Non-fungible token integration in neurosurgery: a technical review

In the rapidly evolving world of digital technology, few concepts have garnered as much attention and intrigue as non-fungible tokens (NFTs). Originating from the domain of art and collectibles, NFTs have transcended their initial use cases to impact various fields, from entertainment to real estate, and now, healthcare [1]. While fields like ophthalmology, dermatology, and plastic surgery have begun exploring the potential applications of NFTs, neurosurgery stands at the threshold of a new era, where digital ownership and blockchain can revolutionize patient care, data management, and surgical innovations [2–5]. Neurosurgery, with its intricate procedures and reliance on detailed imaging and data, offers a fertile ground for NFT applications [6]. Whether it’s ensuring the authenticity of patient scans, safeguarding the intellectual property of novel surgical techniques, or even creating a transparent ledger for pharmaceutical transactions, NFTs hold promise to bring about enhanced security, autonomy, and innovation to the realm of neurosurgery. As technological advancements intertwine with medical progress, the importance of integrating secure and transparent digital systems becomes paramount. In this context, this review delves into the nuances of NFTs, elucidating their potential roles and impacts within the multifaceted domain of neurosurgery. For a clearer understanding of the specialized terminology used in this paper, readers are encouraged to refer to the glossary of key terms presented in Table 1. Methodology


Introduction
In the rapidly evolving world of digital technology, few concepts have garnered as much attention and intrigue as non-fungible tokens (NFTs).Originating from the domain of art and collectibles, NFTs have transcended their initial use cases to impact various fields, from entertainment to real estate, and now, healthcare [1].While fields like ophthalmology, dermatology, and plastic surgery have begun exploring the potential applications of NFTs, neurosurgery stands at the threshold of a new era, where digital ownership and blockchain can revolutionize patient care, data management, and surgical innovations [2][3][4][5].
Neurosurgery, with its intricate procedures and reliance on detailed imaging and data, offers a fertile ground for NFT applications [6].Whether it's ensuring the authenticity of patient scans, safeguarding the intellectual property of novel surgical techniques, or even creating a transparent ledger for pharmaceutical transactions, NFTs hold promise to bring about enhanced security, autonomy, and innovation to the realm of neurosurgery.As technological advancements intertwine with medical progress, the importance of integrating secure and transparent digital systems becomes paramount.In this context, this review delves into the nuances of NFTs, elucidating their potential roles and impacts within the multifaceted domain of neurosurgery.
For a clearer understanding of the specialized terminology used in this paper, readers are encouraged to refer to the glossary of key terms presented in Table 1.

Methodology
The author (ALM) conducted a comprehensive scoping review to explore the potential applications of NFTs in neurosurgery.A systematic search was carried out using key electronic databases: PubMed, Embase, IEEE Xplore, and Google Scholar, without date restrictions.The search was executed in August 2023.To ensure a broad capture of relevant literature, the search terms utilized were "("nonfungible token*" OR NFT OR NFTs OR blockchain OR "block chain") AND (neurosurg* OR "neurological surgery")."Given the novelty of the topic, grey literature sources, including preprint repositories and conference proceedings, were also scrutinized to capture emerging research and concepts in the field.Articles not written in English, those that were merely abstracts, and case reports were excluded to maintain the specificity of the review.Articles that specifically discussed the applications, challenges, or innovations of NFTs within neurosurgical practices or related patient data management were included.Further pertinent articles were identified and sourced from the reference lists of the initial set of articles.Additionally, relevant texts from non-neurosurgical medical domains and ancillary fields were examined to gain a comprehensive understanding and to identify potential cross-disciplinary applications and insights.Data from these articles were extracted and synthesized to inform the main content of the review.

Blockchain and NFTs: a primer
At the foundation of NFT technology is the blockchain -a decentralized ledger system that supports cryptocurrencies and decentralized applications.But what exactly is a blockchain?In essence, a blockchain is a chain of blocks, where each block contains data, and each subsequent block carries a unique cryptographic signature, ensuring the integrity and immutability of the data stored within [7][8][9].
NFTs are unique tokens minted on blockchains.Unlike cryptocurrencies like Bitcoin or Ethereum, which are 207 Page 2 of 8 fungible and interchangeable, NFTs are distinct and cannot be exchanged on a one-to-one basis [10].This uniqueness is what grants NFTs their name -non-fungible.When an NFT is minted, it's associated with a specific piece of digital content, be it an artwork, music, or even medical data.The metadata of this content, akin to a certificate of authenticity, is recorded on the blockchain.This ensures proof of ownership and provides a transparent trail of any transactions or changes made to the associated content.While the most popular platform for NFTs is currently the Ethereum blockchain, various other blockchains also support NFTs, each bringing its own set of features and benefits [11].
For a detailed, sequential overview of how blockchain technology and NFT function, especially in the context of medical data management, refer to Table 2.

Potential applications of NFTs in neurosurgery
NFTs, with their unique ability to authenticate and provide undisputed digital ownership, can offer transformative solutions to longstanding issues in data management, procedure verification, and patient engagement [12,13].This section delves into specific applications where NFTs might play a pivotal role in reshaping neurosurgical practices, enhancing both patient care and operational efficiency.

Patient data ownership and control
In neurosurgery, the precision and clarity of diagnostic imaging are paramount [14].Procedures often rely on detailed MRI and The process of creating a new NFT Non-fungible token (NFT) A type of digital asset representing ownership of a unique item or piece of content, usually stored on a blockchain Proof-of-stake An alternative to proof-of-work, where participants prove ownership of a certain amount of cryptocurrency Proof-of-work A consensus algorithm used in blockchain where participants solve complex mathematical problems Public/private key A cryptographic system that uses pairs of keys: public keys (known to everyone) and private keys (kept secret) Smart contract Self-executing contracts with the terms of the agreement directly written into code Tokenize The process of converting rights to an asset into a unique digital representation on a blockchain This data is represented digitally, ready to be linked to a unique token 3. Blockchain initialization A digital ledger, known as a blockchain, is set up to record transactions.This can be on existing platforms like Ethereum or newer healthcare-specific chains 4. NFT minting A unique non-fungible token (NFT) is created ("minted") to represent the specific piece of data.This process gives the data a unique identifier on the blockchain 5. NFT ownership Once minted, the NFT is assigned to an owner, usually the patient or the institution that created the data 6.Data verification Anytime the data is accessed or transferred, the blockchain verifies the authenticity and ownership using the NFT 7. Data sharing/selling The owner can choose to share or sell the data.If sold, the NFT's ownership can be transferred to the new owner 8. Royalties and resale If the NFT is set up with royalties, any future sales or transfers ensure the original owner receives a percentage of the transaction 9. Data access control The owner can grant or revoke access permissions to the data linked to the NFT 10.NFT destruction If needed, NFTs can be "burned" or destroyed, removing their representation from the blockchain Page 3 of 8 207 CT scans.NFTs can provide a framework for patients to have indisputable ownership of their diagnostic images.This ownership isn't just about possession; it's about control.Patients can choose to share their scans with specific medical professionals, research entities, or even for broader educational purposes.This controlled sharing ensures patient privacy while still allowing for the potential aggregation of data for larger studies or machine learning applications.

Genomic data in neurological disorders
Neurological conditions often have underlying genetic components.As genomic sequencing becomes more commonplace, there's an increasing amount of data about individual genetic predispositions to certain neurological conditions or even the genetic constitution of individual tumors [15].NFTs can serve as a tool for individuals to control and share their genomic data [16].While the primary purpose might be for personalized treatment plans, there's also the potential for individuals to contribute their data to broader research initiatives, aiding in the development of treatments or understanding disease progression.

Enhancing clinical trial record security
Clinical trials are the cornerstone of medical advancements, and the integrity of their records is paramount [17].Neurosurgical trials, given their complexity, generate a vast array of data points, ranging from patient demographics to intricate procedural outcomes [18].
Ensuring the authenticity, tamper-proof nature, and traceability of this data is essential [19].NFTs can be employed to tokenize individual trial records, granting them a unique digital identity on the blockchain [20,21].This ensures that each trial entry is original and hasn't been altered post-registration.Moreover, the transparent nature of the blockchain ensures a verifiable trail of any data changes or access, instilling confidence in both participants and regulatory bodies.By leveraging NFTs, neurosurgical clinical trials can achieve enhanced data security, minimize fraudulent activities, and uphold the highest standards of scientific research.

Verification of neurosurgical procedures and achievements
The field of neurosurgery is constantly evolving, with new techniques and procedures being developed regularly [22].
NFTs can be employed to validate the introduction and successful implementation of these novel methods.Surgeons could use NFTs as a form of credentialing for specific procedures, ensuring that they've undergone the necessary training and have achieved a certain level of proficiency.Furthermore, institutions can issue NFT-based verifications for completed training programs, workshops, or milestones achieved by neurosurgeons [23].

Pharmaceutical implications
Neurosurgical treatments often involve the use of specialized medications, for example, 5-aminolevulinic acid hydrochloride (Gliolan) for tumor resections, selumetinib (Koselugo) for neurofibromatosis type 1-related inoperable plexiform neurofibroma, or bevacizumab (Avastin) for neurofibromatosis type 2-related vestibular schwannomas [24][25][26].Ensuring the authenticity of these medications is crucial.NFTs can serve as a verification tool, ensuring that the drugs used are genuine and have passed all necessary quality controls [27].By integrating NFTs into the pharmaceutical supply chain, it's possible to track the journey of a drug from the manufacturer to the patient, ensuring transparency and reducing the risk of counterfeit medications entering the system [28].

Tokenized assurance for refurbished medical devices
Refurbished medical devices present economic advantages, yet their reintroduction to the healthcare system often sparks concerns about quality and potential counterfeit risks [29,30].
An NFT-based mechanism can address these challenges by providing a transparent and verifiable record of each device's refurbishment journey.By employing NFTs, each stage of refurbishment can be documented, thereby bolstering confidence in the device's authenticity and safety [31].Such a system may not only deter fraudulent activities but can also enhance the trustworthiness of these vital medical tools within neurosurgery.

Virtual reality and augmented reality in neurosurgery
Virtual reality (VR) and augmented reality (AR) are becoming integral in surgical planning and patient education.Surgeons can use VR to simulate complex procedures, while patients can use AR to better understand their conditions and treatments [32,33].NFTs can be utilized to authenticate these VR and AR models, ensuring they are based on accurate data and have been developed by certified professionals [34].Such authentication may be vital in maintaining the trust and reliability of these digital tools.

Monetization models for NFTs in neurosurgery
NFTs, celebrated for their unique value proposition around digital ownership and authenticity, introduce a myriad of monetization possibilities in neurosurgery [35].It's crucial to clarify that the following exploration of potential monetization models is presented for consideration and discussion, and not as an endorsement.While patient care and ethical considerations remain paramount, it's beneficial to be aware of the diverse ways NFTs might be integrated into the economic fabric of neurosurgery.

Patient-driven sales of medical data
In the current era of data-driven medical research, there's an increasing interest in acquiring expansive datasets [36].
With NFTs solidifying patients' unequivocal ownership of their medical data, individuals have the unique opportunity to monetize their anonymized records for research endeavors [37,38].Such a model necessitates a comprehensive and transparent consent process, ensuring patients are fully aware of the ramifications and potential benefits of their choices [16,39].

Licensing of surgical techniques and innovations
Innovative surgical techniques or proprietary surgical tools could be tokenized and licensed to other professionals or institutions.Instead of a one-time sale, neurosurgeons or institutions could charge a recurring fee for the continued use of their innovations.

Educational content, scientific manuscripts, and virtual training modules
Neurosurgeons could create and tokenize detailed training modules, virtual surgeries, case studies, scientific manuscripts, and their supporting datasets.By doing so, they not only ensure the authenticity and originality of their work but also pave the way for a new era of digital dissemination and access.Medical students, institutions, researchers, or other professionals could purchase access to these educational and research-based NFTs, ensuring genuine content while simultaneously providing a potential revenue stream for the creators.

Premium patient services
In a more patient-centric approach, neurosurgical clinics could offer tokenized premium services.Patients holding a particular NFT could receive benefits such as priority scheduling, access to detailed digital reports, or virtual consultations.
As an example, NFTs could be harnessed to facilitate access to specialized medical services, such as outpatient rehabilitation.Consider a patient who requires a tailored rehabilitation program following a complex neurosurgical procedure.Instead of traditional referral systems or insurance approvals, healthcare providers or insurers could issue NFTs that represent a package of specific rehabilitation services.Upon acquisition, patients could redeem these NFTs at partnered outpatient centers, ensuring they receive the exact suite of services tailored to their recovery needs.Not only could this streamline the patient's access to care, but it also offers a transparent and verifiable method of ensuring service quality and authenticity.Furthermore, the decentralization aspect of blockchain, upon which NFTs are built, can empower patients by giving them direct control over their rehabilitation journey.They can choose when and where to redeem their NFT and even transfer or sell it should they decide on an alternative rehabilitation pathway.

Collaborative research grants and funding
Tokenized research projects could attract funding from institutions, pharmaceutical companies, or even public grants.By purchasing an NFT associated with a research project, funders could receive periodic updates, early access to findings, or even acknowledgment in publications.

Royalties from resales
One of the intrinsic features of NFTs is the ability to embed royalties [40].Every time an NFT is resold, the original creator can receive a percentage of the sale.This ensures that neurosurgeons or institutions continue to benefit from the increasing value of their tokenized assets.

Challenges and limitations
While the integration of NFTs into neurosurgery offers promising avenues, it's essential to approach this frontier with a balanced perspective.The implementation of any new technology, especially one as disruptive as NFTs, brings with it inherent challenges and potential limitations [7,41].From technical hurdles to ethical dilemmas, these challenges warrant careful consideration to ensure that the adoption of NFTs aligns with the overarching goals of patient safety, data security, and ethical medical practice [42].

Energy and environmental concerns
One of the primary criticisms of blockchain technology, and by extension NFTs, is the energy consumption associated with maintaining and validating the blockchain, especially for proof-of-work systems [43].This energyintensive process has raised environmental concerns, especially given the carbon footprint of large-scale mining operations.While strides are being made in transitioning to more energy-efficient consensus mechanisms, such as proof-of-stake, the environmental impact remains a significant point of contention [44].

Data security and privacy implications
Though blockchain is praised for its security and immutability, it's essential to differentiate between the security of the transaction history and the data to which an NFT might link [45].If an NFT points to data stored on a centralized server, that data remains vulnerable to breaches or hacks.Furthermore, while the blockchain can verify the authenticity of an NFT, it cannot guarantee the accuracy of the associated data [46].For neurosurgical applications, where accuracy is paramount, this is a significant consideration.

Ethical considerations
The ability to tokenize medical data, procedures, and even genomic information introduces a host of ethical questions [16].If patients can monetize their medical data, it could lead to potential exploitation, especially in populations that might be financially motivated to share sensitive information [47].Additionally, the idea of tokenizing surgical techniques or procedures could limit the free exchange of knowledge in the medical community, potentially hindering collaborative advancements.

Technical barriers and usability
While the concept of NFTs and blockchain might be familiar to tech-savvy individuals, it remains a complex topic for many.For widespread adoption in the neurosurgical community, there's a need for user-friendly interfaces and platforms that abstract away the technical complexities while retaining the benefits of the technology.Training and education will also play a pivotal role in bridging this gap.

Regulatory and legal challenges
The integration of NFTs into the medical field will undoubtedly face regulatory scrutiny [48].Governments and regulatory bodies will need to establish frameworks for the use, exchange, and sale of medical data or tokenized procedures [49].These legal challenges could slow adoption and introduce additional complexities for practitioners wishing to leverage the technology.

Future prospects and research directions
The path ahead requires targeted research to validate applications, refine methodologies, and ensure optimal integration.The upcoming segments detail specific areas of interest and potential research directions that can shape the future role of NFTs in neurosurgery.

Optimizing blockchain technology for healthcare
The traditional proof-of-work blockchain model, with its high energy consumption, might not be sustainable for widespread healthcare applications.However, emerging consensus mechanisms, such as proof-of-stake and federated blockchains, offer more energy-efficient alternatives.Research into making these models compliant with healthcare requirements can open doors for more sustainable NFT use in neurosurgery.

Developing secure platforms for medical data exchange
As the digitization of medical records and imaging continues to grow, there's a clear need for secure platforms that allow for easy exchange of this data [50].Integrating NFTs into these platforms can provide added layers of authentication and ownership.Research can focus on creating user-friendly platforms that harness the power of NFTs without overwhelming users with technical details.

Ethical and patient-centric approaches to data monetization
While monetizing medical data has its pitfalls, it also offers opportunities.Future research can focus on developing models that prioritize patient welfare, ensuring that patients understand the implications of sharing their data and are fairly compensated for it.Ethical guidelines and best practices can be formulated to guide the process.

Collaborations between tech developers and neurosurgeons
For NFTs to be effectively integrated into neurosurgery, collaborations between blockchain experts, software developers, and neurosurgeons are crucial.Such collaborations can lead to tools and platforms specifically tailored for neurosurgical applications, ensuring that the technology meets the unique needs of the field.

Regulatory frameworks and standardization
With the growing interest in NFTs in healthcare, there's a clear need for standardized protocols and regulatory frameworks [13].Research can be directed towards understanding the implications of NFTs in healthcare settings and developing guidelines that ensure patient safety, data privacy, and compliance with existing medical laws.

Exploring NFTs in medical education and training
Beyond patient data and procedures, there's potential for NFTs to play a role in medical education.Tokenized modules, virtual surgeries, or even patient cases can be used for training purposes, ensuring that students and trainees are accessing authentic and approved educational material.

Conclusion
The integration of NFTs into neurosurgery presents a blend of exciting opportunities and notable challenges.As with any technological advancement in healthcare, the primary focus remains the betterment of patient care, ensuring safety, authenticity, and precision in treatments and interventions.
NFTs have the potential to reshape the way neurosurgeons interact with patient data, authenticate procedures, and even contribute to research and education.Their capacity to offer undisputed ownership and control over digital assets can redefine data sharing, research collaborations, and even the monetization of specific medical assets.However, it's imperative to navigate the ethical, environmental, and technical challenges associated with this technology.
While the current state of NFTs in neurosurgery is nascent, the trajectory suggests a growing interest and potential for wider adoption in the coming years [42].Collaborative efforts between technologists, neurosurgeons, and regulatory bodies will be crucial in ensuring that NFTs find a place in neurosurgery that is both innovative and ethically sound.As the field continues to evolve, it remains crucial for the neurosurgical community to stay informed, engaged, and proactive in shaping the direction of NFT integration, ensuring that it aligns with the core values and goals of the profession.

Table 1
Glossary of key terms in blockchain and NFTs

Table 2
Blockchain and non-fungible tokens (NFTs) -a sequential overview.This table provides a concise step-by-step breakdown of how blockchain and NFT function, especially in the context of medical dataStep Description 1. Data creation Medical data, be it imaging, genomic information, or patient records, is generated 2. Digital tokenization