Neurosurgery videos on online video sharing sites: The next best teacher?
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.258028
Source of Support: None, Conflict of Interest: None
Keywords: Neurosurgical online videos, neurosurgery video editing, neurosurgical training, internet, video bank, surgical skills training, surgical simulation
The dawn of the present century witnessed an upsurge of various e-learning platforms, breaking the barriers to the dissemination of knowledge in the realm of neurosurgery. The situation was different a couple of decades back when neurosurgeons depended mainly on textbooks for augmenting knowledge of the operative neurosurgical techniques. If a picture is worth a thousand words, then especially in the surgical field, videos really help. Online video-sharing sites undoubtedly assume a prominent position among various web-based learning platforms. This is especially so in a developing country like India, where the cost of courses as well as conferences to update one's knowledge, and access to cadaver laboratories are often unaffordable. The abundance of neurosurgical videos available on the net have given the present day neurosurgeon additional opportunities to learn. In this study, we report the results of a quick national survey undertaken to assess the utility of neurosurgical operative videos present on online video-sharing sites.
The participants consisted of resident trainees in neurosurgery, as well as junior and senior consultant neurosurgeons practicing in India. A questionnaire, which consisted of nine multiple-choice questions and a space for remarks, if any, was set up using Google forms. 520 people were contacted between May 2017 and March 2018, either through e-mail or by providing the link through the WhatsApp platform.
Data were collected and entered in the Statistical Package for the Social Sciences (SPSS) version 16 (IBM, Chicago. Illinois, USA). The categorical variables were presented as percentages. Differences between categories were assessed by the chi-square test and P values less than 0.05 were taken as significant. The questionnaire is given in [Table 1].
There were a total of 100 responses, out of which two responses were defective and were discarded. The response rate was 18.84%. This study was, therefore, based on the analysis of 98 responses. The responders included senior consultants (n = 34, 34.7%), junior consultants (n = 46, 46.9%), as well as resident trainees in neurosurgery (n = 15, 15.3%), and other groups of doctors (n = 3, 3.1%) working in an area attached to neurosurgery. The majority of responders were from the urban area (n = 75, 76.5%). Those from the rural area (n = 8, 8.2%) and from semi-urban area (n = 15, 15.3%) together constituted only 23.4% of responders.
Utility of neurosurgical videos
A large majority of neurosurgeons across the country vehemently agreed that such videos are useful in improving their surgical skills (n = 87, 88.8%). Among the senior neurosurgeons, 88.2% (n = 30) were of the opinion that it helped them in improving their surgical skills. A high percentage of resident trainees (n = 12, 80%) and junior consultants (n = 42, 91.3%) responded that it was useful to them. This was irrespective of whether or not they had worked in a rural or an urban setting. One senior consultant from a rural area responded that he had not even seen one such video. Majority of the responders (n = 89, 91.8%) were of the opinion that these surgical videos served a good adjunct to surgical training. Two (2/19) responders commented that these videos can be made a part of the neurosurgical training program.
Even though a large majority of people make use of these videos, only a minority of responders (n = 6, 6.1%) have previously uploaded their own operative videos routinely. Majority of those who uploaded their videos in this study were senior consultants (n = 5, 5.1%).
Need for more videos
Regarding the need for more videos, there were 97 responses. The majority of respondants felt that more such videos must be uploaded (n = 88, 89.8%). This included 30 senior consultants and 41 junior consultants. Five responders did not express a definite opinion.
Rhoton's microneurosurgical videos
The total responders to the question were 95. The majority of the doctors opined that these videos were excellent in improving their knowledge (n = 71, 74.7%). Twelve (12.6%) people were not aware of the existence of these videos. It is of interest to note that nobody opined that it was not useful. It was found that both the senior (n = 24, 75%) as well as junior neurosurgeons (n = 32, 71.1%) opined that these videos were excellent.
The total number of responders were 97. The majority (n = 86, 88.7%) of them felt that there should be some mechanism for ensuring quality assurance. Some (n = 7, 7.2%) felt that it should be the viewers' discretion. Three persons reserved their opinions. Majority (n = 59, 93.6%) of the junior responders including residents were of the opinion that some mechanisms to assure quality should be in place. Among the senior doctors, 27 (79.4%) opined that there should be some quality assurance.
Idea of a video bank
The authors have put forwards the idea of a structured and quality-assured video bank. There were a total of 96 responders for this question. Out of the 96 responders, 92 (95.8%) responders supported the idea.
Under the comments section, the single most common comment which dominated was the demand for unedited videos (expressed by 4 out of 19 doctors who wrote their comments). Another notable comment was regarding the inclusion of videos of successful management of intraoperative complications (expressed by 3 out of 19 doctors who wrote their comments). The cross-tabulation of responses of junior and senior responders is provided in [Table 2].
Our study showed that neurosurgical operative videos on online video-sharing sites are of immense help to both consultants and naïve neurosurgeons in India. India is a vast country where neurosurgeons get trained and work in diverse situations. More and more neurosurgeons have started working in rural and semi-urban areas. From a pan-Indian perspective, there is an unequal distribution of resources in terms of patient load, infrastructure, and learning avenues available to the residents., Our survey was intended to address the question on whether or not the various e-learning platforms help to reduce this disparity to some extent. In our study, the majority (n = 87, 88.8%) of the responders voted that internet videos have helped them in improving their surgical skills. There was no statistically significant difference between people working in rural and urban areas in this regard (P = 0.517). Both senior and junior neurosurgeons are making use of these videos and there was no statistically significant difference between the usage of these sites between the two groups (P = 0.660).
Prof. Yasargil was the first neurosurgeon who recorded and collected his microsurgical cases. Many of them were available in compact discs (CDs) in those days. With the introduction of video-sharing sites like Vimeo in 2004 and YouTube in 2005, the idea of video sharing became rampant. Medical fraternity also embraced and kept pace with advances in technology. Slowly, web-based technologies were also inducted to disseminate knowledge in the field of neurosurgery. Studies have predicted that these technologies can become very important tools for learning and teaching neurosurgery.,, Robert Spetzler wrote, “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.” Some of these videos are a testimony to the developing world that, in fact, a majority of the procedures can be done with a surgical microscope, bipolar, and a limited number of instruments. These high-definition microneurosurgical and endoscopic video footages could be shared on multimedia and mobile-friendly interfaces. With the slashing prices of the 3G and 4G spectrum in India in these recent years and the penetration of internet to semi-urban and rural areas, these web-based technologies were put to use to the maximum by neurosurgeons. Rapp et al., have reported that YouTube is the most frequently used video tool for surgical preparation by trainees. Even though majority (88%) of our responders have opined that surgical videos on online channels have helped them in improving their surgical finesse, there are reports that it is an inadequate source of information.
The present decade has witnessed an exponential growth in the number and quality of neurosurgical online contents including videos. The major YouTube channels are summarized in [Table 3]. The American Association of Neurological Surgeons (AANS) has a YouTube channel which provides access to the Rhoton collections®, AANS/Society of Neurologic Surgeons online sessions, biographies of eminent neurosurgeons, history films. The Neurosurgical Focus of the Journal of Neurosurgery (JNS) publishing group has a collection of video supplements covering neurosurgical operative procedures. The 3D Neuroanatomy is a project based on the development of a huge community that focuses on three-dimensional (3D) neuroanatomy. The members of this group have a YouTube channel which shares details of various 3D neuroanatomy courses conducted by them. The Neurosurgery Research and Education Foundation (NREF) is a nonprofitable organization created by AANS and is dedicated to providing education to neurosurgeons at all stages of their careers. They also have a YouTube channel which contains educational material for residents and fellows. They sustain themselves through voluntary donations, corporate support, and donations from allied groups. The Rhoton collection® has been created with an intention to increase our knowledge of neurosurgical anatomy, thereby making surgery more accurate and safe. It is an online repository of his teaching materials and envisages to contain all his contributions on a platform in two- and three-dimensional formats. The NREF and AANS are currently funding these efforts so that it is freely available worldwide. Many of these videos are available through the AANS YouTube channel. They are also linked with other online resources so that a quick and dynamic cross-referencing can be done through popup windows without actually leaving the site. It can be directly accessed at http://rhoton.ineurodb.org. This website was warmly embraced by neurosurgical community. In our study, 74.7% of the responders opined that this site was an excellent source of information. The NeuroSurgical.tv provides a platform where people can interact, network and exchange ideas. They also have a YouTube channel which contains lectures of eminent persons as well as excerpts from major conferences. In India, the Neurosurgery Education and Training School (NETS) e-learning platform, which has been developed under the composite efforts of the All India Institute of Medical Sciences (AIIMS), New Delhi and the Indian Institute of Technology (IIT) Delhi, provides downloadable presentations, operative videos, lectures, 3D animation-based videos, social networking, and tele-education avenues.
Preparing and publishing quality video-only articles can be thought of. An exclusive platform, which has got its own editing, publishing, and indexing features, can be raised for video articles. This will go a long way in enhancing the value of 'video-publication' and giving a better understanding of the different nuances in the surgical technique. Some journals like Neurosurgery, the Journal of Neurosurgery and Neurology India provide supplemental digital online matters on video-sharing sites. The Neurological Society of India has also recently introduced monthly webinars focused on specific topics that displays multiple videos on the topic of the month.
When it comes to operative videos, the recording quality really matters. Preparing a surgical video consists of three steps- recording, editing, and archiving. Good quality recording is recommended for surgical videos. The minimum basic formats are summarized in [Table 4]. The unique art of editing ensures that the recorded footages are properly sequenced. Surgical videos must ideally contain a pertinent narrative and visual depictions of the relevant radiology, positioning, surgical exposure, technique details, and closure. Most high definition (HD), full high definition (FHD) and ultra-high definition (UHD) videos are digitally heavy and occupy much space. Nowadays, lots of compressing software and codecs are available to reduce the space occupied by such videos. Each online video-sharing site has its own technical specification for uploading videos. Proper 3D knowledge of the surgical anatomy is imperative for operative success, and 3D stereoscopic viewing of this anatomy will accelerate the learning curve. The latest technology allows 3D stereoscopic recording intraoperatively, which can be used for later viewing and for teaching. A head-mounted stereoscopic 3D camera system can be used for this purpose. Several YouTube channels nowadays provide 3D anaglyph videos also. Web-based surgical simulation models have come up which allow the trainee surgeons to practice the simulation of various procedures with a minimum risk to the patients.,, All videos available on online video-sharing sites are not of good quality. In our survey, 88.7% people opined that a quality assessment system should be in place. It is important to devise a tool for video evaluation and quality assessment.
The idea of a video bank was supported by 95.8% of our responders. This would provide a more structured and formulated database. Several such initiatives have been started around the world in this direction. Hernesniemi's 1001 and more microneurosurgical videos – a video book of neurosurgery is a project that includes more than 1100 high-definition videos of neurosurgery which are uploaded to Vimeo, a video-sharing site, and can be accessed through an open access neurosurgical journal, Surgical Neurology International. The project contains both short-version and long-version videos. The Neurosurgical Atlas is also an initiative in this direction which has been warmly welcomed by neurosurgeons. This is evident from the fact that by December 2016, the Neurosurgical Atlas has more than 600 viewers logged on per day. In India, Neurology India has also started an online, peer-reviewed video library linked to the journal. The maximum uploadable size of the video is 100 MB in the MPEG-4 (MP4) format and the duration of the video must be of 5 to 10 minutes.
The study is not, however, without limitations. The response rate is only 18.8%, which is low. The opinions of nonresponders may differ. The target population was, however, purely limited to the small neurosurgical community. The strong inclination of the responders in favor of the pedagogical value of online neurosurgical videos points towards the fact that it is highly probable that the survey reflects the opinion of the general neurosurgical community. The division into junior or senior neurosurgeons, and into the subjects residing in rural, semi–urban, and urban settings was somewhat arbitrary. The questionnaire might have gone to neurosurgeons who were having multiple e-mail identities more than once, but in the introductory comment of the survey, we had requested each neurosurgeon to respond only once.
The neurosurgical videos on the online video-sharing sites are undoubtedly of immense help to the neurosurgeons in India irrespective of whether they are from the rural or urban area, or may be considered as senior or junior neurosurgeons in terms of their operative experience. The various online video-sharing platforms are useful, especially in a country like India with diverse neurosurgical infrastructure. With this paper, we strongly advocate the development and maintenance of a dedicated, high-quality, and structured video bank through collaboration and cooperation of high-volume centers and institutes of repute in India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
[Table 1], [Table 2], [Table 3], [Table 4]