By Geeta Lal
Almost 3 years ago, I woke up with a familiar throbbing pain in my left jaw and face. My first brush with it was four years prior, while caregiving for my mother with cancer. “Stress and teeth grinding…” said the well-meaning oral surgeon I saw, and proceeded to advise soft foods, muscle relaxants and NSAIDS for what was diagnosed as myofascial temporomandibular dysfunction (TMJD). That episode resolved and aside from some intermittent discomfort, I had done reasonably well. This time, however, things were different. The usual measures weren’t helping, and as the days and weeks wore on, the pain extended to my head, neck, shoulder, and upper back – and it refused to go away.
My journey to feeling better has involved many imaging studies, specialist consults, and treatment modalities. But what I didn’t know was that a major contributor for TMJD was the exaggerated head-down posture I had held for many hours during the previous 12 years of my career as an endocrine surgeon. In fact, each 15 degrees of forward flexion of the neck increases the load on the C-spine by several kilograms. In addition, using surgical loupes for magnification causes more pronounced neck hyperflexion. The net result is an activation of the proprioceptive reflexes that then engages other muscles (of the jaw) to keep the head aligned on the spine. Antagonistic co-contraction of these muscles thus leads to symptoms that fall under TMJD. It became pretty easy to see why I was having pain and how adding a headlight (which I had long abandoned) to this could only aggravate the situation further.
My struggles spurred a deeper dive into the injuries faced by surgeons during their careers. I was appalled to discover that musculoskeletal (MSK) problems have been reported in surgeons of almost every specialty – with minimally invasive procedures carrying the highest risk . Not surprisingly, only a small proportion of surgeons report their symptoms or seek treatment for them. However, this doesn’t diminish their impact as MSK pain has been shown to correlate with both professional satisfaction and burnout and the reason many surgeons choose to retire early. This not only has significant financial and workforce implications, but also affects the quality of patient care as 30% of surgeons report taking their own physical symptoms into account when recommending a particular surgical approach.
There are additional sobering statistics. Kokosis et al. recently demonstrated that 52% of plastic surgery residents reported developing MSK symptoms within the first 2 years of training but only 22% had received some type of ergonomics training. More worrisome is that almost 75% of medical students surveyed in a multi-institutional study endorsed MSK pain during their surgical rotation. Furthermore, their interest in entering surgery decreased significantly when made aware of the literature regarding the incidence of MSK injuries in surgeons.
So, what do we do? The first step would be to increase awareness among all surgeons, but especially for our trainees. Surgeons need to be involved in instrument design from product inception. Early research in a multicenter randomized-control study has demonstrated the positive impact of a preventative program (using ergonomic principles in the OR and exercises supervised by physical therapists) in improving back pain and overall quality of life. Microbreaks and targeted exercises appear to decrease shoulder discomfort without disrupting focus and OR flow. Such behavioral interventions are crucial but preserving the health of the current surgeon workforce and safeguarding future generations also needs systematic organizational support and commitment. We should be teaching our residents not only how to operate but also how to do so without compromising their physical health and wellbeing.
Geeta Lal MD MSc FRCS(C) FACS is Associate Professor of Surgery at the University of Iowa and a fellowship-trained endocrine surgeon with extensive experience in thyroid and parathyroid surgery, including re-operative surgery and pediatric thyroid cancer. She serves as Co-Leader of the Endocrine Multi-disciplinary Oncology Group at the Holden Comprehensive Cancer Center and also headed and NIH-funded basic science lab focused on the role of ECM1 in thyroid, breast and other malignancies for many years. She has since transitioned to an administrative role as the Associate Chief Quality Officer for Adult Inpatient services at her institution. She chairs the AWS Grants and Fellowship Committee and the American Association of Endocrine Surgeons’ Information Technology committee. In addition, she has authored or co-authored numerous peer-reviewed articles and book chapters related to her areas of interest. She is committed to increasing awareness and developing solutions to counteract the impact of poor ergonomics on surgeons’ professional and personal lives.
Follow her on Twitter @GeetaLalMD
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