Comment on: Work-Related Musculoskeletal Discomfort and Injury in Microsurgeons
25 August 2019 (online)
We read with great interest the recent article by Howarth et al titled “Work-related musculoskeletal discomfort and injury in microsurgeons.” In this study, the authors performed a very timely and important survey of musculoskeletal problems, specifically in microsurgeons.
Last year, we published a survey of 865 plastic surgeons in the United States, Canada, and Norway. We found that United States plastic surgeons had a significantly higher risk of having work-related musculoskeletal symptoms than Norwegian plastic surgeons. We also compared plastic surgical subspecialties. The microsurgeons in our study were at the highest risk for discomfort in the shoulders and upper back.
Howarth et al found that the use of loupes and microscope was associated with musculoskeletal discomfort. Interestingly, most studies have not identified a link between the use of modern lightweight loupes and musculoskeletal discomfort. On the other hand, microscope-related discomfort is likely due to three very common ergonomic errors that we identified in our study:
Forward head position: This is the typical position of a surgeon using a microscope. Microsurgeons should be aware that the effective weight of the head, as perceived by the cervical spine, increases by 10 pounds for every inch that the head is positioned forward. This can lead to significant cervical and shoulder discomfort and long-term damage. Surgeons should be cognizant of this issue, and consciously ensure that their neck is vertical rather than forward-leaning.
Sustained shoulder elevation: This is also a common ergonomic error among microsurgeons. One way to address it is to consciously relax one's shoulders, and to make sure the operating table is not too high. Surgeons should also avoid prolonged static positioning, as this has been associated with higher muscle strain. Taking frequent 30-second microbreaks after every few stitches under the microscope reduces the risk of musculoskeletal injuries.
Pelvic girdle asymmetry: This occurs when microsurgeons have to partially lean over the patient and twist their body to align it with the microscope. This is common in microsurgical breast reconstruction when the patient's arm boards are at a 90 degrees angle, and the microsurgeon has to twist their body around the arm board to reach the microscope. We wholeheartedly agree with the adjustments described in Table 2. Surgeons must adapt the operating room to their body, and make frequent adjustments to bed position as needed.
One strategy that we explored in our study was the adoption of habits outside the operating room in order for surgeons to condition their bodies for the “endurance sport” of surgery. Many surgeons stated that adding core-strengthening and stretching exercises to their daily routines reduced their work-related musculoskeletal symptoms.
Surgeons must pay careful attention to their bodies early in their careers. While work-related musculoskeletal symptoms may initially be sporadic and isolated to the time period during or immediately after a physically-demanding operation, they may become chronic and constant as the surgeon ages. Our study found that 13.6% of plastic surgeons were in constant chronic pain, and that 6.7% had required surgery to treat their symptoms. The authors' findings that 29% of plastic surgeons sought medical treatment for their symptoms, and 8% required time off for rehabilitation, add valuable data to this body of literature. Surgeons must be aware that, in order to best take care of their patients, they have to take care of themselves too.
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