Innovative Educational Three-Dimensional Model of the Human Brainstem: Enhancing Neuroanatomy Learning for Medical Students

Innovative Educational Three-Dimensional Model of the Human Brainstem: Enhancing Neuroanatomy Learning for Medical Students | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Innovative Educational Three-Dimensional Model of the Human Brainstem: Enhancing Neuroanatomy Learning for Medical Students Mansour Homayoun, Mehrnoush Malekzadeh, Samin shafiei, Saeed Zamani This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6747723/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Medical students and other professionals in the field of neuroscience need a comprehensive understanding of the anatomy of the brain stem. Physical models have shown promise for teaching anatomy and increasing learning level. It is necessary to create a model that can reveal the internal structures of the brain stem, such as the functional component of cranial nerve nuclei and neural pathways, as the models currently available for educational purposes only depict the external features. In this study, we implemented and evaluated a novel 3D model showing the internal structures of the brain stem. 59 medical students offered their time to assess the impact of this 3D model. In the anatomy lab, 29 students received traditional instruction as a lecture group, while the others received instruction on the brain stem as a 3D model group. The participants were evaluated both before the start and after completion of the intervention. Participants' level of satisfaction with the value of the 3D model was also assessed. The 3D model group mean score was found to be significantly higher than that of the lecture group based on the results. Students were more satisfied with the educational process as a result of the satisfaction. Our results suggest that 3D model of brain stem is an effective method for teaching internal structures of the brain stem and will better prepare students for learning and visualization of functional component of cranial nerve. Additionally, it ensures a higher level of student satisfaction throughout the learning process. Brain stem Education 3D model Internal structures Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Learning anatomy is crucial for students pursuing a range of medical specialties, as it is one of the fundamental knowledge bases of medical science. Dissection is one of the most popular methods used to teach anatomy. The best teaching aids for anatomy are cadaver dissection or dissected cadaveric specimens, as they give students a crucial three-dimensional(3D) perspective of the human body( 1 ). That being said, a great number of medical schools across the globe restrict or prohibit access to cadavers ( 2 ) as a result of monetary, ethical, legal, and cultural barriers; however, many nations also face a scarcity of cadaver donors ( 3 ). In light of the declining significance of cadaver dissection and the requirement for ongoing anatomy training, more investigation should be conducted into the efficaciousness of substitute approaches to anatomy instruction. It is necessary to use 3D computer programs, plastic models, plastinated specimens, and medical imaging for enhancement of anatomical education ( 4 ). 3D anatomical models include digital and non-digital models which can be placed in different positions and views( 5 ). In this way, students can learn the spatial relationships between different structures and manipulate desired targets( 1 ). Studies show that 3D anatomical models can be used to support the curriculum and promote students' spatial visualization skills (whether digital or non-digital) are preferable for students of medicine, dentistry and other medical sciences( 6 )( 7 ). Because it requires precise, abstract thinking to perceive its complex spatial relationships, neuroanatomy is still regarded as one of the most difficult areas of anatomy ( 8 ). Usually taught as a course of the medical curriculum, this curriculum makes use of plastic models, 2D images, and brain cross-sections. The importance of the Central Neural System (especially the brainstem) in clinical examination and disease diagnosis underscores the need for higher education in this section( 9 ). Thus, one of the fundamental requirements of the educational system is the creation of models that, through providing a three-dimensional view of anatomical structures, aid in tangible understanding. Among the structures of the nervous system, the brainstem is one of the most complicated topics for students, making teaching and learning difficult and requiring 3D insight. It seems students with spatial imagination and normal intelligence quotients (IQs) have difficulty learning the internal structures of brainstem due to their inability to understand topography. The brainstem is the structure that connects the cerebrum to the spinal cord and cerebellum. It consists of three sections in descending order: midbrain, pons and medulla oblongata. The brainstem contains many important collections of white and gray matter( 10 ). The gray matter in this area consists of nerve cell bodies and forms many important brainstem nuclei. The white matter of the brainstem includes axons of nerves that traverse their course to various structures. The majority of axons originate from cell bodies located elsewhere in the central nervous system (CNS) (Neuroanatomy, Brainstem. PUBMED). Considering that the training of the internal structures of the brain stem is practically not possible using a cadaver due to the small size and same color elements, so the use of alternative methods such as the use of 3D computer programs and accurate educational models is required. The difficulty of this course may be related to the high density of various structures in a limited space, which are not easily seen at autopsy. Even when preserved human brains are available for educational purposes, it can be very difficult to reveal the complex architecture of internal structures of the brain stem, such as the spatial position of the cranial nerve nuclei and the neural pathways. Also, it is very difficult to understand the cross-sections of different regions of the brain stem using two-dimensional images or plastinated specimens. This program aims to design and create a precision model with all the specific details, using the least amount of funding and facilities possible, in order to train medical students in the most effective way possible. This is because of the importance of this area, particularly the importance of the cranial nerves and their use in clinical examinations. Actually, the fundamental objective of current research is to design a 3D model that can shows the internal structures of the brainstem and their unique relationships in order to give an effective learning method. In the present study, the 3D model based on images of the brainstem in different views was developed and assessed at Isfahan University of Medical Sciences, Iran. The Pre-test and post-test were created to assess students' fundamental understanding of the brain stem. Accordingly, it was hypothesized that a 3D brainstem model would significantly improve students understanding of the functional component of the cranial nerve and the spatial location of the neural pathways by promoting visual and kinesthetic learning. This approach can free the anatomist from the educational limitations and also enable a more realistic representation of brainstem anatomy. Materials and methods Design and Development of the Three-Dimensional Model In this study, we designed a 3D model of the right half of the brainstem. To build this model, depending on the appearance of the brainstem, a resin shell is required, which is done in the following steps: A plaster model (with a height of 55 cm) was made using images of the brainstem in different views. A negative mold was made using silicone that resembles the properties of the right half of the plaster model. By using plaster, a holding layer was created for the silicone mold to prevent from moving in the next steps. The internal surface of the negative silicone mold was covered with the same thickness (2 mm) of sculpture paste. A 5 mm thick silicone layer was then applied on the paste layer. After the new silicone layer has dried, the positive mold of the brainstem model is created. An additional plaster holding layer was made for the positive mold. After removing the paste layer, both the positive and negative silicone molds were placed next to each other along with theirs plaster holding and secured with screws and nuts. The resin shell of the brainstem was created by injecting liquid epoxy resin into the space between the molds. Afterwards, the cranial and non-cranial nuclei were made by 3D printer. The attachment site of each cranial nerves to the brainstem model was perforated with a dental drill, and the fibers of each individual cranial nerve emerged through their respective foramen. Development of the 3D Printed Nuclei The design process of nuclei was based on illustrations and anatomical data from the books NETTER ATLAS of HUMAN ANATOMY 8th edition, from Elsevier and Gray's Atlas of Anatomy, 3rd Edition 41th edition, from Elsevier, as well as on the team's clinical experience. The boundaries of each nucleus were drawn through Solidwork software version 2022. Algorithm is then applied to create a 3D model from the boundaries. The 3D model is in the stereolithography (.stl) file format which can be used by 3D printers directly. The nuclei were printed on an Ultimaker Extended Printer, (Ultimaker B.V., Geldermalsen, The Netherlands) which used fused deposition modeling (FDM) technology to melt polylactic acid (PLA) material, allowing it to be extruded from a heated nozzle in consecutive layers onto the printer build plate. Additional post work included painting the cranial nuclei with red (motor nuclei), blue (sensory nuclei) and yellow (parasympathetic nuclei). The nuclei were fixed in their own specific space using a silicone partition. In addition to the cranial nerve nuclei, the important neural pathways of the brainstem were designed using colored wires and localized to their respective spatial locations. Course Descriptions The medical education at Isfahan University of Medical Sciences consists of 14 undergraduate semesters, each lasting 17 weeks. Students complete the neuroanatomy course in the third semester of the curriculum. All students attend in 90-minute sessions weekly. These sessions take place in the lecture hall or anatomy laboratory. Four of these sessions are dedicated to interactive lectures on brain stem anatomy (three sessions for theory and one session for practice). The theorical sessions are reserved for teaching external features and internal structures and clinical point of the brain stem, but due to the lack of a suitable model, training was carried out using two-dimensional images of brain stem sections. There are many different resources used in these lecture sessions, such as Power Point slides, textbooks, lectures, and 2D and 3D images. Additionally, plastic anatomical brainstem models and atlases have been used, along with plastinated human brain sections. Study Population & Design This trial was conducted at Isfahan University of Medical Sciences with 3rd -semester medical students to assess whether use of the 3D model improved medical students’ knowledge of brain stem anatomy, more than a standard, didactic lecture. This study was approved by the research ethics committee of “Alzahra Research Centers” (IR.ARI.MUI.REC.1402.032) and complies with the Declaration of Helsinki. Informed consent form was obtained from all the participants. (Clinical trial number: not applicable) These students usually learn about the brainstem anatomy on lecture based with 2D images and are evaluated at the end of the semester using a multiple-choice exam that assesses the students' level of knowledge. To avoid giving them about the subject of the study prior to the test, all participants were recruited through announcements that refrained from mentioning the brain stem. 64 3rd -semester medical students were invited to participate in the study. Among whom 62 agreed to cooperate. One further medical student was excluded, due to her previous exposure to the content in the last semester and also two students were not attended to the class. This resulted in 59 students being randomly allocated to either the 3D model (n = 30) or lecture group (n = 29). The durations of study involvement of the two student groups were equivalent (Fig. 1 ). The 3D model group was trained for 60 min session using brain stem model by related professor and afterwards the students were encouraged to do self-study about 30 min. The standard lecture consisted of one 60- min class. The professor who every year teaches neuroanatomy delivered her regular lecture. The students were able to review about 30 min using textbook and 2D images.In order to reduce bias, the didactic professors received structured content on brainstem anatomy from the principal investigator (PI). Questionnaires A set of forty questions was used to create the questionnaire, which had fourteen multiple-choice questions and five possible answers. Two highly qualified neuroanatomy professors from Isfahan University of Medical Sciences independently examined each question in the pool and reached a consensus regarding both the questions' content and degree of difficulty. The majority of the questions were designed to evaluate the cognitive learning domain, which aligns with Bloom's taxonomy's levels of comprehension and memory( 11 ). Exam questions cover the following topics: four questions on the external features of the brain stem and the location of cranial nerve attachments; four questions on the neural pathways and their features; and six questions on the spatial arrangement of nuclei and the functional components of cranial nerves. Tests were given to both groups right before (Pre-Test) and right after (Post-Test) their instruction. The user's basic understanding of the brainstem's anatomy was evaluated in the pre-test, and their knowledge was further gauged in the post-test following their use of the 3D model or lecture. Since the 14 questions were chosen from the pool of questions, no student answered the same question more than once. Satisfaction Survey User satisfaction with the 3D model was measured using surveys with a five-point Likert scale. Five components were evaluated: enjoyment, authenticity, learning efficiency, attitude, and intention to use (with 1 representing strongly disagree, 2 representing somewhat disagree, 3 representing neither agree nor disagree, 4 representing somewhat agree, and 5 representing strongly agree) (Likert, 1932). Eight survey questions were shared by the 3D group and the responses were analyzed. Statistical Analysis The effect of the 3D model was evaluated by analyzing students’ scores on assessment quizzes and a satisfaction survey based on the five-point Likert scale. Continuous variables were described as mean ± standard deviation (SD), and the categorical variables were described by the frequency (n) and corresponding proportion (%). Multiple-choice questions from the knowledge quiz were graded and average scores were calculated. Pre-quiz and post-quiz scores were calculated independently by two reviewers. As predetermined, a paired samples t-test was used to compare pre-quiz and post-quiz scores within the same group and an unpaired samples t-test was used to analyze student performance between groups, using SPSS statistical package, version 24.0 (IBM Corp., Armonk, NY). The P values ≤ 0.05 were considered statistically significant unless otherwise stated. Results 3D model of brain stem 3D model of brain stem was successfully created that showing the external features of brain stem such as sulci, depressions and raised areas of various surfaces of brain stem especially external view of 4th ventricle and also attachment site of cranial nerve. This model also shows cranial nerve nuclei by color codes, motor nuclei (red), sensory nuclei(blue) and parasympathetic nuclei (yellow). In addition to the cranial nerve nuclei, the ascending and descending pathways of the brainstem have been shown and localized to their respective spatial locations, such as corticospinal, corticonuclear, lateral lemniscus, rubrospinal, medial longitudinal fasciculus (MLF), medial lemniscus and spinocerebellar pathways (Figs. 2 and 3 ). Evaluation of the 3D model of brain stem in medical anatomy teaching To evaluate the efficacy of 3D model in brain stem anatomy teaching, two groups of medical students were assessed. There were 29 students in the lecture group and 30 students in the 3D model group and none had prior exposure to brain stem anatomy training. The Pre-Test, Post-Test scores for both groups summarize in Table 1 . There was no significant difference in the baseline Pre-Test mean scores between the groups, being 2.65 (18.9%) and 2.26 (16.2%) in the standard lecture and 3D model groups, respectively (p = 0.29). The mean scores result of Post Test was 5.72 (40.9%) in lecture group and 7.93 (56.6%) in 3D model group (Fig. 4 ). The analysis of the post-test results indicated that the mean score of the 3D model group was significantly higher than its counterpart in the lecture group (p < 0.001). Table 1 Mean test scores and group Statistics Groups N Mean Std. Deviation Std. Error Mean Pre-test Lecture 29 2.6552 1.23276 .22892 3D Model 30 2.2667 1.55216 .28338 Post-test Lecture 29 5.7241 1.33354 .24763 3D Model 30 7.9333 2.53164 .46221 Student satisfaction In terms of satisfaction, the 3D model group students rated their experience significantly more positive (Table 2 ). In particular, students about “usefulness of structure’s color-coding” expressed that this property helped them to identify the various component of the cranial nerves(Q7). In addition, the surveys demonstrated that utilizing this model in teaching brainstem topics will play a key role in raising students' spatial perception and understanding cranial nuclei and neural pathways (Q5 and Q6). The 3D model also received much better overall “satisfactory experience” ratings (Q8). Table 2 Degree of participants satisfaction with the educational value 3D model of brain stem Row 1 2 3 4 5 1 This training session with 3D model is a useful teaching method for learning brain stem anatomy 16.7% ( 5 ) 20% ( 6 ) 43.3% ( 13 ) 20% ( 6 ) 2 Using of 3D model has motivated me to learn 3.3% ( 1 ) 10% ( 3 ) 20% ( 6 ) 33.3% ( 10 ) 33.3% ( 10 ) 3 3D model could replace lecture-based method as a traditional teaching method 3.3% ( 1 ) 16.7% ( 5 ) 26.7% ( 8 ) 30% ( 9 ) 23.3% ( 7 ) 4 The understanding of the external features of the brain stem is improved by using 3D model comparing to the using common models 3.3% ( 1 ) 26.7% ( 8 ) 36.7% ( 11 ) 33.3% ( 10 ) 5 3D model improved my understanding and learning of cranial nuclei and neural pathway 16.7% ( 5 ) 46.7% ( 14 ) 36.7% ( 11 ) 6 The 3D model offers the ability to appreciate 3D topographical relationships of nearby structures more readily. 3.3% ( 1 ) 16.7% ( 5 ) 33.3% ( 10 ) 46.7% 14 7 The color coding by nuclei and pathway types in the 3D printed model helped me identify the motor, sensory and parasympathetic component 6.7% ( 2 ) 40% ( 12 ) 53.3% ( 16 ) 8 In general, the experience with this session has been satisfactory total scores 6.7% ( 2 ) 20% ( 6 ) 60% ( 18 ) 13.3% ( 4 ) *A five-point Likert scale was used (1 = strongly disagree, 2 = somewhat disagree, 3 = neither agree nor disagree, 4 = somewhat agree, 5 = strongly agree; number of participants n = 30). It should be mentioned that most of the students acknowledged that using this model not only takes less time to learn cranial nerves, but also increases the learning rate due to its objectivity. Furthermore, the illustration of various neural pathways located in the brainstem and the level of crossing of these pathways is another reported feature of this model which makes it possible for the learner to reach a high level of knowledge by touching and following neural pathways. Discussion Neuroanatomy is generally regarded as a challenging subject at all medical education levels especially medical students and residents ( 12 ). The term "neurophobia," which was coined in 1994 ( 13 ), still captures the sentiment that many students around the world have toward this subject. Because of this perception, the high complexity of neuroanatomical structures, and the limited amount of teaching time, educators usually recommend a variety of pedagogical strategies to increase students' interest and understanding in these subjects ( 14 ). For the first time, the internal structures of the human brainstem can be learned and taught using a 3D model, according to this study. The current study assessed the 3D brainstem model's perceived educational value for teaching anatomy, and the results indicated that most students found the model to be useful teaching aids. This study approved that the anatomical accuracy, distinguishing power, and structural accessibility of 3D models make them useful tools for anatomy education. It has been proposed that students will struggle to understand the 3D organization of the anatomical structures and the relationships between them if their learning is limited to two-dimensional static images in textbooks, screen images, and plastic models ( 15 ) ( 16 ). As stated by Mashiko et al. 3D physical models are promising for understanding the human anatomical structures ( 17 ). Most studies have demonstrated more interaction is provided by models via various somatosensory inputs (touch, visual and texture) which are consistent with our reported findings ( 17 ) ( 18 ). The brain processes and integrates these various sensory inputs to improve stereoscopic perception of the object( 17 ). In line with the findings of this study, we report that, the anatomical structures give tactile and visual feedback regarding location and relationship when students touch the 3D model of the brainstem. Having a priori knowledge of organization of internal structures of brainstem will be helpful for clinicians to localize lesions of the brainstem. Using color-coded components, the 3D model illustrates the locations of the cranial nuclei, neural pathways, and the spatial relationships between them in order to improve conceptual understanding of the brain stem. Students thought favorably of the color-coding of the model, which allowed them to distinguish between different structures and identify cranial nerve motor nuclei (red), sensory nuclei (blue), and parasympathetic nuclei (yellow). It has been proved that color-coding anatomical specimens is most beneficial for students studying the principles of anatomy ( 19 ) ( 20 ). According to prior assessments of 3D models in education, multicolored 3D models are more enjoyable for students to use in comparison to monochromatic models( 19 ) ( 21 ). The results of this study further support these findings by significantly improving both student learning and their satisfaction with the learning process. There was a known concern with the student about the lack of accurate understanding of the internal structure of brain stem. These factors could impact negatively on learning of cranial nerve functional component and spatial location of neural pathway. It can be claimed that the majority of issues have been successfully resolved using 3D model based on statements of students which told that this model allowed them to explore deeper structures and visualize location of structure in different sections and their proximity to each other. Additionally, using this 3D model will help them better understand the embryology, particularly developmental process of various components of cranial nerves. By analyzing the results, it was determined, the mean pre-test scores across both groups were approximately between 16% and 19%. We posit that this could be due to the random selection of correct answers because these students had no exposure to brain stem anatomy training before. The short self-study period and possibly the level of difficulty of the questions contributed to the mean post-test scores in both groups not rising above a maximum of 57%. The high complexity of brain stem structures and the fact that the post-test was given right away in the lab following the intervention could be the other reasons for these scores. Interestingly, compared to the lecture group, the 3D model’s mean post-test scores increased significantly, indicating that they had a better understanding of the brain stem and may have benefited from the self-study time spent going over the brain stem 3D model. The 3D model group outperformed the lecture group on post-test questions concerning the internal organization of the brain stem that were either highlighted or illustrated on the 3D model. These questions included determining the precise location of neural pathways and cranial nuclei as well as the level of crossing neural tracts, all of which were not visible on the plastinated or cadaveric specimen. Results for the most challenging question regarding the functional component show the advantages of color-coding specific structures for the 3D model group in comparison to the lecture group. Emotion plays a significant part in learning, which is more than just a logical and rational process( 22 ) ( 23 ). Simulation models, whether virtual or physical, seem to improve students' perceptions of their education( 24 ) ( 25 ). The 3D model group highly rated the usefulness this model compared to the lecture group. This indicates that one of the main objectives of the 3D model was to help students better understand the spatial relationship of the internal structure of the brain stem, especially the various components of cranial nerve. The observations also agree with the results reported by Black and Stang that showed 3D printed models was useful in perception of the students and also satisfaction surveys indicated overall enjoyment toward a learning modality have a lasting effect on student’s attitudes( 26 ) ( 27 ). Students selected more "strongly agreed" when asked about the fifth satisfaction survey item, "3D model improved my understanding and learning of cranial nuclei and neural pathway.". The 3D model group students noted that color-coding was a very helpful learning tool for them, because they were able to manipulate the 3D model to explore the internal structure of the brain stem. Promoting spatial understanding is achieved by Kinesthetic learning which enhances knowledge retention by allowing students to actively manipulate challenging anatomical structures (28) ( 29 ). In addition to building a foundation for surgical and radiological applications, it is necessary to have basic anatomical understanding( 30 ) based on spatial skills ( 31 ) ( 32 ). According to the highly positive feedback from the 3D model group, we found that many of the characteristics of the 3D model were ideal and satisfied the preferences of the students. This results clearly demonstrated the consistency with the previous studies about the increased learning satisfaction of students ( 33 ), and pediatric residents ( 34 ) has been illustrated by using 3D printed models as teaching tools. In conclusion, this study explains how a highly detailed 3D brain stem model can be used to create a mobile, kinesthetic, and reasonably priced teaching tool for use in medical education. According to survey analyses, students' understanding of the brain stem is greatly enhanced by the 3D model. Limitations of the study Despite the success of this model demonstrated in improving student performance and enjoyment during brain stem education, a significant limitation is that long-term effects of this model were not made clear given the short time frame of the study. This should be considered in future experiments to follow up how the effectiveness of the 3D model at the end of semester. It was better to build up this model with 3D printer but given that the Polylactic Acid (PLA) as the main material of the 3D printer is an opaque material, we could not use this method for making resin shell. A final limitation of this study relates to ensuring that the sessions were simultaneous, it should be noted that the professors for each group were different. To minimize bias, the professors in both groups had comparable training and experience. Conclusions Overall, the results strongly suggest that 3D physical modeling is a useful method for teaching and learning neuroanatomy and helping students visualize the structure of the brainstem. We believe that 3D model of brain stem is suitable method for better comprehension of neuroanatomy. These kinds of hands-on tools can help students learn anatomical structures more effectively. The 3D fabricated brainstem model makes it easier and more enjoyable for students to have an active role in learning and gives students a better 3D understanding. Declarations Clinical trial number: not applicable. Human Ethics & Consent Declaration This study involving human participants was conducted in accordance with the Declaration of Helsinki. Ethical approval was granted by the research ethics committee of “Alzahra Research Centers” Institutional Review Board (IRB) (Approval No: IR.ARI.MUI.REC.1402.032). Written informed consent was obtained from all participants prior to participation. Consent to Participate All participants provided written informed consent. Ethical Standard Cited Conducted in accordance with the Declaration of Helsinki. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Funding This study was supported in part by a grant received from the Isfahan University of Medical Sciences and Health Services, Tehran, Iran (grant number: 140212). Author Contribution Mansour Homayoun conceived and designed the research; Mehrnoush Malekzadeh performed the research and acquired the data. Samin Shafiei analyzed and interpreted the data and Saeed Zamani drafted the commentary. All authors were involved in drafting and revising the manuscript Acknowledgement The authors acknowledge and thank all study participants for their time and cooperation. We furthermore also acknowledge the Department of Anatomical Sciences at Medical Sciences of Isfahan University, for making it possible to conduct this study. 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Spatial learning disabilities and underachievement among university anatomy students. Med Educ. 1985 Jan;19(1):13–26. Crafts TD, Ellsperman SE, Wannemuehler TJ, Bellicchi TD, Shipchandler TZ, Mantravadi A V. Three-Dimensional Printing and Its Applications in Otorhinolaryngology-Head and Neck Surgery. Otolaryngol neck Surg Off J Am Acad Otolaryngol Neck Surg. 2017 Jun;156(6):999–1010. Wanzel KR, Hamstra SJ, Anastakis DJ, Matsumoto ED, Cusimano MD. Effect of visual-spatial ability on learning of spatially-complex surgical skills. Vol. 359, Lancet (London, England). England; 2002. p. 230–1. Garas M, Vaccarezza M, Newland G, McVay-Doornbusch K, Hasani J. 3D-Printed specimens as a valuable tool in anatomy education: A pilot study. Ann Anat = Anat Anzeiger Off organ Anat Gesellschaft. 2018 Sep;219:57–64. Loke YH, Harahsheh AS, Krieger A, Olivieri LJ. Usage of 3D models of tetralogy of Fallot for medical education: impact on learning congenital heart disease. BMC Med Educ. 2017 Mar;17(1):54. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6747723","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":492682886,"identity":"1d4b0586-39ae-4473-9485-5b4a6e1dd2d1","order_by":0,"name":"Mansour Homayoun","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYFACHhiD+QADAxuIBvMkiNHClkCyFh4DiBZCQLeB9+CjGzWH5Qxu93zd8KGMIdrgOAPjhx8MFvm4tJgd4Es2zjl22NjgztltN2ecY8jdcJiBWbKHQcKyAacWHjPpHLbDiRtu5G67zdsG1sIgDfSLAW5bQFr+gbTkPLv9F6KF+TdBLbltYC1stxkhWtjw23KYx9g4ty/dWPJGmtnNnnMSuTMPM7ZZ9hjg0XK8x/BxzjdrOb4byc9u/Cizye07f/jwjR8VdTi1QCOuGcYFxSBjAwMDbg0wUEdQxSgYBaNgFIxgAABpZlTlGs4SWgAAAABJRU5ErkJggg==","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Mansour","middleName":"","lastName":"Homayoun","suffix":""},{"id":492682887,"identity":"14b1df04-bfa5-45b9-980b-c1e2a757ee59","order_by":1,"name":"Mehrnoush Malekzadeh","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mehrnoush","middleName":"","lastName":"Malekzadeh","suffix":""},{"id":492682888,"identity":"2afe868d-5335-44b5-8639-ce96e54945bf","order_by":2,"name":"Samin shafiei","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Samin","middleName":"","lastName":"shafiei","suffix":""},{"id":492682889,"identity":"8aca2eb5-9027-49ed-9b5e-12a9101d5cf0","order_by":3,"name":"Saeed Zamani","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Saeed","middleName":"","lastName":"Zamani","suffix":""}],"badges":[],"createdAt":"2025-05-26 06:39:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6747723/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6747723/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88034740,"identity":"c2f89770-48b3-4818-86c8-200f1a1bfe37","added_by":"auto","created_at":"2025-07-31 16:09:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":307855,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of study design\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6747723/v1/f9df5d6ac3d6c181d200df9d.png"},{"id":88034741,"identity":"debb08c6-b61c-46d5-87a0-19636123ca07","added_by":"auto","created_at":"2025-07-31 16:09:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":645131,"visible":true,"origin":"","legend":"\u003cp\u003eSagittal view of 3D model of brainstem. It shows motor nuclei and motor fibers(red), sensory nuclei and sensory fibers(blue) and parasympathetic nuclei and parasympathetic fibers(yellow).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.Resin shell 2. Silicone partition 3. Foramina for placement of structures 4. Mid brain 5. Pons 6. Medulla 7. Red nucleus 8. Corticospinal 9. Corticonuclear 10. Edinger–Westphal nucleus 11. Oculomotor nucleus 12. MLF 13. Trochlear nucleus 14. Trochlear nerve 15. Rubrospinal tract 16. Medial lemniscus 17. Trigeminal sensory nucleus 18. Trigeminal motor nucleus 19. Lateral lemniscus 20. Superior salivatory nucleus 21. Abducens nucleus 22. Facial nucleus 23. Inferior salivatory nucleus 24. Ambiguus nucleus 25. Hypoglosal nucleus 26. Solitarius nucleus 27. ventral spinocerebellar 28. Dorsal spinocerebellar 29. Spinal part of accessory nucleus\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6747723/v1/909cbab597e0987d350a027f.png"},{"id":88035717,"identity":"0bcfb342-76f8-4b4b-9c37-c70e66a93e15","added_by":"auto","created_at":"2025-07-31 16:17:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":785197,"visible":true,"origin":"","legend":"\u003cp\u003eAnterolateral(A) and posterior(B) view of 3D model of brainstem. Attachment site of cranial nerve and features of fourth ventricle floor.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1. Trigeminal Nerve 2. Facial Abducens nerve 3. Intermediate nerve 4. vestibulocochlear nerve 5. glossopharyngeal nerve 6. Vagus nerve 7. Olive 8. Tuberculum cinereum 9. Accessory nerve 10. Abducens nerve 11. Hypoglosal nerve 12. Pyramid 13. Trochlear nerve 14. Facial colliculus 15. Hypoglosal trigone 16. Cuneatus tubercle 17. Gracilis tubercle 18. Locus coeruleus 19. Superior fovea 20. Inferior fovea 21. Cochlear nuclei 22. Vestibular area 23. Vagal triangle\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6747723/v1/98e886c9ca82cb282e62815d.png"},{"id":88037095,"identity":"bfe8cc46-8240-474b-abe5-6bdaf7f35f86","added_by":"auto","created_at":"2025-07-31 16:25:33","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":215362,"visible":true,"origin":"","legend":"\u003cp\u003eThe Comparisons between mean post-test scores of lecture and 3D model groups. analysis of results shows the Significant difference between 3D model versus lecture groups (p-values \u0026lt;0.001).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6747723/v1/a15742120e4ee0a80a93f4b4.png"},{"id":89290699,"identity":"9c3885a0-c3ae-43de-901c-287074d0b1a9","added_by":"auto","created_at":"2025-08-18 12:17:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2980564,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6747723/v1/a4f3f768-fab3-48ff-a58b-283a6d526ad7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Innovative Educational Three-Dimensional Model of the Human Brainstem: Enhancing Neuroanatomy Learning for Medical Students","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLearning anatomy is crucial for students pursuing a range of medical specialties, as it is one of the fundamental knowledge bases of medical science. Dissection is one of the most popular methods used to teach anatomy. The best teaching aids for anatomy are cadaver dissection or dissected cadaveric specimens, as they give students a crucial three-dimensional(3D) perspective of the human body(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). That being said, a great number of medical schools across the globe restrict or prohibit access to cadavers (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) as a result of monetary, ethical, legal, and cultural barriers; however, many nations also face a scarcity of cadaver donors (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In light of the declining significance of cadaver dissection and the requirement for ongoing anatomy training, more investigation should be conducted into the efficaciousness of substitute approaches to anatomy instruction. It is necessary to use 3D computer programs, plastic models, plastinated specimens, and medical imaging for enhancement of anatomical education (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e3D anatomical models include digital and non-digital models which can be placed in different positions and views(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In this way, students can learn the spatial relationships between different structures and manipulate desired targets(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Studies show that 3D anatomical models can be used to support the curriculum and promote students' spatial visualization skills (whether digital or non-digital) are preferable for students of medicine, dentistry and other medical sciences(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBecause it requires precise, abstract thinking to perceive its complex spatial relationships, neuroanatomy is still regarded as one of the most difficult areas of anatomy (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Usually taught as a course of the medical curriculum, this curriculum makes use of plastic models, 2D images, and brain cross-sections. The importance of the Central Neural System (especially the brainstem) in clinical examination and disease diagnosis underscores the need for higher education in this section(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Thus, one of the fundamental requirements of the educational system is the creation of models that, through providing a three-dimensional view of anatomical structures, aid in tangible understanding.\u003c/p\u003e\u003cp\u003eAmong the structures of the nervous system, the brainstem is one of the most complicated topics for students, making teaching and learning difficult and requiring 3D insight. It seems students with spatial imagination and normal intelligence quotients (IQs) have difficulty learning the internal structures of brainstem due to their inability to understand topography.\u003c/p\u003e\u003cp\u003eThe brainstem is the structure that connects the cerebrum to the spinal cord and cerebellum. It consists of three sections in descending order: midbrain, pons and medulla oblongata. The brainstem contains many important collections of white and gray matter(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The gray matter in this area consists of nerve cell bodies and forms many important brainstem nuclei. The white matter of the brainstem includes axons of nerves that traverse their course to various structures. The majority of axons originate from cell bodies located elsewhere in the central nervous system (CNS) (Neuroanatomy, Brainstem. PUBMED).\u003c/p\u003e\u003cp\u003eConsidering that the training of the internal structures of the brain stem is practically not possible using a cadaver due to the small size and same color elements, so the use of alternative methods such as the use of 3D computer programs and accurate educational models is required. The difficulty of this course may be related to the high density of various structures in a limited space, which are not easily seen at autopsy.\u003c/p\u003e\u003cp\u003eEven when preserved human brains are available for educational purposes, it can be very difficult to reveal the complex architecture of internal structures of the brain stem, such as the spatial position of the cranial nerve nuclei and the neural pathways. Also, it is very difficult to understand the cross-sections of different regions of the brain stem using two-dimensional images or plastinated specimens. This program aims to design and create a precision model with all the specific details, using the least amount of funding and facilities possible, in order to train medical students in the most effective way possible. This is because of the importance of this area, particularly the importance of the cranial nerves and their use in clinical examinations.\u003c/p\u003e\u003cp\u003eActually, the fundamental objective of current research is to design a 3D model that can shows the internal structures of the brainstem and their unique relationships in order to give an effective learning method. In the present study, the 3D model based on images of the brainstem in different views was developed and assessed at Isfahan University of Medical Sciences, Iran. The Pre-test and post-test were created to assess students' fundamental understanding of the brain stem.\u003c/p\u003e\u003cp\u003eAccordingly, it was hypothesized that a 3D brainstem model would significantly improve students understanding of the functional component of the cranial nerve and the spatial location of the neural pathways by promoting visual and kinesthetic learning. This approach can free the anatomist from the educational limitations and also enable a more realistic representation of brainstem anatomy.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eDesign and Development of the Three-Dimensional Model\u003c/h2\u003e\u003cp\u003eIn this study, we designed a 3D model of the right half of the brainstem. To build this model, depending on the appearance of the brainstem, a resin shell is required, which is done in the following steps:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cli\u003e\u003cp\u003eA plaster model (with a height of 55 cm) was made using images of the brainstem in different views.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eA negative mold was made using silicone that resembles the properties of the right half of the plaster model.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBy using plaster, a holding layer was created for the silicone mold to prevent from moving in the next steps.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe internal surface of the negative silicone mold was covered with the same thickness (2 mm) of sculpture paste.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eA 5 mm thick silicone layer was then applied on the paste layer. After the new silicone layer has dried, the positive mold of the brainstem model is created.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAn additional plaster holding layer was made for the positive mold.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAfter removing the paste layer, both the positive and negative silicone molds were placed next to each other along with theirs plaster holding and secured with screws and nuts.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe resin shell of the brainstem was created by injecting liquid epoxy resin into the space between the molds.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAfterwards, the cranial and non-cranial nuclei were made by 3D printer.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe attachment site of each cranial nerves to the brainstem model was perforated with a dental drill, and the fibers of each individual cranial nerve emerged through their respective foramen.\u003c/p\u003e\u003c/li\u003e\u003c/ol\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eDevelopment of the 3D Printed Nuclei\u003c/h3\u003e\n\u003cp\u003eThe design process of nuclei was based on illustrations and anatomical data from the books NETTER ATLAS of HUMAN ANATOMY 8th edition, from Elsevier and Gray's Atlas of Anatomy, 3rd Edition 41th edition, from Elsevier, as well as on the team's clinical experience.\u003c/p\u003e\u003cp\u003eThe boundaries of each nucleus were drawn through Solidwork software version 2022. Algorithm is then applied to create a 3D model from the\u003c/p\u003e\u003cp\u003eboundaries. The 3D model is in the stereolithography (.stl) file format which can be used by 3D printers directly. The nuclei were printed on an Ultimaker Extended Printer, (Ultimaker B.V., Geldermalsen, The Netherlands) which used fused deposition modeling (FDM) technology to melt polylactic acid (PLA) material, allowing it to be extruded from a heated nozzle in consecutive layers onto the printer build plate. Additional post work included painting the cranial nuclei with red (motor nuclei), blue (sensory nuclei) and yellow (parasympathetic nuclei). The nuclei were fixed in their own specific space using a silicone partition. In addition to the cranial nerve nuclei, the important neural pathways of the brainstem were designed using colored wires and localized to their respective spatial locations.\u003c/p\u003e\n\u003ch3\u003eCourse Descriptions\u003c/h3\u003e\n\u003cp\u003eThe medical education at Isfahan University of Medical Sciences consists of 14 undergraduate semesters, each lasting 17 weeks. Students complete the neuroanatomy course in the third semester of the curriculum. All students attend in 90-minute sessions weekly. These sessions take place in the lecture hall or anatomy laboratory. Four of these sessions are dedicated to interactive lectures on brain stem anatomy (three sessions for theory and one session for practice). The theorical sessions are reserved for teaching external features and internal structures and clinical point of the brain stem, but due to the lack of a suitable model, training was carried out using two-dimensional images of brain stem sections.\u003c/p\u003e\u003cp\u003eThere are many different resources used in these lecture sessions, such as Power Point slides, textbooks, lectures, and 2D and 3D images. Additionally, plastic anatomical brainstem models and atlases have been used, along with plastinated human brain sections.\u003c/p\u003e\n\u003ch3\u003eStudy Population \u0026 Design\u003c/h3\u003e\n\u003cp\u003eThis trial was conducted at Isfahan University of Medical Sciences with 3rd -semester medical students to assess whether use of the 3D model improved medical students\u0026rsquo; knowledge of brain stem anatomy, more than a standard, didactic lecture. This study was approved by the research ethics committee of \u0026ldquo;Alzahra Research Centers\u0026rdquo; (IR.ARI.MUI.REC.1402.032) and complies with the Declaration of Helsinki. Informed consent form was obtained from all the participants. (Clinical trial number: not applicable)\u003c/p\u003e\u003cp\u003eThese students usually learn about the brainstem anatomy on lecture based with 2D images and are evaluated at the end of the semester using a multiple-choice exam that assesses the students' level of knowledge. To avoid giving them about the subject of the study prior to the test, all participants were recruited through announcements that refrained from mentioning the brain stem.\u003c/p\u003e\u003cp\u003e64 3rd -semester medical students were invited to participate in the study. Among whom 62 agreed to cooperate. One further medical student was excluded, due to her previous exposure to the content in the last semester and also two students were not attended to the class. This resulted in 59 students being randomly allocated to either the 3D model (n\u0026thinsp;=\u0026thinsp;30) or lecture group (n\u0026thinsp;=\u0026thinsp;29). The durations of study involvement of the two student groups were equivalent (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe 3D model group was trained for 60 min session using brain stem model by related professor and afterwards the students were encouraged to do self-study about 30 min. The standard lecture consisted of one 60- min class. The professor who every year teaches neuroanatomy delivered her regular lecture. The students were able to review about 30 min using textbook and 2D images.In order to reduce bias, the didactic professors received structured content on brainstem anatomy from the principal investigator (PI).\u003c/p\u003e\n\u003ch3\u003eQuestionnaires\u003c/h3\u003e\n\u003cp\u003eA set of forty questions was used to create the questionnaire, which had fourteen multiple-choice questions and five possible answers. Two highly qualified neuroanatomy professors from Isfahan University of Medical Sciences independently examined each question in the pool and reached a consensus regarding both the questions' content and degree of difficulty. The majority of the questions were designed to evaluate the cognitive learning domain, which aligns with Bloom's taxonomy's levels of comprehension and memory(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Exam questions cover the following topics: four questions on the external features of the brain stem and the location of cranial nerve attachments; four questions on the neural pathways and their features; and six questions on the spatial arrangement of nuclei and the functional components of cranial nerves. Tests were given to both groups right before (Pre-Test) and right after (Post-Test) their instruction. The user's basic understanding of the brainstem's anatomy was evaluated in the pre-test, and their knowledge was further gauged in the post-test following their use of the 3D model or lecture. Since the 14 questions were chosen from the pool of questions, no student answered the same question more than once.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eSatisfaction Survey\u003c/h2\u003e\u003cp\u003eUser satisfaction with the 3D model was measured using surveys with a five-point Likert scale. Five components were evaluated: enjoyment, authenticity, learning efficiency, attitude, and intention to use (with 1 representing strongly disagree, 2 representing somewhat disagree, 3 representing neither agree nor disagree, 4 representing somewhat agree, and 5 representing strongly agree) (Likert, 1932). Eight survey questions were shared by the 3D group and the responses were analyzed.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eThe effect of the 3D model was evaluated by analyzing students\u0026rsquo; scores on assessment quizzes and a satisfaction survey based on the five-point Likert scale. Continuous variables were described as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), and the categorical variables were described by the frequency (n) and corresponding proportion (%). Multiple-choice questions from the knowledge quiz were graded and average scores were calculated. Pre-quiz and post-quiz scores were calculated independently by two reviewers. As predetermined, a paired samples t-test was used to compare pre-quiz and post-quiz scores within the same group and an unpaired samples t-test was used to analyze student performance between groups, using SPSS statistical package, version 24.0 (IBM Corp., Armonk, NY). The P values\u0026thinsp;\u0026le;\u0026thinsp;0.05 were considered statistically significant unless otherwise stated.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3D model of brain stem\u003c/h2\u003e\u003cp\u003e3D model of brain stem was successfully created that showing the external features of brain stem such as sulci, depressions and raised areas of various surfaces of brain stem especially external view of 4th ventricle and also attachment site of cranial nerve. This model also shows cranial nerve nuclei by color codes, motor nuclei (red), sensory nuclei(blue) and parasympathetic nuclei (yellow). In addition to the cranial nerve nuclei, the ascending and descending pathways of the brainstem have been shown and localized to their respective spatial locations, such as corticospinal, corticonuclear, lateral lemniscus, rubrospinal, medial longitudinal fasciculus (MLF), medial lemniscus and spinocerebellar pathways (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eEvaluation of the 3D model of brain stem in medical anatomy teaching\u003c/h2\u003e\u003cp\u003eTo evaluate the efficacy of 3D model in brain stem anatomy teaching, two groups of medical students were assessed. There were 29 students in the lecture group and 30 students in the 3D model group and none had prior exposure to brain stem anatomy training.\u003c/p\u003e\u003cp\u003eThe Pre-Test, Post-Test scores for both groups summarize in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. There was no significant difference in the baseline Pre-Test mean scores between the groups, being 2.65 (18.9%) and 2.26 (16.2%) in the standard lecture and 3D model groups, respectively (p\u0026thinsp;=\u0026thinsp;0.29). The mean scores result of Post Test was 5.72 (40.9%) in lecture group and 7.93 (56.6%) in 3D model group (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The analysis of the post-test results indicated that the mean score of the 3D model group was significantly higher than its counterpart in the lecture group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMean test scores and group Statistics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroups\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eStd. Deviation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eStd. Error Mean\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePre-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLecture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.6552\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.23276\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.22892\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3D Model\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.2667\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.55216\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.28338\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePost-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLecture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.7241\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.33354\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.24763\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3D Model\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.9333\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.53164\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.46221\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eStudent satisfaction\u003c/h2\u003e\u003cp\u003eIn terms of satisfaction, the 3D model group students rated their experience significantly more positive (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In particular, students about \u0026ldquo;usefulness of structure\u0026rsquo;s color-coding\u0026rdquo; expressed that this property helped them to identify the various component of the cranial nerves(Q7). In addition, the surveys demonstrated that utilizing this model in teaching brainstem topics will play a key role in raising students' spatial perception and understanding cranial nuclei and neural pathways (Q5 and Q6). The 3D model also received much better overall \u0026ldquo;satisfactory experience\u0026rdquo; ratings (Q8).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDegree of participants satisfaction with the educational value 3D model of brain stem\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRow\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThis training session with 3D model is a useful teaching method for learning brain stem anatomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16.7%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e43.3%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e20%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUsing of 3D model has motivated me to learn\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.3%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e33.3%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e33.3%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3D model could replace lecture-based method as a traditional teaching method\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.3%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16.7%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e26.7%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e30%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e23.3%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe understanding of the external features of the brain stem is improved by using 3D model comparing to the using common models\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.3%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e26.7%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e36.7%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e33.3%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3D model improved my understanding and learning of cranial nuclei and neural pathway\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16.7%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e46.7%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e36.7%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe 3D model offers the ability to appreciate 3D topographical relationships of nearby structures more readily.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.3%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16.7%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e33.3%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e46.7%\u003c/p\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe color coding by nuclei and pathway types in the 3D printed model helped me identify the motor, sensory and parasympathetic component\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.7%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e40%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e53.3%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIn general, the experience with this session has been satisfactory total scores\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.7%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e60%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e13.3%\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e*A five-point Likert scale was used (1\u003csub\u003e=\u003c/sub\u003e strongly disagree, 2\u003csub\u003e=\u003c/sub\u003e somewhat disagree, 3\u003csub\u003e=\u003c/sub\u003e neither agree nor disagree, 4\u003csub\u003e=\u003c/sub\u003e somewhat agree, 5\u003csub\u003e=\u003c/sub\u003e strongly agree; number of participants n\u003csub\u003e=\u003c/sub\u003e 30).\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIt should be mentioned that most of the students acknowledged that using this model not only takes less time to learn cranial nerves, but also increases the learning rate due to its objectivity. Furthermore, the illustration of various neural pathways located in the brainstem and the level of crossing of these pathways is another reported feature of this model which makes it possible for the learner to reach a high level of knowledge by touching and following neural pathways.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eNeuroanatomy is generally regarded as a challenging subject at all medical education levels especially medical students and residents (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The term \"neurophobia,\" which was coined in 1994 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), still captures the sentiment that many students around the world have toward this subject. Because of this perception, the high complexity of neuroanatomical structures, and the limited amount of teaching time, educators usually recommend a variety of pedagogical strategies to increase students' interest and understanding in these subjects (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFor the first time, the internal structures of the human brainstem can be learned and taught using a 3D model, according to this study. The current study assessed the 3D brainstem model's perceived educational value for teaching anatomy, and the results indicated that most students found the model to be useful teaching aids. This study approved that the anatomical accuracy, distinguishing power, and structural accessibility of 3D models make them useful tools for anatomy education. It has been proposed that students will struggle to understand the 3D organization of the anatomical structures and the relationships between them if their learning is limited to two-dimensional static images in textbooks, screen images, and plastic models (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). As stated by Mashiko et al. 3D physical models are promising for understanding the human anatomical structures (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Most studies have demonstrated more interaction is provided by models via various somatosensory inputs (touch, visual and texture) which are consistent with our reported findings (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The brain processes and integrates these various sensory inputs to improve stereoscopic perception of the object(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In line with the findings of this study, we report that, the anatomical structures give tactile and visual feedback regarding location and relationship when students touch the 3D model of the brainstem. Having a priori knowledge of organization of internal structures of brainstem will be helpful for clinicians to localize lesions of the brainstem.\u003c/p\u003e\u003cp\u003eUsing color-coded components, the 3D model illustrates the locations of the cranial nuclei, neural pathways, and the spatial relationships between them in order to improve conceptual understanding of the brain stem. Students thought favorably of the color-coding of the model, which allowed them to distinguish between different structures and identify cranial nerve motor nuclei (red), sensory nuclei (blue), and parasympathetic nuclei (yellow). It has been proved that color-coding anatomical specimens is most beneficial for students studying the principles of anatomy (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAccording to prior assessments of 3D models in education, multicolored 3D models are more enjoyable for students to use in comparison to monochromatic models(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The results of this study further support these findings by significantly improving both student learning and their satisfaction with the learning process. There was a known concern with the student about the lack of accurate understanding of the internal structure of brain stem. These factors could impact negatively on learning of cranial nerve functional component and spatial location of neural pathway. It can be claimed that the majority of issues have been successfully resolved using 3D model based on statements of students which told that this model allowed them to explore deeper structures and visualize location of structure in different sections and their proximity to each other. Additionally, using this 3D model will help them better understand the embryology, particularly developmental process of various components of cranial nerves.\u003c/p\u003e\u003cp\u003eBy analyzing the results, it was determined, the mean pre-test scores across both groups were approximately between 16% and 19%. We posit that this could be due to the random selection of correct answers because these students had no exposure to brain stem anatomy training before. The short self-study period and possibly the level of difficulty of the questions contributed to the mean post-test scores in both groups not rising above a maximum of 57%. The high complexity of brain stem structures and the fact that the post-test was given right away in the lab following the intervention could be the other reasons for these scores.\u003c/p\u003e\u003cp\u003eInterestingly, compared to the lecture group, the 3D model\u0026rsquo;s mean post-test scores increased significantly, indicating that they had a better understanding of the brain stem and may have benefited from the self-study time spent going over the brain stem 3D model. The 3D model group outperformed the lecture group on post-test questions concerning the internal organization of the brain stem that were either highlighted or illustrated on the 3D model. These questions included determining the precise location of neural pathways and cranial nuclei as well as the level of crossing neural tracts, all of which were not visible on the plastinated or cadaveric specimen. Results for the most challenging question regarding the functional component show the advantages of color-coding specific structures for the 3D model group in comparison to the lecture group.\u003c/p\u003e\u003cp\u003eEmotion plays a significant part in learning, which is more than just a logical and rational process(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Simulation models, whether virtual or physical, seem to improve students' perceptions of their education(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe 3D model group highly rated the usefulness this model compared to the lecture group. This indicates that one of the main objectives of the 3D model was to help students better understand the spatial relationship of the internal structure of the brain stem, especially the various components of cranial nerve. The observations also agree with the results reported by Black and Stang that showed 3D printed models was useful in perception of the students and also satisfaction surveys indicated overall enjoyment toward a learning modality have a lasting effect on student\u0026rsquo;s attitudes(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eStudents selected more \"strongly agreed\" when asked about the fifth satisfaction survey item, \"3D model improved my understanding and learning of cranial nuclei and neural pathway.\". The 3D model group students noted that color-coding was a very helpful learning tool for them, because they were able to manipulate the 3D model to explore the internal structure of the brain stem. Promoting spatial understanding is achieved by Kinesthetic learning which enhances knowledge retention by allowing students to actively manipulate challenging anatomical structures (28) (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In addition to building a foundation for surgical and radiological applications, it is necessary to have basic anatomical understanding(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) based on spatial skills (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAccording to the highly positive feedback from the 3D model group, we found that many of the characteristics of the 3D model were ideal and satisfied the preferences of the students. This results clearly demonstrated the consistency with the previous studies about the increased learning satisfaction of students (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), and pediatric residents (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) has been illustrated by using 3D printed models as teaching tools.\u003c/p\u003e\u003cp\u003eIn conclusion, this study explains how a highly detailed 3D brain stem model can be used to create a mobile, kinesthetic, and reasonably priced teaching tool for use in medical education. According to survey analyses, students' understanding of the brain stem is greatly enhanced by the 3D model.\u003c/p\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eLimitations of the study\u003c/h2\u003e\u003cp\u003eDespite the success of this model demonstrated in improving student performance and enjoyment during brain stem education, a significant limitation is that long-term effects of this model were not made clear given the short time frame of the study. This should be considered in future experiments to follow up how the effectiveness of the 3D model at the end of semester.\u003c/p\u003e\u003cp\u003eIt was better to build up this model with 3D printer but given that the Polylactic Acid (PLA) as the main material of the 3D printer is an opaque material, we could not use this method for making resin shell. A final limitation of this study relates to ensuring that the sessions were simultaneous, it should be noted that the professors for each group were different. To minimize bias, the professors in both groups had comparable training and experience.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOverall, the results strongly suggest that 3D physical modeling is a useful method for teaching and learning neuroanatomy and helping students visualize the structure of the brainstem. We believe that 3D model of brain stem is suitable method for better comprehension of neuroanatomy. These kinds of hands-on tools can help students learn anatomical structures more effectively. The 3D fabricated brainstem model makes it easier and more enjoyable for students to have an active role in learning and gives students a better 3D understanding.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\u003cp\u003e\u003ch2\u003eHuman Ethics \u0026amp; Consent Declaration\u003c/h2\u003e\u003cp\u003eThis study involving human participants was conducted in accordance with the Declaration of Helsinki. Ethical approval was granted by the research ethics committee of \u0026ldquo;Alzahra Research Centers\u0026rdquo; Institutional Review Board (IRB) (Approval No: IR.ARI.MUI.REC.1402.032). Written informed consent was obtained from all participants prior to participation.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eConsent to Participate\u003c/h2\u003e\u003cp\u003eAll participants provided written informed consent.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eEthical Standard Cited\u003c/h2\u003e\u003cp\u003eConducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting Interests\u003c/h2\u003e\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis study was supported in part by a grant received from the Isfahan University of Medical Sciences and Health Services, Tehran, Iran (grant number: 140212).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMansour Homayoun conceived and designed the research; Mehrnoush Malekzadeh performed the research and acquired the data. Samin Shafiei analyzed and interpreted the data and Saeed Zamani drafted the commentary. All authors were involved in drafting and revising the manuscript\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors acknowledge and thank all study participants for their time and cooperation. We furthermore also acknowledge the Department of Anatomical Sciences at Medical Sciences of Isfahan University, for making it possible to conduct this study. The authors thank the Isfahan University of Medical Sciences and Health Services, Isfahan, Iran.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGhosh SK. 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Anat Cell Biol. 2020 Mar;53(1):48\u0026ndash;57. \u003c/li\u003e\n\u003cli\u003eAzer SA, Azer S. 3D Anatomy Models and Impact on Learning: A Review of the Quality of the Literature. Heal Prof Educ. 2016 Dec 1;2(2):80\u0026ndash;98. \u003c/li\u003e\n\u003cli\u003eUllman S. Three-dimensional object recognition based on the combination of views. Cognition. 1998 Jul;67(1\u0026ndash;2):21\u0026ndash;44. \u003c/li\u003e\n\u003cli\u003eAl-Ani SA, Chandla D, Delieu J, Yu ST, Fratini A, Gkountiou R, et al. Use of 3D foot and ankle puzzle enhances student understanding of the skeletal anatomy in the early years of medical school. Surg Radiol Anat. 2024;46(9):1429\u0026ndash;38. \u003c/li\u003e\n\u003cli\u003eArantes M, Barbosa JM, Ferreira MA. Neuroanatomy education: The impact on perceptions, attitudes, and knowledge of an intensive course on general practice residents. 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Evaluation by medical students of the educational value of multi-material and multi-colored three-dimensional printed models of the upper limb for anatomical education. Anat Sci Educ. 2018;11(1):54\u0026ndash;64. \u003c/li\u003e\n\u003cli\u003ePintrich PR, Marx RW, Boyle RA. Beyond Cold Conceptual Change: The Role of Motivational Beliefs and Classroom Contextual Factors in the Process of Conceptual Change. Rev Educ Res [Internet]. 1993 Jun 1;63(2):167\u0026ndash;99. Available from: https://doi.org/10.3102/00346543063002167\u003c/li\u003e\n\u003cli\u003eChan LK, Cheng MMW. An analysis of the educational value of low-fidelity anatomy models as external representations. Anat Sci Educ. 2011;4(5):256\u0026ndash;63. \u003c/li\u003e\n\u003cli\u003eCorton MM, McIntire DD, Wai CY, Ling FW, Wendel GDJ. A comparison of an interactive computer-based method with a conventional reading approach for learning pelvic anatomy. Am J Obstet Gynecol. 2006 Nov;195(5):1438\u0026ndash;43. \u003c/li\u003e\n\u003cli\u003eEllington DR, Shum PC, Dennis EA, Willis HL, Szychowski JM, Richter HE. Female Pelvic Floor Immersive Simulation: A Randomized Trial to Test the Effectiveness of a Virtual Reality Anatomic Model on Resident Knowledge of Female Pelvic Anatomy. J Minim Invasive Gynecol. 2019;26(5):897\u0026ndash;901. \u003c/li\u003e\n\u003cli\u003eBlack SJ, Everhart DE, Durham TW, Walker M, Golden J, Demaree HA. The effects of anxiety on affective learning and serial position recall. Int J Neurosci. 2008 Sep;118(9):1269\u0026ndash;85. \u003c/li\u003e\n\u003cli\u003eStang DJ. Effects of \u0026ldquo;mere exposure\u0026rdquo; on learning and affect. J Pers Soc Psychol. 1975 Jan;31(1):7\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eLanglois J, Bellemare C, Toulouse J, Wells GA. Spatial abilities and anatomy knowledge assessment: A systematic review. Anat Sci Educ. 2017 Jun;10(3):235\u0026ndash;41. \u003c/li\u003e\n\u003cli\u003eTanner K, Allen D. Approaches to biology teaching and learning: learning styles and the problem of instructional selection--engaging all students in science courses. Cell Biol Educ. 2004;3(4):197\u0026ndash;201. \u003c/li\u003e\n\u003cli\u003eRochford K. Spatial learning disabilities and underachievement among university anatomy students. Med Educ. 1985 Jan;19(1):13\u0026ndash;26. \u003c/li\u003e\n\u003cli\u003eCrafts TD, Ellsperman SE, Wannemuehler TJ, Bellicchi TD, Shipchandler TZ, Mantravadi A V. Three-Dimensional Printing and Its Applications in Otorhinolaryngology-Head and Neck Surgery. Otolaryngol neck Surg Off J Am Acad Otolaryngol Neck Surg. 2017 Jun;156(6):999\u0026ndash;1010. \u003c/li\u003e\n\u003cli\u003eWanzel KR, Hamstra SJ, Anastakis DJ, Matsumoto ED, Cusimano MD. Effect of visual-spatial ability on learning of spatially-complex surgical skills. Vol. 359, Lancet (London, England). England; 2002. p. 230\u0026ndash;1. \u003c/li\u003e\n\u003cli\u003eGaras M, Vaccarezza M, Newland G, McVay-Doornbusch K, Hasani J. 3D-Printed specimens as a valuable tool in anatomy education: A pilot study. Ann Anat = Anat Anzeiger Off organ Anat Gesellschaft. 2018 Sep;219:57\u0026ndash;64. \u003c/li\u003e\n\u003cli\u003eLoke YH, Harahsheh AS, Krieger A, Olivieri LJ. Usage of 3D models of tetralogy of Fallot for medical education: impact on learning congenital heart disease. BMC Med Educ. 2017 Mar;17(1):54. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Brain stem, Education, 3D model, Internal structures","lastPublishedDoi":"10.21203/rs.3.rs-6747723/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6747723/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMedical students and other professionals in the field of neuroscience need a comprehensive understanding of the anatomy of the brain stem. Physical models have shown promise for teaching anatomy and increasing learning level. It is necessary to create a model that can reveal the internal structures of the brain stem, such as the functional component of cranial nerve nuclei and neural pathways, as the models currently available for educational purposes only depict the external features.\u003c/p\u003e\u003cp\u003eIn this study, we implemented and evaluated a novel 3D model showing the internal structures of the brain stem. 59 medical students offered their time to assess the impact of this 3D model. In the anatomy lab, 29 students received traditional instruction as a lecture group, while the others received instruction on the brain stem as a 3D model group. The participants were evaluated both before the start and after completion of the intervention. Participants' level of satisfaction with the value of the 3D model was also assessed. The 3D model group mean score was found to be significantly higher than that of the lecture group based on the results. Students were more satisfied with the educational process as a result of the satisfaction.\u003c/p\u003e\u003cp\u003eOur results suggest that 3D model of brain stem is an effective method for teaching internal structures of the brain stem and will better prepare students for learning and visualization of functional component of cranial nerve. Additionally, it ensures a higher level of student satisfaction throughout the learning process.\u003c/p\u003e","manuscriptTitle":"Innovative Educational Three-Dimensional Model of the Human Brainstem: Enhancing Neuroanatomy Learning for Medical Students","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-31 16:09:28","doi":"10.21203/rs.3.rs-6747723/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fce0d5e3-2007-4712-94a7-50f64f18baf5","owner":[],"postedDate":"July 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-18T12:08:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-31 16:09:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6747723","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6747723","identity":"rs-6747723","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}