In July 2019, Talar Tejirian, MD, had surgery to repair a herniated disk at the C5-C6 vertebrae, which provides flexibility and support to the neck. The operation went well. Aside from a stiff neck, she felt pretty good.
However, Dr. Tejirian’s condition soon deteriorated during the physical rehabilitation process. Her physical therapist noted weakness in her right arm and started her on a weight lifting regimen, bypassing standard exercises to improve her range of motion.
She soon developed new, more severe pain in her right arm.
“I knew something was wrong,” said Dr. Tejirian, a general surgeon at Kaiser Permanente in Los Angeles. “I had never before experienced this type of pain.”
A nerve conduction test delineated the problem. The results hit her hard.
“The damage to my right arm at that point was irreversible,” she said. “My window of opportunity for the nerve function to fully recover had passed.”
She would never operate again.
To help cope with the news, Dr. Tejirian began researching her injury. She was surprised to learn that work-related injuries, especially along the C5 to C7 vertebrae, are common among surgeons. A 2017 analysis found that most surgeons—up to 90%—experience pain in the back, neck and hands, and almost 28% reported an injury or a chronic condition (J Am Coll Surg 2017;224:16-25.e1). Years of standing in the OR for long procedures, contorted in static positions while maneuvering delicate tools, will eventually take its toll on the body (Surgeons as Educators. Springer; 2017:387-417).
“Surgery is a demanding job and that won’t change, but small problems can add up over time and we can make changes to reduce our risk of injury,” said Scott Hollenbeck, MD, the vice chief of research and an associate professor of surgery in the Division of Plastic, Maxillofacial, and Oral Surgery at Duke University School of Medicine, in Durham, N.C.
But few institutions provide ergonomics education and training, and surgeons may be hesitant to get help. A 2018 meta-analysis, evaluating 40 papers, found that almost 70% of 5,152 surgeons surveyed reported pain from operating—most frequently in the back (50%), neck (48%), and arm or shoulder (43%)—but only 29% sought care (Ann Med Surg 2018;27:1-8).
“As surgeons, we may push through any kind of pain and believe it’s part of the job,” Dr. Tejirian said. “But it doesn’t have to be, if ergonomics and other preventive techniques are built into a surgeon’s life and training.”
A Pervasive Problem Below the Radar
In 2012, Dhruv Singhal, MD, was in Taiwan, participating in a craniofacial fellowship.
“When my mentor saw me put on a headlight, he stopped me,” said Dr. Singhal, the director of lymphatic surgery and an associate professor at Beth Israel Deaconess Medical Center, in Boston. “He pointed out how the headlight forced me to crane my neck to move the light where I wanted it. He gave me handheld retractors equipped with lights so I could just manipulate my hands, not my neck.”
The full significance of this informal feedback became clear several years ago, when Dr. Singhal found himself attending more and more lectures on the prevalence and impact of work-related musculoskeletal disorders on surgeons.
The lectures brought him back to this moment in his fellowship. So, when Sherise Epstein, MD, MPH, a medical student at the time, came to him about studying this issue more deeply, Dr. Singhal jumped in.
To understand the scope of ergonomic pain and injury among physicians, Drs. Singhal, Epstein and their colleagues conducted an extensive literature review of studies, published between 1974 and 2016, exploring work-related musculoskeletal disorders. Of the 21 studies analyzed, the authors found a high prevalence of work-related musculoskeletal disorders among more than 5,800 physicians (JAMA Surg 2018;153:e174947). The most common injuries included degenerative lumbar spine disease (19% or 544 physicians), degenerative cervical spine disease (17% or 457 physicians), rotator cuff pathology (18%), and carpal tunnel syndrome (9%).
Of physicians reporting these injuries, 12% needed to take a leave of absence, restrict or modify their routine or retire early. Physicians also highlighted a lack of awareness and education about ergonomic challenges associated with the job.
These results were confirmed when the authors conducted a survey evaluating the current state of surgical ergonomics education in the United States (Ann Surg 2019;269:778-784). With insights from 130 surgical and medical program directors, the authors discovered that only 33 offered informal information on surgical ergonomics and just two provided formal education.
“I think the data are pretty clear: Work-related pain and injuries are real issues for surgeons,” Dr. Singhal said. “But if surgeons don’t know ergonomics are a problem, they will be way behind the 8-ball when it comes to prevention and treatment.”
An Ergonomics Education
By the time Dr. Tejirian found Jarel Russell, OTR/L, an occupational therapist in Glendale, Calif., she knew her days in the OR were over.
During their first session, Mr. Russell asked Dr. Tejirian to share her story.
“Understanding her injury, treatment experiences, where she is in her life and career are essential parts of the therapeutic process,” said Mr. Russell, the clinical director at Flex Motion Physical Therapy who specializes in treating lumbar, thoracic, cervical spine and shoulder pathologies. “Knowing these details helped us build trust and helped me provide a tailored treatment approach.”
Mr. Russell knew Dr. Tejirian faced a long, slow road ahead. He outlined a regimen of targeted exercises to help stabilize the weak points along her spine and back, and train her to recruit her core—what he calls the gateway to everything—to alleviate strain on her back. [Next month, Dr. Tejirian details her story and the specific physical therapy regimen created by Mr. Russell.]
Dr. Tejirian is not alone in her predicament. Many of the surgeons whom Mr. Russell treats come to see him after an injury has become chronic.
“By the time you feel pain, something major is already going on,” Mr. Russell said. “That’s why it’s important to regularly condition the body for our daily activities to create balance and prevent injuries. Increasing awareness and detecting potential issues early also means we can correct these problems before surgery and make sure surgeons can continue operating.”
Currently, two surgery programs in the United States have been leading the way on formal ergonomic education—Mayo Clinic in Rochester, Minn., and Duke University.
Duke Surgery launched its program in early 2017, along with the university’s Ergonomics Division. The impetus came from general surgery residents who discovered the source of their neck pain: poorly fitted loupes.
The residents approached the chair of surgery, Allan Kirk, MD, about starting an ergonomics program to increase education on this kind of problem. As part of that program, the residents proposed a loupe-fitting initiative to help reduce strain on their neck and back.
In addition to adjusting tools and technology to prevent injury in the OR, Dr. Hollenbeck highlighted a range of other strategies: taking short stretching breaks during surgery, wearing support stockings or supportive footwear, and varying procedures performed day-to-day. “But it’s important to remember that no single strategy will solve every ergonomic problem or necessarily work for everyone,” Dr. Hollenbeck said.
That is why Marissa Pentico, an occupational therapist at Duke, began to go to the OR to watch individual surgeons operate, take pictures and meet with them one-on-one.
“After reviewing the pictures with her, you really see yourself differently,” said Dr. Hollenbeck, who learned exercises to counteract the neck pain and finger numbness he began experiencing. “For me, stretching before surgery, just like I would before a run, has made a big difference.”
Although ergonomic education for surgeons has been slow to take hold across the country, Dr. Hollenbeck is starting to observe a shift.
“I’ve seen a growing awareness and urgency surrounding musculoskeletal strain and injury in surgery over the past few years and an openness to discuss these issues,” Dr. Hollenbeck said. “The culture of surgery is changing, and we’re realizing that the old-school approach of ‘never take a break, never complain, never say you’re hurting or weak’ may not be the best way to go through life. Rather, the opposite: Surgeons will be more productive and enjoy a longer career if we address these physical concerns earlier.”
Dr. Tejirian hopes surgeon-specific education and physical training will become non-negotiable elements of surgical training and practice.
“The narrative on musculoskeletal pain and physical injury can change for surgeons,” Dr. Tejirian said. “I can never operate again, I know that. But I hope sharing my experience will help others. I hope I can use my experience to help prevent other surgeons from injury.”
This article is from the July 2021 print issue.
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