Surgery Is a Contact Sport

It was several months after my C5-C6 spine disk replacement surgery when I learned that i it is commonplace for surgeons to have C5-C7 cervical spine problems. Interesting. Why had I never heard of this before? Not once during training, during my time as an attending or after participating in numerous surgical conferences had I ever come across this information. But clear as day, to others, my problem was not unique. I was just another surgeon suffering the same spine problems that so many before me had suffered. If I am not the first, then I surely will not be the last. We must stop ignoring surgeons’ physical health and actively promote prevention.

It was this realization that jogged my memory from surgical internship. “Surgery is a contact sport.” Almost 20 years ago, I first heard this statement from my senior resident. It was said many times throughout my residency, and I probably repeated it to interns and junior residents as I progressed in my training. It is possible that many of you have also heard this statement or repeated it to others. But until now, I did not fully comprehend what it meant.

Surgery is a mentally, emotionally and physically demanding profession. We spend countless hours in the OR for many years acquiring skills to operate safely and care for our patients. We learn disease processes, treatments and surgical techniques with increasing complexity and responsibility. We are expected to stand for hours—bodies contorted—to get the correct exposure, to perfect the dissection and complete the operation with the patient’s physical well-being as the main goal. But what we rarely take into consideration is the surgeon’s physical well-being.

Without a doubt, the patient’s welfare is the foremost consideration for every operation. But ignoring surgeons’ physical well-being does a disservice to our patients and our profession.

“Surgery is a contact sport” because surgeons are the endurance athletes of medicine. Athletes physically train their bodies to be able to maximally perform and avoid injury. So, why it is that, as surgeons, we don’t train our bodies to endure the repeated physical demands of our job?

In surgery, ergonomic modifications are helpful, but have their limitations, especially with challenging operations. Surgery-specific physical endurance training and body mechanics retraining can make a difference. Just as athletes train, continuously and without fail, surgeons should physically train. Regular, scheduled physical training with very specific body mechanics and strength training for surgeons can help to lower the chances of surgeon-specific physical problems.

Body mechanics for surgeons is rarely discussed. Body mechanics is defined as “the study of the action of muscles in producing motion or posture of the body” (Farlex Partner Medical Dictionary, 2012). There are techniques of body mechanics retraining that can help minimize the chances of physical injury, especially during lengthy and difficult cases. These techniques are the ally of correct ergonomics; the two fields are necessary and collaborative. By applying correct body mechanics and using larger muscle groups, stress can be off-loaded away from the neck, back and arms of a surgeon. But this type of massive change to physical behavior is not intuitive. It requires surgeon-specific body mechanics and strength training and retraining, along with continued regular maintenance during dedicated time.

It is time we bring the importance of surgeons’ physical well-being to the forefront of practice. We must recognize that the problem exists, then quickly, as a community of surgeons, make the concerted effort to maximize prevention, set aside regular time for body mechanics and strength training, and not be hesitant to seek medical attention if any pain or problems are ongoing. We are the endurance athletes of medicine, and we must start acting as such. Together, we can improve physical health and increase career longevity for all surgeons. Together, we can ensure the future of surgery—resolute with enduring strength and health.

Below, we highlight some techniques that can help surgeons get started on their body mechanics and strength training routines. Jarel Russell, OTR/L, is a doctor of occupational therapy with certifications in orthopedic manual therapy, concussion rehabilitation and advanced hand therapy. He specializes in treating surgeons.

Dr. Russell has developed Elite Prehab, an individualized program for surgeons to improve specific body mechanics, functional strengthening, postural retraining and neuromuscular reeducation. The goal is to maximize career longevity and minimize career-related physical injuries. Dr. Russell has a background in the prehabilitation/rehabilitation of combat athletes and blood flow restriction therapy.

As with any other physical training program, a thorough evaluation and skilled progression through a treatment program with a specialist is best to maximize therapeutic results and prevent further injury. For surgeons with current neck, back or arm pain, please do not ignore or disregard the problem; get evaluated and maximize correction and treatment as much as possible.

By JAREL RUSSELL, OTR/L By

The C5-C7 cervical spine segment is frequently affected by poor posture and highly susceptible to pathologic diseases such as degeneration, disk herniation, radicular pain and trauma. By design, the C1-C2 segments are the load-bearing joints during upright activity. However, when surgeons are performing open operations, the C5-C7 cervical segments function as high load-bearing joints. These segments provide flexibility and support to much of the neck while in an operating posture. Not having adequate muscle balance while operating results in pathology of these spinal segments. Pain is a precursor that signals the beginning of a problem. If pain is ignored, the disease process progresses.

Key concepts of pain science explain the interaction of pain and prolonged operating posture. The three key concepts are: • trauma • muscle imbalance • compensatory movement patterns

Altered movement patterns

Muscle imbalance

Each of these key components feeds into the other. The figure below illustrates that it does not matter which event occurs first. Prolonged operating posture is a hidden component that can lead to further advancement along the pain continuum.

While the research does not support the ideology of “perfect posture,” every individual has an ideal posture that can aid in the prevention of injuries. The foundation to optimal posture is built upon a strong core. The concept of the “core” muscles is more extensive than most people realize and encompasses numerous muscle groups, as illustrated to the right. The core plays a role in almost every movement the body makes. From walking to running to sitting, picking up objects from the floor or top shelf, to maintaining a prolonged posture during a surgical procedure, your core is activated and supporting you during all these activities. A strong core can help prevent forward head posture to stabilize the C5-C7 cervical segments for surgeons.

The other two muscle groups that stabilize the cervical spine are the periscapular and deep neck flexor muscles. Weak periscapular muscles often lead to muscle imbalance and upper crossed syndrome. With upper crossed syndrome, the shoulder, chest and neck muscles are imbalanced with some being weak and others tight. The syndrome is a component of poor posture of the shoulders and upper back. The deep neck flexors help to maintain neck stability and are an essential component of good posture.

External (but also internal) obliques Diaphragm Multifidus Erector Spinae

Rectus Abdominis Pelvic Floor Muscle Quadratus Lumborum

Transversus Abdominis

Research shows that 70% of people with chronic neck pain have weak deep neck flexor muscles (J Phys Ther Sci 2016;28[1]:269273). Strengthening these muscles involves a neuromuscular reeducation program that should be completed with a specialist.

I would like to stress that therapy should be used for both prevention and recovery. Typically, the underlying pathology is complex, and stretching alone is not a good treatment. However, it is useful when combined with an individualized program consisting of strengthening and orthopedic manual therapy techniques. This is the premise behind the Elite Prehab program for surgeons. Elite Prehab involves individualized orthopedic evaluation using differential diagnosing, postural analysis and neurodynamic assessment. The goals are twofold. The first goal is to uncover the underlying reason for pain and muscle imbalances to fully understand the pathology impeding performance. The second goal is prevention of any future problems that commonly plague surgeons.

Each surgeon should have a customized program for their unique situation. The exercises can be easily incorporated into normal daily routines. The goal of the program is to maximize performance of essential job-related tasks, while improving function of everyday activities. It is skilled progression through a treatment and prevention program with neurodynamic cervical stabilization and strength/balance restructuring that can prevent problems, relieve pain and allow surgeons to maximize career longevity in the context of optimal physical health. ■

—Dr. Tejirian is a general surgeon in Los Angeles.

—Dr. Russell is a doctor of occupational therapy with certifications in orthopedic manual therapy, concussion rehabilitation and advanced hand therapy, in Los Angeles. He specializes in treating surgeons.