The training of residents and medical students in the surgical disciplines can be challenging since it is often both time-consuming and costly.1,2 This is becoming increasingly important because in modern-day surgical training the time spent in the operating room (OR) is limited by reduced working hours and an increasing volume of patients with a condensation of workflows.3 The global coronavirus disease 2019 (COVID-19) pandemic has now significantly exacerbated these problems. Hands-on courses and elective surgeries are kept to a minimum, limiting two of the key factors in surgical education: observation and practice.4–7
Conventional surgical videos are limited to the video of the surgical microscope. Attempts to provide a true 3D perspective of the surgeon’s view with head-mounted cameras to visualize the complex interactions in the OR have proved impractical.10,11 Currently, with rapidly evolving technologies, more tools like virtual reality (VR) are available to drive modern surgical training. VR allows for a multisensory immersive experience based on the stereoscopic 3D (S3D) view that has been successfully implemented in videos and simulators.9,12 The immersion and interactivity of VR have proved to increase learner’s motivation13 and understanding of spatial relationships8,14 for neuroanatomy, as well as operative performance, reducing operative time in laparoscopic surgery.15
A rather new development in surgical training is the implementation of 360° videos, which give traditional surgical videos a new dimension and enable all-round access to the OR.16 To create a 360° video, an S3D-capable 360° camera with ambisonic microphones, which is placed at a central point, captures the entire OR and enables the trainee to turn in all possible directions to see the complete environment. If the microscope video is also embedded in the 360° video, the trainee can not only watch the microsurgical video, but also observe the surgeon’s actions and interaction within the OR. Different surgical or procedural 360° videos have already been tested in various medical disciplines and setups17–21 such as physical examination,22 laparoscopic surgery16,23 or gastrointestinal endoscopy.24 With regard to surgical training, Yoganathan et al., for example, showed in a randomized controlled trial in 2018 that the acquisition of knot-tying skills in surgery residents was better with a 360° 3D VR video than with a 2D video.25 The University of Leiden uses 360° 3D VR videos as part of an online course in transplant medicine.26 However, the major innovation that 360° videos provide is the possibility to superimpose interactive elements like illustrations or annotations. This is particularly helpful to not only highlight the complex intraoperative anatomy, but also explain the multiple processes, such as neuronavigation and neuromonitoring, that are essential, especially with neurosurgical procedures. Such augmented 360° videos provide a holistic approach and therefore are supposed to not only teach surgical skills, but also promote conceptual knowledge. However, to our knowledge, for complex neurosurgical or neurointerventional procedures so far, only S3D GoPro or 180° videos, but not augmented 360° 3D VR videos, exist.10,11,27,28 In this study, we wanted to demonstrate that augmented 360° 3D VR videos are feasible as training elements for complex neurosurgical approaches and to further evaluate whether they are regarded as useful by neurosurgical residents.
Methods
Study Design
In cooperation with gamelab.berlin, which is associated with Humboldt University (Berlin, Germany), we produced three augmented 360° 3D VR videos. The videos demonstrate an excision of a lumbar disc herniation via the interlaminar approach (lumbar disc), microsurgical resection of cerebral metastasis (tumor), and microsurgical clipping of an intracranial aneurysm (aneurysm) (Figs. 1 and 2). Then, in a prospective study, from June 2020 to January 2021 we showed the training videos to neurosurgical residents in postgraduate years (PGYs) 1–7 at our department using a head-mounted display (HMD). Questionnaires before and after watching each video were applied. This study was approved by the local ethics committee of Charité–Universitätsmedizin Berlin. Each patient and member of the involved surgical team was informed about the recording of the operation and gave consent. The detailed methods, including production, demonstration of 360° 3D VR videos, and questionnaires and statistics, are reported in Supplementary Methods.
Photograph of the intraoperative setting while recording the clipping of a middle cerebral artery bifurcation aneurysm with a 360° camera attached to the lighting system.
Screenshot of the augmented 360° 3D VR video of the resection of a cerebral metastasis. The stereoscopic operative microscope video is projected onto a virtual screen within the OR. Please contact the corresponding author for a one-time link to view the video using a smartphone VR headset, if needed.
Results
Participant Characteristics
In this study, 22 neurosurgical residents with a mean age (range) of 30.3 (25–35) years and a mean experience of 3.2 years, ranging from the 1st to the 7th year of training, were included. Most residents were in PGY-1 (n = 7, 31.8%) (Table 1). Majority of the participants were male (63.6%). Only 3 of the 22 trainees had more than 15 minutes of VR experience prior to this study, whereas most residents had no (40.9%) or less than 15 minutes (45.5%) of experience with VR (Table 1).
Characteristics of the participants including VR experience and self-assessment of satisfaction with the existing technical learning opportunities at our institution, independent of any particular procedure, using a 5-point Likert scale
| Characteristic | Value |
|---|---|
| Total no. of participants | 22 |
| Age, yrs | 30.27 (25–35) |
| Female/male sex | 36.4%/63.6% |
| Mean experience in neurosurgery, yrs | 3.16 (1–7) |
| Distribution over the years of training | |
| PGY-1 | 7 (31.8) |
| PGY-2 | 4 (18.2) |
| PGY-3 | 1 (4.5) |
| PGY-4 | 3 (13.6) |
| PGY-5 | 3 (13.6) |
| PGY-6 | 3 (13.6) |
| PGY-7 | 1 (4.5) |
| Experience with VR | |
| None | 9 (40.9) |
| <15 mins | 10 (45.5) |
| >15 mins | 3 (13.6) |
| I am satisfied with the technical learning opportunities at my institution | 2 [1.75–3.0] |
Values are presented as number (%), mean (range), or median [IQR] unless otherwise indicated.
Self-Assessment of Surgical Skills Before the 360° 3D VR Videos
Fifty-five questionnaires were completed (22 lumbar disc, 17 tumor, 16 aneurysm). The quantification of residents’ experience and their self-assessment regarding the particular procedure are summarized in Table 2. Of the three given surgeries, the residents most often had performed a resection of a disc herniation partially or completely self-reliantly (mean [range] 11.2 [0–40] and 9.8 [0–40] times, respectively). The experience with clipping of aneurysms was limited to assistance during the procedure. Accordingly, the subjective perception of good preparation for the surgical procedure was highest in the case of disc herniation (mean [range] 4 [2–4]), with the highest estimate for the self-sustaining performance of the operation (mean [range] 59.5% [0%–100%]).
Evaluation of the standing for the individual operations before viewing of the 360° 3D VR videos
| Lumbar Disc (n = 22) | Tumor (n = 17) | Aneurysm (n = 16) | |
|---|---|---|---|
| Objective experience | |||
| No. of times in which this operation was performed partially self-reliantly | 11.2 (0–40) | 4.4 (0–40) | 0 |
| No. of times in which this operation was performed totally self-reliantly | 9.8 (0–40) | 1.5 (0–10) | 0 |
| No. of times assisted in this operation | |||
| <10 | 7 (31.8) | 7 (41.2) | 10 (62.5) |
| 10–30 | 6 (27.3) | 6 (35.3) | 5 (31.25) |
| >30 | 9 (40.9) | 4 (23.5) | 1 (6.25) |
| Subjective feeling of experience/preparation | |||
| I feel well prepared for this operation | 4.0 (2.0–4.0) | 2.0 (2.0–4.0) | 2.5 (1.25–3.0) |
| I have a lot of experience with this operation | 2.0 (1.0–3.0) | 2.0 (1.0–3.0) | 1.5 (1.0–2.0) |
| I have substantial knowledge about the anatomy in the operation situs | 4.0 (3.0–4.0) | 4.0 (2.5–4.0) | 4.0 (2.5–4.0) |
| I can do _% of this operation by myself | |||
| Mean (range) | 59.5 (0–100) | 40.8 (0–100) | 10.1 (0–30) |
| Median [IQR] | 80 [10–95] | 20 [10–85] | 10 [0–18.8] |
This table summarizes the objective and subjective experiences of the participants per surgical approach prior to viewing the 360° 3D VR videos. Values are presented as number (%), mean (range), or median [IQR].
Assessment of the Quality of the 360° 3D VR Videos
After watching the videos, the participants answered questions regarding their quality. The overall quality of the videos was rated similarly for each video, between very good and good, with a median (IQR) of 1.5 (1.0–2.0) according to German school grades: 1 (very good) to 6 (insufficient). The separate items regarding the quality of the 360° videos can be seen in Table 3. Briefly, the length of the video was reported to be neither too long nor too short. Mild VR sickness (feeling of dizziness/nausea) occurred only in 3 of 55 instances (5.45%); however, VR sickness did not cause interruption or pausing of the video in any of the cases. Participants mostly agreed that the important steps of the surgeries were included and described appropriately, and the crucial structures were easy to identify (median of 4 for both questions for all videos). The user interface and wearing comfort of the VR headset were satisfying. Audio overlay was rated very good in all the videos, while the quality of the resolution seemed to differ between the videos (mean [range] 3 [3–5] for disc herniation to mean 5 [3.5–5] for metastasis). Participants had the feeling of being in the OR for all videos as an indicator for immersion.
Assessment of the quality and content of the 360° 3D VR videos, as well as the user interface and convenience of the VR headset, using a 5-point Likert scale
| Items | Lumbar Disc (n = 22) | Tumor (n = 17) | Aneurysm (n = 16) |
|---|---|---|---|
| This video is a suitable preparation for this operation | 5.0 [3.75–5.0] | 5.0 [4.5–5.0] | 5.0 [4.25–5.0] |
| I had the feeling of being in the OR | 4.0 [3.0–5.0] | 4.0 [4.0–5.0] | 4.0 [4.0–5.0] |
| I experienced nausea/dizziness/headaches while watching the video | 1.0 [1.0–2.0] | 1.0 [1.0–2.0] | 1.0 [1.0–2.0] |
| The video was too short | 2.0 [1.0–3.25] | 2.0 [1.0–3.0] | 1.5 [1.0–2.75] |
| The video was too long | 1.0 [1.0–2.0] | 1.0 [1.0–2.5] | 1.5 [1.0–2.75] |
| The important structures were easy to identify | 3.0 [2.75–4.0] | 4.0 [4.0–5.0] | 4.0 [4.0–5.0] |
| The important steps were described appropriately | 4.0 [4.0–5.0] | 4.0 [3.5–5.0] | 4.0 [3.25–5.0] |
| The important segments of the operation were included | 4.0 [4.0–5.0] | 4.0 [4.0–5.0] | 4.0 [4.0–5.0] |
| The resolution was good | 3.0 [3.0–5.0] | 5.0 [3.5–5.0] | 4.5 [4.0–5.0] |
| The audio was good | 5.0 [4.0–5.0] | 5.0 [4.5–5.0] | 5.0 [4.0–5.0] |
| I am satisfied with the user interface | 4.5 [3.75–5.0] | 5.0 [4.0–5.0] | 4.5 [4.0–5.0] |
| I am satisfied with the wearing comfort of the VR headset | 4.0 [4.0–5.0] | 4.0 [4.0–5.0] | 4.0 [3.25–5.0] |
| Quality (German school grades) | 1.5 [1.0–2.0] | 1.5 [1.0–2.0] | 1.5 [1.0–2.0] |
Values are presented as median [IQR].
Subjective Evaluation of the Benefits of 360° 3D VR Videos
In general, 20 of 22 trainees agreed or strongly agreed with the statement that 360° 3D VR videos are a good addition to surgical training (Fig. 3). To evaluate the subjective benefit of the participants, we assessed whether any open questions about the respective operation could be resolved. Here, we observed variable ratings for the lumbar disc video and rather good ratings for the tumor and aneurysm videos. In most cases, the participants felt more confident after viewing the videos. Overall, participants strongly agreed that the augmented 360° 3D VR videos are a suitable preparation for the particular operation (Fig. 3).
Subjective evaluation of the usefulness of the 360° 3D VR operative videos for each of three recorded surgeries: clipping of a middle cerebral artery bifurcation aneurysm, removal of a brain tumor (metastasis), and excision of a lumbar disc herniation via an interlaminar approach.
Correlation Analysis
For all three videos, there was a positive correlation of the rating of the resolution with the reported feeling of immersion (Spearman rank correlation coefficient [rs] = 0.562, p = 0.013; rs = 0.747, p = 0.002; and rs = 0.792, p = 0.001 for disc herniation, frontal metastasis, and aneurysm, respectively) (Table 4). However, there was no correlation between the experience with a certain operation and the rating of the usefulness of the respective video as a preparation (Table 4). For the disc herniation video, but not for the other videos, there was a strong and statistically significant correlation between the feeling of immersion and the evaluation of the usefulness for preparation for this operation (rs = 0.55, p = 0.008). However, even though this correlation could not be confirmed statistically for brain surgery videos, both the usefulness and immersion scored 4 to 5 on the Likert scale (Table 4).
Results of correlation analysis of key elements using the Spearman rank correlation coefficient
| Question Correlated | Lumbar Disc (n = 22) | Tumor (n = 17) | Aneurysm (n = 16) | |||
|---|---|---|---|---|---|---|
| rs | p Value | rs | p Value | rs | p Value | |
| Feeling of immersion to rating of resolution | 0.562 | 0.013 | 0.747 | 0.002 | 0.792 | 0.001 |
| Feeling of immersion to rating of usefulness as a preparation tool | 0.55 | 0.008 | 0.219 | 0.454 | 0.089 | 0.926 |
| No. of times in which this operation was performed partially self-reliantly to rating of usefulness | 0.404 | 0.088 | 0.256 | 0.332 | NA | NA |
| No. of times in which this operation was performed self-reliantly to rating of usefulness | 0.274 | 0.253 | 0.251 | 0.385 | NA | NA |
NA = not applicable.
Discussion
The main finding of our study is that augmented 360° 3D VR videos are feasible and provide a viable and useful tool to complement neurosurgical training, and the acceptance of such videos by neurosurgical trainees is high. We successfully recorded and created 360° 3D VR neurosurgical videos that combine a full 360° view of the OR with the stereoscopic microscope video of the surgical site. Further, these videos were augmented with didactic overlays, pictures of neuroimaging, and audio comments. Almost all interns and residents stated that the 360° videos are a good preparation for the respective operation and complement the surgical training on site well.
Surgical Training
A career in neurosurgery begins as early as medical school. Training, starting from the medical student stage through residency to qualified membership on a highly specialized interprofessional team, is an essential component of a modern university hospital. Surgical training in particular is demanding, since practicing and observing are essential, but the high workload and strict working time regulations significantly reduce the time spent in the OR.3 The trainees find themselves in a constant field of tension between patient care tasks, administrative tasks, teaching, training, and research, which leads to time pressure and stress, both of which have a negative effect on surgical training.29 There is growing concern that the next generation of surgeons will not be sufficiently qualified at the end of their training to perform operations independently.3 The COVID-19 pandemic exacerbated these problems, as case volume decreased and further diminished residents’ but also students’ neurosurgical exposure.6,30 Therefore, new and innovative teaching strategies were and are needed to maintain and improve the training quality of surgical residents. Given the critical role of spatial awareness,31 combined with sound conceptual and procedural knowledge of the pertinent steps in neurosurgical operations, the training material should aspire to an authentic and realistic representation of the anatomy and overall scenario. According to Heath and Cohen-Gadol, anatomical relations can be better understood by depiction of depth via 3D imaging, which enables trainees to comprehend the intraoperative surgical decision-making based on the surgical anatomy (e.g., a clip application for an aneurysm or tumor dissection technique).9 A recent review by van Beurden et al. analyzed the benefits of stereoscopic visualization and emphasized that all pertinent studies concluded a stereo advantage when used in training.32 More recent studies also highlighted the advantage of stereoscopy in neuroanatomy teaching.14,33,34 Importantly, S3D imaging can be helpful not only in a purely visual sense, but also for learning visuospatial tasks that involve sensing or grasping objects.9 However, since even the improved instructional videos with head-mounted cameras using stereoscopic visualization do not allow full visualization of the surgical procedure,10,11 stereoscopic 360° 3D VR videos could be a perfect addition to the training material in this regard. Such videos represent a holistic approach with additional external observation of every step. Consequently, the number of 360° 3D VR videos has been continuously increasing since the onset of the COVID-19 pandemic.17–20,22,35
One of the major add-ons of 360° 3D VR videos is immersion, in this case the feeling of being in the OR. Immersion is crucial for VR applications in general. While viewing the 360° 3D VR videos, the user can observe the entire OR as if they were standing in the OR and follow the complex interactions between the surgeon, OR nurse, and anesthetist. In our study, the rating of resolution correlated positively with the feeling of immersion. In the lumbar disc video, immersion also correlated with usefulness in preparing for surgery, underscoring the importance of the 360° effect. However, this was not the case in the other two videos. Yet, these videos received only high Likert scale ratings (at least 4 of 5) for both immersion and usefulness. However, the lack of correlation with consistently high ratings and a relatively small sample do not rule out a positive correlation between immersion and usefulness. In fact, the exclusively positive ratings regarding immersion and usefulness support the importance of the 360° effect in brain surgery. In this study, we used Oculus Go HMDs with a resolution of 1280 × 1440 pixels per eye; however, because HMDs with a better resolution will likely provide an even more immersive experience, possibly providing a greater learning benefit, further evaluations should take this into account. This lines up with the findings of Gutiérrez et al. and Rupp et al., in which a high degree of immersion not only enhanced the viewing experience, but also improved learning performance and led “to a greater desire to learn about the video’s subject-matter.”36,37 In line with this, Chan et al. showed higher engagement in medical students learning anatomy with 360° videos compared with traditional 2D videos.35 In a randomized crossover study with 2D and 360° videos of a laparoscopic cholecystectomy, Harrington et al. also showed higher engagement, together with fewer thoughts unrelated to the task, indicating better concentration.23
However, there are also studies that did not show superior results for 360° videos. For instance, a 360° 3D VR video of a gentle cesarean section in addition to the standard curriculum did not lead to better knowledge retention in students.17 According to the authors, this could be because of the split-attention effect or an increased cognitive load.17 In this regard, Andersen et al. and Frederiksen et al. reported higher cognitive load for VR simulation and immersive VR videos compared with traditional simulators or 2D videos, possibly inhibiting performance and learning according to the cognitive load theory.38–40 Our approach with augmentation of the 360° video, however, might address this issue using interactive elements that can be selected, played, or repeated separately, and more studies will be necessary to evaluate the effectiveness of augmented 360° videos and their impact on cognitive load. Another important point is the selection of the intervention for such training videos. In procedures with a complex intraoperative anatomy requiring interactive teamwork, 3D perception and a 360° overview of the OR are probably more advantageous. Likewise, more complex operations including a large surgical team interacting could benefit more from an immersive 360° approach than an intervention done by one person (e.g., central venous catheter implantation).19 Standardized operations with a regular workflow are especially suitable for teaching conceptual knowledge and the respective sequence of steps. Neurosurgical procedures often require elaborate and extensive intraoperative technologies such as neuromonitoring and neuronavigation and might therefore be more suitable.
Augmented 360° Videos in Neurosurgery
Recent studies have shown encouraging results for the usability of 360° videos in other surgical disciplines.18,24 However, in neurosurgery, only S3D videos captured with a head-mounted camera10 or 180° 3D videos, in which the surgeon’s point of view was augmented with anatomical overlays and CT scans,27,28 have been evaluated so far. The detailed view of the surgical microscope combined with a 360° view offers a new dimension to video-based learning. To our knowledge, this is the first study on the implementation of augmented 360° 3D VR videos in neurosurgery, although 3D imaging plays a huge role in neurosurgical research and education.41 As neurosurgery is a diversified and manifold field, we chose three different exemplary interventions covering three main areas: spine, tumor, and vascular. These operations also represent different stages of experience for the trainee. According to Stienen et al., supratentorial craniotomy (including the resection of a frontal cerebral metastasis) and dorsal noninstrumented spine surgery (including lumbar discectomy) are most frequently performed during neurosurgical residency in Europe.2 Microsurgical treatment of vascular pathologies such as the clipping of an aneurysm, however, is usually only done as an assistant during residency and is rarely performed supervised or even independently,2 as also observed in our cohort. Most of the participants agreed with the statement that the videos helped them feel more confident about performing the operation. Similar to our results, 360° videos improved the self-confidence of residents in orthognathic surgery for performing Le Fort I osteotomy.42,43 We decided to tailor the enhanced 360° videos specifically to the needs of beginners, and the study participants were consequently young residents. Interestingly, however, there was no significant correlation between the number of surgical procedures already performed independently by the trainees and their assessment of the quality and usefulness of the videos. This underlines the usefulness of 360° educational videos also for more experienced trainees.
The role of pre-education in the success of manual training for orthopedic surgery residents has already been shown to increase the intraoperative performance and knowledge retainment.44 We have limited the duration of the videos to 7.5–9.5 minutes so that they can be viewed quickly before performing a similar operation, and also to reduce the risk of VR sickness, which is a common problem in VR applications with symptoms such as nausea, disorientation, headache, dizziness, or eye strain.45 In the study of Arents et al., which analyzed the role of 360° videos in teaching the performance of a cesarean section to students, more than 50% of the participants reported VR sickness.17 According to a meta-analysis on factors associated with VR sickness with HMDs, a video length of less than 10 minutes, low visual stimulation, and matching of user-initiated movement to the environment were helpful in reducing the risk.45 Accordingly, our participants found the length of the videos appropriate.
Drawbacks of the 360° 3D VR Technology, Possible Future Implementations, and Generalizability
While 360° 3D VR videos provide an innovative and promising surgical training approach, the need for sophisticated equipment and advanced technical support is a drawback and might limit the general availability and widespread implementation in neurosurgical and other surgical programs. Such videos require a 360° camera and a specialized team for recording, editing, and stitching, which increases the costs considerably compared with conventional 2D videos.23 At our institution, the creation of one 360° 3D VR video costs around €3000. Therefore, the production of 360° VR videos might be reserved to centers with the necessary financial resources and technical means. At the same time, the videos can also be distributed to other hospitals and countries, necessitating only translation into different languages. This approach is also a way to support developing countries, as a simple VR headset is sufficient to use the videos for high-level teaching. Another positive aspect is the ability to tailor the same 360° VR video to different user groups, in order to provide different professional groups with educational videos with different focuses. For instance, Edwards et al. demonstrated the improved confidence, understanding, technical skills, and efficiency of OR nurses with 360° videos.43 Taken together, VR videos are substantially more sustainable and their benefits outweigh the high production costs. Furthermore, according to Benet et al., 3D imaging in neurosurgical research and education can help reduce overall healthcare costs and improve patient outcomes as a result of improved surgical skills and shortened learning curves.41 In our opinion, these advantages also apply to 360° 3D VR videos and should be further assessed in the future. The introduced setup consisting of one 360° camera with integration of the surgical microscope video is particularly suitable for primarily microsurgical procedures.
These first insights in 360° 3D VR videos encouraged us to implement a VR video library in our department with instructional videos for a variety of standard neurosurgical procedures. The HMD and videos are now readily accessible to interns and residents at any time and should be seen as an effective complement to self-study and surgical preparation (Fig. 4). Further studies are planned to confirm the benefits of augmented 360° 3D VR videos on comprehensive learning and cognitive load. As a future perspective, we also aim to adjust these videos for patient education, like previous studies demonstrated for radiation therapy planning.46
Representative image of the VR video library in our department. The television screen is on to demonstrate the content the participant is watching.
Limitations
As this was only a feasibility study at a single center, our study is subject to some well-known limitations. First, the sample size and the number of videos were rather small. Second, our study relies on subjective ratings of usefulness by the residents. However, the Likert scale represents a suitable tool to assess the subjective evaluation in a scientific manner and has been commonly used in similar evaluation studies.47–49 Still, further studies that objectively assess knowledge retention and gain in surgical skills using augmented 360° 3D VR videos compared with conventional videos are warranted to assess whether experience with 360° VR significantly outperforms that with simple tools. In this study, the feasibility and usefulness of this approach were shown for the first time for neurosurgical training. In fact, our videos could only exploit some of the enormous potential of augmented 360° 3D VR operation videos. As a next step, our goal is to add interactive elements that allow the user to go into detail for different steps or categories such as anatomy, procedural knowledge, and interactions, thereby individualizing the videos to fit each user’s needs.
Conclusions
This initial evaluation provides encouraging results about the practicality and usefulness of 360° VR videos as a complement of neurosurgical training that warrants further investigations. Immersive VR videos can prepare students, interns, and residents for the OR, potentially shortening the learning curves. Furthermore, 360° 3D VR videos are sustainable and can also help address additional training challenges due to the pandemic. However, the impact on knowledge retention or skill acquisition needs further investigation in future studies.
Acknowledgments
Dr. Acker is a participant of the Berlin Institute of Health–Charité Clinician Scientist Program that is funded by the Charité–Universitätsmedizin Berlin and the Berlin Institute of Health. We acknowledge the support of the Cluster of Excellence: “Matters of Activity. Image Space Material” funded by the Deutsche Forschungsgemeinschaft (DFG; German Research Foundation) under Germany’s Excellence Strategy (EXC 2025-390648296). We also acknowledge the help of gamelab.berlin as well as Matías Bertoia, 360° video editor.
Disclosures
The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Author Contributions
Conception and design: Acker, Bruening, Stein, Picht. Acquisition of data: Bruening, Fuellhase. Analysis and interpretation of data: Acker, Bruening. Drafting the article: Acker, Bruening, Truckenmueller. Critically revising the article: Acker, Truckenmueller, Stein, Fuellhase, Vajkoczy, Picht. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Acker. Statistical analysis: Bruening. Administrative/technical/material support: Stein, Fuellhase, Vajkoczy, Picht. Study supervision: Acker, Vajkoczy, Picht.
Supplemental Information
Online-Only Content
Supplemental material is available online.
Supplementary Methods and Figures. https://thejns.org/doi/suppl/10.3171/2022.5.FOCUS2261.
Previous Presentations
Portions of this work were presented virtually in abstract form at the German Neurosurgical Society (Deutsche Gesellschaft für Neurochirurgie) Annual Conference on Neuro-Oncology, October 17, 2020; and at the German Neurosurgical Society (Deutsche Gesellschaft für Neurochirurgie) Annual Conference, June 9, 2021.
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