The UpSurgeOn hands-on-touch non-cadaver training was biphasic and took place in four medical schools in Cameroon; the universities of Bamenda, Buea, Garoua, Douala, and the Yaounde military hospital. The first phase consisted of lectures on neuroembryology, neuroanatomy, and neurophysiology presented by consultant neurosurgeons, senior residents, and members of the Association of Future African Neurosurgeons (Figure 1). The second phase was practical and consisted of hands-on-touch learning using the UpSurgeOn non-cadaveric neuroanatomy models (Figure 2). Four to five students or neurosurgery residents operated on the same non-cadaver brain box models under the supervision of at least one neurosurgeon tutor (Figure 3).

The overall number of participants in attendance was over 1,000. All participants in the training were aspiring neurosurgeons (medical students, early career physicians, or neurosurgery residents) with basic knowledge of embryology, anatomy, and physiology of the central nervous system and the skull. The course was run for eight hours on a single day at the various institutions mentioned above. All necessary surgical instruments to perform the surgery were provided, and the procedures mimicked the real surgical setting (Figure 4). The procedures included craniectomies, skull drilling, exploration of intracranial aneurysms, and skull base visualization just to name a few.

We designed a standardized anonymous questionnaire using Google Forms (Google, USA) in Cameroon's official languages (French and English). The questionnaire was validated by IE (consultant and academic neurosurgeon). A convenient sampling method was used to recruit our study of participants from the students who attended the course. This 35-item questionnaire featured a combination of multiple-choice and Likert-scale questions divided into eight sections. These questions aimed to capture data on (i) basic sociodemographics; (ii) previous experience and exposure to neuroanatomy; (iii) previous experience and exposure to neurosurgery; (iv) previous experience with the UpSurgeOn neurosurgery tool; (v) perception of the UpSurgeOn neurosurgery tool; (vi) attitudes towards the UpSurgeOn neurosurgery tool; (vii) impact of the UpSurgeOn neurosurgery tool to neurosurgical training (Supplementary Material).

The questionnaire was distributed following the training via the Whatsapp and Telegram social media platforms of the participants. The anonymized dataset collected is available on the Open Science Framework (https://osf.io/dyfh5/).

The data collected were tidied on Excel 2016 (Microsoft Corp., USA). Summary descriptive statistics were generated, and the Chi-Square test was used in SPSS v26 (IBM, USA). To ease the analysis, the Likert scale was broken down into three categories. Strongly agree and agree merged as agree, and strongly disagree and disagree merged as disagree. The threshold of significance was set at p < 0.05.

Cameroon counts nine medical schools with a population of about 28.4 milion people and a density of 56/km2 (17). Its Surgical Preparedness Index is 81 +/− 12.5 which is one of the highest in central Africa, indicating that Cameroon has a better healthcare system than most other LMICs (18). We recruited a total of 86 students from six medical schools in Cameroon who attended the UpSurgeOn training and completed the post-training questionnaires. Amongst the respondents, 61.6% were male (n = 53) and the mean age was 21.2 ± 1.868 years. Up to 62.8% (n = 54) of respondents were in their preclinical years of medical school, while 37.2% (n = 32) were in their clinical years of medical school.

Before the training, most participants had a fair knowledge of neuroanatomy (n = 25, 29.4%) (Figure 5). Textbooks (n = 50, 60.2%) and Youtube videos (n = 49, 59.0%) were the most common neuroanatomy learning tool employed (Figure 6), and 91.5% (n = 75) had never performed a neuroanatomy/neurosurgery cadaver lab dissection.

For neurosurgery experience, Textbooks, and Youtube videos were the most common (n = 39, 51.3%) neurosurgery learning tools used before the training (Figure 7). Only 22.6% (n = 19, N = 84) and 17.6% (n = 15, N = 85) had witnessed and performed at least one craniotomy, respectively. Of those with prior craniotomy experience, 17.9% (n = 5) were main operators, 25% (n = 7) were second operators, and the temporal box was the most common brain box (n = 11, 40.7%) to which they were exposed (Figure 8). Previous surgical microscopes and neurosurgical instrument use were common in 11.1% (n = 9) and 15.5% (n = 13) of the participants, respectively.

The majority found UpSurgeOn Box easy to use (60.9%), needed to learn just a few things before getting acquainted with the UpSurgeOn Box (60%), and neurovascular structures and skull base anatomy were realistic and appropriately detailed for surgical orientation (58.6%) (Table 1).

Most would like to use the UpSurgeOn Box frequently (76.7%) and advocate for the incorporation of this method of training into the standard training curriculum (67.1%) (Table 2). However, only 24.6% agreed that they would not need the support of a technical person to be able to use UpSurgeOn Box (Table 2).

Up to 68.7% (n = 57) had no use of the UpSurgeOn Neurosurgery App and the AR simulator. More than half of the participants affirm that using this model has helped to increase their familiarity and to acquire neurosurgical skills (62.3%), and has helped to develop their orientation skills needed during neurosurgical approach, in addition to traditional resources (59.7%) (Table 3).

To the best of our knowledge, this study is the first to assess access the perception, impact, and attitudes towards using 3D printed non-cadaveric models for neurosurgery/neuroanatomy education in Africa. Our study highlights that knowledge of neuroanatomy wasn’t optimal, traditional sources of learning were used and exposure to neuroanatomy/neurosurgery cadaver lab dissection was scarce in this context. Also, there was little exposure to neurosurgical procedures and experience with the use of a surgical microscope/neurosurgical equipment. Moreover, the majority were using the UpSurgeOn app for the first time, found the box easy to use, were willing to use it more frequently, were happy for it to be integrated into the medical training curriculum, and using this model has helped to increase their neurosurgical skills.

The training of medical students in Cameroon incorporates the provision of explicit anatomy practicals which includes cadaveric dissections (19). Cadaveric dissections are essential for adequate anatomy exposure amongst African students (7, 20, 21). Despite this knowledge, African countries such as Cameroon are faced with multifaceted barriers to performing dissections including neuroanatomy dissections (10, 11). In this study, almost all the participants had never performed a neuroanatomy/neurosurgery cadaver lab dissection. As a result, these students are forced to turn to other traditional and online resources to acquire anatomy knowledge. In our study, the majority used digital resources for the acquisition of neuroanatomy knowledge. Despite these sources being accessible, they can be misleading, inaccurate (22), and disable the student from the physical experience with cadavers (8, 9). As a result of this learning curve, this will contribute to inadequate neuroanatomy exposure as is the case in this study.

Similar to our study, limited neurosurgery exposure was previously reported in a continental survey by aspiring African neurosurgeons (4). This can be attributed to similar reasons justifying the low exposure to neuroanatomy mentioned above. Also, the lack of an affiliated neurosurgery facility, limited neurosurgery lectures, and ultimately the lack of a neurosurgery mentorship in medical schools are known to be key contributors to this deficit (4). A considerable proportion of participants in this study have neither witnessed or performed a craniotomy, nor have previously used a surgical microscope or neurosurgical instrument. This explains why majority use Textbooks and Youtube to gain neurosurgical experience. Also, the main factors contributing to this deficit include; The paucity of neurosurgical centers in Cameroon limits their exposure (23). Moreover, Cameroon neurosurgeons are overburdened, limiting the time allocated for education and mentorship (24).

Acknowledging the neurosurgical workforce deficit and the burden of neurotrauma in Africa (25, 26), evoked strategies to attain global neurosurgical goals such as task shifting (27, 28) improving undergraduate exposure to neurosurgical practices early in their career is essential (4). Neurosurgery/neuroanatomy exposure can be improved in multiple ways. First and foremost, enhancing mentorship with existing neurosurgery interest groups (29, 30). This will serve as a vehicle to connect medical students, with trainees and consultants in neurosurgery via educational activities. Participating in conferences, symposiums onsite and online has also been advocated (31). Also, the organization by the available neurosurgical centers of continental annual or bi-annual neurosurgery boot camps taking into consideration regional level of excellence and geographical proximity will improve the neurosurgical know-how of undergraduate students (4, 32). A valid strategy to improve at the same time for neurosurgery exposure and cadaver dissection which is crucial to neurosurgical training is the use of hands-on-touch non-cadaver model for neuroanatomy/neurosurgery learning such as the UpSurgeOn models (33, 34).

Gradually migrating from traditional cadaver dissection to cadaver-free laboratories, the place of neurosurgery simulators such as the UpSurgeOn tool is indisputable. Results from our study have it that it is easy to use and easy to get acquainted with, sanctioned by a 60% and 60.9% scores on our study. This is consistent with a similar study carried out using UpSurgeOn tools, where More than 89% of the residents assessed that the application and the augmented reality simulator were very helpful in improving orientation skills during neurosurgical approaches (34). Indeed, 89.3% of participants found brain and skull anatomy highly realistic during their tasks (34). Moreover, workshop exercises were considered useful in increasing the competency and technical skills required in the operating room by 85.8 and 84.7% of residents, respectively (34). The data collected confirmed that the anatomical model and its application were intuitive, well-integrated, and easy to use. However, the lower score in our study (60.9% as opposed to 89%) could be liked to the difference in the academic level of the participants involved, as more of our participants were undergraduates, compared to residents in the latter study, who are considered to have a better appraisal and understanding of the general concepts of neurosurgery, and neuroanatomy.

Given the positive perception of the UpSurgeOn Neurosurgery App, it is not surprising that the majority of our participants would like to use it and advocate for its integration into the national medical curriculum as a teaching tool. This demonstrates its efficiency in facilitating the teaching of neuroanatomy and neurosurgery to imporove knowledge transmission in neurosurgery teaching centers.However, only 24.6% of our participants agreed they would not need the support of a technical person to be able to use UpSurgeOn Box. This emphasizes the degree of independence this tool provides to trainees in the acquisition of neurosurgery and neuroanatomy knowledge.

The results from this study have a few limitations. Our first limitation is that the questionnaire was a one-phase questionnaire. Other studies propose a two-phase questionnaire (pre-test and post-test) to better access the knowledge and practices of participants before and after the training and the impact the training had on their experiences. Our second limitation is that the questionnaire's questions may not have been appropriate to the target population of the survey. Our questionnaire was guided by previous studies, and were filled after the training. The third limitation is that some faculties did not involve the whole student body in the training, as just a few selected classes were allowed to partake in the training due to the measures aimed at reducing overcrowding in line with COVID-19 barrier measures still practiced in Cameroon at the time of our training. The fourth limitation is our sample size which was less than the number of participants in the training. This sample size is also not reflective of the medical student population in Cameroon. We are aware this might affect the generalization of our results. However, the findings gotten are from varied medical schools in Cameroon and truly reflect their realities. Finally, the qualitative nature of this study cannot be undermined, as there was very little quantitative sampling in our study.

Based on the results of this study, it is appropriate to believe that there is a need for a more inclusive study on this topic involving a majority of students from all medical schools in Cameroon and other African countries. Our results emphasize the impact of simulation tools in facilitating the acquisition of neuroanatomy and neurosurgery knowledge by trainees, therefore stakeholders responsible for policy-making and curriculum drafting for medical schools should consider facilitating the utilization of these simulation tools in the training of our healthcare professionals. Our study provides companies and institutions involved in the production and distribution of simulation tools with evidence of the positive impact of these tools on trainees, this should encourage organizations that are involved in improving surgical education and care in low-resourced settings to provide training institutions in these settings with these simulation tools to accelerate neurosurgery training and increase the neurosurgical workforce in these settings.