Orthopedic Surgery is Dangerous…for the Surgeon!

In a recent survey of the current and 12 former presidents of the Scoliosis Research Society (SRS):

• seven of the 13 had rotator cuff pathologies (one bilateral);
• five had lumbar pathologies, including three cases of herniated nucleus pulposus, two of which were treated surgically;
• three reported having had carpometacarpal joint arthritis, one resulting in retirement;
• one reported lateral epicondylitis;
• a case of carpal tunnel syndrome required bilateral surgery; and
• one suffered an acute distal phalanx fracture during surgery.

That’s a lot of workplace injuries. Is this small sample an anomaly? No, according to Baron Lonner, M.D., Professor of Orthopaedic Surgery at Mount Sinai Hospital and Director, Scoliosis and Spine Associates in New York City, who presented these harsh stats in mid-March at the annual meeting of the American Academy of Orthopaedic Surgeons (AAOS).

Dr. Lonner was also one of the researchers in a larger survey, “Musculoskeletal Disorders Among Spine Surgeons: Results of a Survey of the Scoliosis Research Society Membership” led by Joshua D. Auerbach, M.D., in 2011. Among 561 respondents (of 904 SRS members), that earlier survey found:

“The most common self-reported diagnoses included neck pain/strain/spasm (38%, 215/561), lumbar disc herniation/radiculopathy (31%, 172/561), cervical disc herniation/radiculopathy (28%, 155/561), rotator cuff disease (24%, 134/561), varicose veins or peripheral edema (20%, 112/561), and lateral epicondylitis (18%, 99/561). For lumbar disc disease, 7.1% (40/561 × 100) and for cervical disc disease, 4.6% (26/561 × 100) of spine surgeons underwent surgery.”

Also, “19.1% reported instrumentation-related injury (most commonly superficial cuts/abrasion).”

There were and are contributing factors, the study said. “Among active spine surgeons, multiple linear regression analysis revealed that total caseload correlated with neck pain (P = 0.01) and lower extremity edema (P = 0.03), while the number of deformity cases correlated with wrist pain (P = 0.003) and hand pain (P = 0.03). Age was correlated with shoulder (P = 0.03), elbow (P = 0.04), and hand pain (P = 0.02). Number of years in practice did not correlate with MSDs [musculoskeletal disorder].”

Another likely factor: the pressure to work fast. Both Medicare and private insurance put the entire operating room staff, and especially surgeons, under financial pressure to stay on schedule.

Is the surgeon injury situation improving? No.

Injury rates seem to be steady or, if the number of recent studies dedicated to the subject of physician injuries is any indication, growing worse. A meta-study published in 2018, “Prevalence of Work-Related Musculoskeletal Disorders Among Surgeons and Interventionalists – A Systematic Review and Meta-analysis,” showed somewhat less dramatic, but still shocking injury rates for all surgeons (suggesting that possibly scoliosis surgeons face greater hazard of injury). Of 5,828 surgeons in 21 articles, the pooled crude prevalence estimates of injuries and pathologies were:

• 17% (457 of 2406) suffered degenerative cervical spine disease;
• 18% (300 of 1513) had rotator cuff pathology;
• 19% (544 of 2449) had degenerative lumbar spine disease;
• 9&% (256 of 2449) had carpal tunnel syndrome.

The “Prevalence” study concluded that injury rates have been growing over the years, and that injuries are cutting into surgeons’ careers, both in days away from work and early, injury-related retirement: “From 1997 to 2015, the prevalence of degenerative cervical spine disease and degenerative lumbar spine disease increased by 18.3% and 27%, respectively. Pooled prevalence estimates for pain ranged from 35% to 60% and differed by assessment instrument.”

Of those with a work-related musculoskeletal disease, “12% (277 of 2319) required a leave of absence, practice restriction or modification, or early retirement,” that JAMA Network study reported.

It’s a worldwide surgeon injury epidemic.

A search of Google Scholar with these keywords, “prevalence of musculoskeletal injuries in orthopedic surgeons,” reveals several more U.S. studies published in 2018—and reveals that it’s not just happening here. That one search of a few Scholar pages turned up similarly dire surgeon injury reports from Canada, India, Italy, Korea, Kuwait, Norway, Poland, and Saudi Arabia in 2018, Iran in 2017, and the United Kingdom in 2014.

Nor are orthopedic surgeons the only victims: recent studies say dentists, bariatric, heart, and plastic and reconstructive surgeons are vulnerable as well. Two 2010 studies added laparoscopic surgeons to this list.

Another study, “Work-Related Musculoskeletal Discomfort and Injury in Microsurgeons,” says that microsurgeons who use loupes and microscopes to see what they’re doing are at high risk of a certain range of injuries and pathologies.

Here are some of its numbers: “Half of the surgeons reported pain within 4 hours of surgery, and 57% feared that pain would influence future surgical performance. Surgeon discomfort affected posture (72%), stamina (36%), sleep (29%), relationships (25%), concentration (22%), and surgical speed (19%). Tremor caused by the discomfort occurred in 8%. Medical treatment for discomfort was sought by 29%. Time off work for treatment occurred for 8%.”

Spine surgeons face those risks as well. Dr. Lonner told us that bending over a loupe to see three-dimensionally into a spine is a common source of back pain in scoliosis surgery.

However, the intense, forceful interventions needed for some orthopedic specialties seem to put these surgeons at higher risk than all but dentists, and … veterinary surgeons. They experience the same musculoskeletal issues as orthopedists—but surgeons with human patients are usually spared the bites and scratches reported as veterinary hazards in a 2009 Australian study that popped up in one of our searches.

But where’s OSHA? What’s the government doing to help?

Hospital non-fatal injury rates are far higher than industry generally. Indeed, factories and other industrial businesses have cut their rates from 61 injuries per full-time work equivalents (FTEs) in 2000 to 2.9 injuries per 100 full-time equivalents (FTEs) in 2017. Compare those numbers with hospitals for these selected years:

1997: 10.0
2000: 9.1
2010: 6.5
2014: 6.2
2015: 6.0
2016: 5.5
2017: 5.3

The 2017 rate is still 83% higher than for workplaces overall, but it’s a 47% decrease in hospital worker injuries in two decades.

The Occupational Safety and Health Administration (OSHA) has a hospital microsite, dedicated to concerns about hospital “workers.” Everything about the language at that site suggests that the “workers” of concern to OSHA aren’t surgeons.

While OSHA goes about preventing injuries to other hospital workers, there is “Very little or no practical involvement with physician MS (musculoskeletal) overuse,” Dr. Lonner said in his presentation. At the OSHA microsite, none of the safety suggestions are specific to operating rooms. Some examples of OSHA’s concerns:

• “By implementing a minimal-lift policy and other safety initiatives, Cincinnati Children’s Hospital reduced lost time days by 83 percent in just three years.”
• “After investing $800,000 in a safe lifting program, Stanford University Medical Center saw a five-year net savings of $2.2 million. Roughly half of the savings came from workers’ compensation, and half from reducing pressure ulcers in patients.”
• “Tampa General Hospital’s lift teams have used mechanical lifting equipment to reduce patient handling injuries by 65 percent and associated costs by 92 percent.”
• “By implementing a safe handling program, a small hospital in South Carolina cut turnover of older nurses by 48 percent and saved $170,000 on associated costs.”

But nothing on how to address surgeon injuries.

What should be done?

The SRS presidents Dr. Lonner polled had these suggestions:

• Use power tools for screw placement and bone scalpeling.
• Avoid overhead bins when traveling so as not to lift overhead.
• Use fellows to assist.
• Allow more junior surgeons to do some of the operating grunt work.
• There’s a need for less weighty tools and batteries.
• Maintain general fitness/exercise (see below).
• Wear compression stockings for lower extremity edema and discomfort.
• Get treatment for your own orthopedic problems early.
• Education is needed.

Dr. Lonner suggests also using appropriately sized tools and ergonomic tools, such as screwdrivers which can be used at an angle, and new visualization techniques, including loupes and endoscopes with right-angle mirrors to see into the spine.

He cited a Duke University School of Medicine study which recommends:

• Adjust the height/position of the patient and operating table.
• Alternate postures by sitting when feasible.
• Select the most ergonomic equipment.

Where are the programs to keep surgeons in good physical shape?

As Orthopedics This Week Publisher Robin Young wrote in a 2016 article on this same subject, athletic training can be a vital component in the musculoskeletal health of surgeons:

“At the recently concluded NATA (National Athletic Trainers Association) conference in Baltimore several speakers presented strong data that the athletic trainer model—which is a basic fact of life for both amateur and professional athletes—can effectively lower work place musculoskeletal injuries by 40%, 50%, 60% or more.

“And a wide variety of industries are trying this out.

“Aerospace, auto manufacturing, law enforcement, military and virtually every college or university are embracing the concept of certified athletic trainers in their workforce to assess and treat employees at work…. But not, it would seem, hospitals and clinics—despite the high rate of musculoskeletal injuries and workplace injury absenteeism…. When asked, executives who set up industrial athlete programs told OTW that hospitals and clinics were among the worst industries at adopting the principles of athletic trainers.”

“Whatever the cause,” Robin wrote, “it’s a fact that the hospital athlete could benefit significantly from the athletic training model.”