis, we sought to include video collections that have been sponsored Additionally, it includes videos from The Rhoton Collection, a core curriculum developed in conjunction by the AANS and the Society of Neurosurgery, interviews of "Leaders in Neuroscience," and historical films. 

Manual curation of each operative video from the aforementioned video sources was compiled in a database (Microsoft Excel version 16.37). Video characteristics (subspecialty and 2D vs 3D format), source, patient demographics (age and sex), and senior author information (name, institution, and country) were compiled. Videos depicting more than 1 patient were annotated along with individual patient demographics. For subspecialty designations, each video J o u r n a l P r e -p r o o f was annotated as relating to 1 or more core neurosurgical subspecialties: tumor, vascular, spine, pediatrics, functional, peripheral, and/or trauma. For the two YouTube channels, the number of views for each video was recorded. Data collection for all videos was completed by May 8, 2020.

All analyses were performed using R (version 3.5.1; RStudio, https://rstudio.com) with either base stats package or rstatix (version 0.4.0; https://cloud.r-project.org/package=rstatix). Visualizations of intersecting sets were generated using UpSet (https://ieeexplore.ieee.org/document/6876017). Geocoding was performed using ggmap Significance level α was set to 0.05 for all analyses except after multiple testing correction, where α was set to 0.1. Normality of continuous variables was assessed using the Shapiro-Wilk test. Continuous variables were summarized using median and interquartile range (IQR). Comparisons across groups were performed with the Krukal-Wallis test and post-hoc pairwise Dunn's test with BH correction. Count data was compared across groups using the Chisquare test followed by post-hoc pairwise Fisher's exact test with BH correction.

Analysis of the number of hits/views for each video was limited to the two YouTube channels. The number of hits for each video were analyzed per subspecialty and pairwise comparisons were performed between videos that were related versus those that were unrelated J o u r n a l P r e -p r o o f to each subspecialty. The number of hits were normalized to the number of years for which each video was accessible. Video, the AANS YouTube channel, and The Neurosurgical Atlas following with 6.25%, 5.7%, and 0%, respectively (Fig. 2b) .

Overall, the most highly represented subspecialties included vascular (48.3% of the videos), tumor (35.2%), and skull base surgery (27.5%) (Fig. 3) . Spine, pediatrics, functional, peripheral, and trauma followed with 16.2%, 7.8%, 3.1%, 2.2%, and 0.8% of the videos, respectively. Additionally, 52 videos (4.2%) depicted endoscopic surgery (data not shown). (Fig. 4) .

Aside from the 395 videos of The Neurosurgical Atlas, which were contributed by Dr. 

Over the last 20 years, education at all levels has undergone radical change brought about by the digital revolution and the ever increasing access to information. Increasingly, curricula have adopted eLearning, which refers to an approach to teaching and training that utilizes electronic media in order to facilitate learning. 7-9 eLearning may occur in either a synchronous fashion, in which the instructor and learner interact in real time, or in an asynchronous manner, in which the material has been prerecorded. In either case, eLearning relies on the use of Web 2.0 tools-dynamic tools and technologies that provide access to user-generated content. These tools include websites, wikis, blogs, and social networking sites, all of which can be harnessed by medical educators. [10] [11] [12] [13] Within neurosurgery, numerous electronic resources, including but not limited to the Surgical videos serve a number of critical roles. First and foremost, such videos are an invaluable resource for neurosurgical trainees. As stated by James Rutka, "If a picture is worth a thousand words, just imagine the relative worth in words of an operative video!" 14 It is not surprising, therefore, that many medical students and residents use online videos to supplement their traditional learning and prepare for cases. 15, 16 Data from The Neurosurgical Atlas project show that operative videos have become increasingly popular over time, with the web site logging an increased number of video sessions. 10, 17 The increased web traffic has been attributed largely to an increase in "trainee engagement," with a large proportion of the visitors being in the 18-34

year age group. Residents who participate in video-based training have been shown to achieve learning milestones in shorter amounts of time, presumably due to the ability to repeatedly watch a video prior to performing the procedure. 18 Conversely, videos of trainees can be used to assess their operative skills. Assessment tools have been developed to confirm the competency of general surgery trainees and have been shown to be highly reliable, thereby providing an objective way to "grade" surgical competence. 19 Although used primarily by surgical trainees, operative videos can also facilitate postgraduate education. A study that used optoelectronic and video motion analyses to record kinematic data demonstrated that consistent, specific movements and tasks are performed by experienced neurosurgeons when performing microvascular anastomoses. 23 Using edited J o u r n a l P r e -p r o o f operative videos to continually review the technical steps performed by master neurosurgeons is key to refining the science, as well as the art of neurosurgery throughout our careers. 14 Indeed, a survey of neurosurgeons in India found that 88% of senior neurosurgeons reported that online neurosurgical videos helped improve their surgical skills. 15 Whether used by neurosurgical trainees or established attendings, web-based operative videos appear to play an important role globally, particularly in low-to-middle income countries where limited resources restrict the access of many surgeons to journals, cadaver labs, workshops, and conferences. 7, 24 While there are also barriers to the utilization of web-based resources, including limited technology, limited access to the internet, limited user support, and language and cultural barriers, the free nature of many electronic resources offers an opportunity to expand neurosurgical educational efforts to the developing world. 7, 15, 24, 25 A survey of neurosurgeons in India found that 88% of senior neurosurgeons, 91% of junior consultants, and 80% of resident trainees found online videos helpful in improving their surgical skills. 15 The authors concluded that e-learning platforms can help provide educational opportunities to neurosurgeons across globally diverse environments-trainees, consultants, and senior surgeons in urban, semi-urban, and rural areas alike. Anyone with internet access anywhere in the world can watch online videos and learn from them. This low-cost resource avoids the expenses associated with journals and textbooks, and is readily available to all neurosurgeons throughout the world.

Given the theoretical utility of online operative videos for facilitating global neurosurgical education, are such videos actually being used on an international scale? Analytics J o u r n a l P r e -p r o o f data from The Neurosurgical Atlas suggest that the online resource is, in fact, being used globally. Between 2016 and 2017, while the single largest group of people accessing the site came from the United States (29% of viewers), the remainder came from Brazil (6%), India (4%), and a variety of other countries. 10 In an updated analysis between 2018 and 2019, the overall breakdown was similar with 39% of viewers originating from the United States, 5% from India, and 4% from Brazil, but impressively, users from 208 individual countries accessed the website. 17 Conversely, although electronic resources are being utilized by an international audience, contributions to those very resources seem to be more consolidated. A survey of neurosurgeons in India found that although the vast majority of respondents used online videos, only 6% had previously uploaded videos of their own. 15 Similarly, in the current study, of the 1,233 videos that were reviewed, 1,012 (82.1%) were contributed by institutions based in the United States. Our study also demonstrates that in addition to geographic consolidation, the operative videos are heavily weighted toward several neurosurgical subspecialties-tumor, vascular, and skull base in particular-which account for 35.2%, 48.3%, and 27.5% of the videos, respectively.

Overall, 86% of the videos in this study were related to 1 or more of these subspecialties. At the other end of the spectrum, functional, peripheral nerve surgery, and trauma account for only 5.9% of the overall videos. Spine surgery, in particular, is notable for representing a relatively low percentage (16.2%) of the overall videos, but a relatively high percentage of the overall hits, J o u r n a l P r e -p r o o f suggesting a demand for additional spine-related videos. Further analyses of the number of views or hits should be used in the future to help guide calls for additional videos.

The disparity in subspecialty representation is likely due, at least in part, to the technicalities of recording video during a surgery. The intraoperative microscopes and endoscopes used during tumor, vascular, and skull base cases have built-in recording features that afford the audience the same view seen by the surgeon, whereas these technologies are not typically required for many of the other subspecialties. Nevertheless, website analytical data have shown that among visitors to The Neurosurgical Atlas site, general neurosurgical topics were viewed the most frequently, and that other subspecialty topics (tumor, vascular, pain, epilepsy, and spine) were viewed with a similar frequency. 10 There seems to be demand for a well-rounded assortment of videos, particularly if these videos are to be used to build or supplement a neurosurgical curriculum. Overhead lights with built-in cameras, miniature cameras mounted to headlights, and other emerging technologies can be used to capture surgical recordings without a microscope or endoscope. Additionally, the "Call for Videos" format employed by Neurosurgical Focus: Video provides a unique opportunity to guide the topics of videos that are submitted to the journal. Upcoming topics include "Surgery for Cranio-Cervical Deformity and Instability," "Surgery for Pain", and "Craniosynostosis," suggesting a recognition by the editors that these are areas that have been underrepresented to date.

Operative videos that are accessible online, particularly those that are found on usergenerated video-sharing sites, come with an important caveat: many have not been peerreviewed, and the reliability of the content has not been verified. 24 Without academic oversight, poor-quality videos demonstrating false information and poor techniques can make their way J o u r n a l P r e -p r o o f onto the internet, particularly when there are conflict of interest issues in play-for instance, videos that highlight specific instrumentation rather than a surgical technique. 18 Calls for a more scholarly approach have resulted in the development of validated scoring scales, such as the DISCERN instrument. 26, 27 DISCERN is a rating tool that assigns a score out of 80 based on 15 questions that are each rated on a scale of 1 to 5. Although initially designed to evaluate written consumer health information, the DISCERN instrument has also been used to grade online videos based on critical assessments of their content. 18, 28, 29 An analysis of the top 160 videos on YouTube related to neurosurgery used the DISCERN instrument to evaluate each video and demonstrated that videos that were created by physicians and academic institutions were of higher quality. 29 However, the DISCERN tool was specifically designed to assess consumer health information-resources for patients and the lay public-rather than operative videos to be watched by other surgeons. Other criteria are likely to be of value when evaluating a surgical video. The same study of neurosurgical YouTube videos found that of the 24 operative videos that were identified, only 33% had auditory commentary, and only 25% provided educational learning points, thereby lessening their educational impact. The authors called for clinicians and institutions to "hold themselves and each other to a higher standard of content creation." 29 In contrast, the video sources that were analyzed in the current study are examples of high-quality video libraries that are endorsed by senior neurosurgical leadership, national/international neurosurgical associations, and respected neurosurgical publications. In particular, Operative Neurosurgery and Neurosurgical Focus: Video are unique and forwardthinking resources that emphasize the importance of the peer-review process. Indeed, a breakdown of the number of videos uploaded each year suggests that authors are increasingly turning to these journals as a destination for their videos, rather than YouTube channels. Videos published in these journals are indexed in PubMed, which has likely contributed to their J o u r n a l P r e -p r o o f popularity. The journals have a more formal structure for their submissions-videos are encouraged to include a brief history and physical, pertinent imaging, positioning, exposure, closure, and postoperative imaging, in addition to the "critical" aspect of the surgery. Including these details, while remaining concise, is essential for ensuring that these videos maximize their educational potential. 15 It is equally important to include sufficient follow-up information, so that the viewer may understand the impact of various surgical techniques on the patient's outcome.

Videos that highlight techniques for managing complications should be encouraged; viewers are otherwise at risk for developing a false sense of security by watching highly selected videos that only demonstrate the best outcomes. 15 A modified DISCERN instrument that takes these factors into consideration may be useful both as part of the peer review process, as well as for neurosurgeons viewing a published video. Features that can be assessed include: 1) a disclosure of conflicts of interest, 2) audio commentary, 3) a history and physical, 4) preoperative imaging, 5) a discussion of preoperative decision-making, 6) patient positioning, 7) the exposure and closure, 8) annotation of the relevant anatomy with labels, and 9) a discussion of the postoperative course and long-term follow-up. Depending on the targeted forum for the video, a short discussion with educational learning points may follow the operative portion of the video, as well. Developing such a tool may assist in maintaining high standards for neurosurgical operative videos, thereby maximizing their educational impact.

There are several important limitations to this study. The current analysis is not a complete inventory of the existing operative videos, as there numerous YouTube videos that are sponsored by individual surgeons and/or institutions. Our goal was to provide an overview of J o u r n a l P r e -p r o o f those videos that are specifically endorsed by reputable neurosurgical organizations. We provide a snapshot of the available videos to date, but as new videos are frequently uploaded, the numbers cited in the current study may rapidly change. Additionally, the video sources that were selected for analysis are based in North America, which is an important confounder when considering the analysis of geographic representation. Future studies will be necessary to truly assess the global contribution to neurosurgical operative videos, which was not within the scope of the present study. Future studies may also provide more detailed analyses of operative videos dealing with an individual surgical technique.

Operative videos are only one component of the electronic resources that are currently being used to supplement neurosurgical education. The Neurosurgical Atlas, for instance, contains not only operative video cases, but also "volumes" with text-based explanations of various topics, as well as "grand rounds" webinars. These other multimedia formats are important elements of building a full neurosurgical curriculum, but a full analysis of these resources was outside the scope of our study. Additionally, while prior publications have used Web 2.0 analytics to study web traffic data, we were unable to do so as such tools are limited to the owners of the individual website. 10, 13, 17 However, knowing which operative videos are most frequently viewed would help identify the need for additional video topics in a dynamic manner.

Neurosurgical operative videos are a useful educational adjunct, both for neurosurgical trainees as well as for the continued education of neurosurgery attendings. To date, most of the operative videos that are accessible have come from surgeons in the United States and relate to tumor, vascular, and/or skull base cases. While these videos are typically of high quality, future J o u r n a l P r e -p r o o f efforts may benefit from the curation of videos highlighting underrepresented subspecialties, providing long-term follow-up data, and demonstrating techniques for managing complications.

The authors wish to thank Andrew J. Gienapp (Neuroscience Institute, Le Bonheur Children's Hospital and Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN) for copy editing and publication assistance.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 

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Knopf: Investigation, Data curation, Formal analysis, Writing -review and editing

Rahul Kumar: Investigation, Data curation, Formal analysis, Methodology, Visualization, Writing -review and editing

Michael Barats: Investigation, Data curation, Writing -review and editing

Supervision, Writing -review and editing

Boop: Supervision, Writing -review and editing L. Madison Michael II: Supervision, Writing -review and editing

Martin: Supervision, Writing -review and editing

Markus Bookland: Supervision, Writing -review and editing

Conceptualization, Project administration, Supervision, Writing -original draft preparation, Writing -review and editing