How to Keep Your Cervical Spine Safe for Your Entire Career : Plastic and Reconstructive Surgery

How to Keep Your Cervical Spine Safe for Your Entire Career : Plastic and Reconstructive Surgery

How to Keep Your Cervical Spine Safe for Your Entire Career
Rohrich, Rod J. M.D.; Alleyne, Brendan M.D.; Bellamy, Justin M.D.; Stuzin, James M.D.
Dallas, Texas; and Miami, Fla.
From the Dallas Plastic Surgery Institute and the Institute of Aesthetic Medicine.
Related digital media are available in the full-text version of the article on www.PRSJournal.com .
Disclosure:Dr. Rohrich receives instrument royalties from Eriem Surgical, Inc., and book royalties from Thieme Medical Publishing, is a clinical and research study expert for Allergan, Inc., Galderma, and MTF Biologics, is a medical monitor for Merz North America, and is the owner of Medical Seminars of Texas, LLC. Drs. Alleyne and Bellamy have no financial interests to disclose. Dr. Stuzin is chairman of the Baker Gordon Symposium on Cosmetic Surgery. No funding was received for this article.
Rod J. Rohrich, M.D., Dallas Plastic Surgery Institute, 9101 North Central Expressway, Suite 600, Dallas, Texas 75231, [email protected] , Twitter: @DrRodRohrich , Instagram: @Rod.Rohrich
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Surgeons are accustomed to long days and strenuous physical feats on our feet—especially in the operating room, where we must stand still and concentrate for hours during surgery. It is a calling that demands both technical skill and physical and mental stamina. Passion and focus drive us to the limit in all we do so our patients can obtain the best results possible. However, all too commonly, the repetitive motion and positioning required to execute procedures can take a toll on our cervical and lumbar spines which, all too often, produce long-term consequences for surgeons.
“Sit when you can. Stand when you must.” This article could be titled “Why I Still Hate the Headlight” as an update to the 2001 article by Rohrich. 1 The principles from this editorial are still valid, but we felt required to update it because of technological changes and an enhanced understanding of ergonomics. In 2020, the variety of loupes, headlights, and custom instruments has enhanced surgical optics, but these new and improved tools have not necessarily improved the ergonomics of technical execution. The sales pitch for these devices often focuses more on the brightness of the headlight or the longevity of the battery rather than the ergonomics of the device. These pieces of equipment certainly have utility, but increasing reliance on their routine use should be discouraged. For example, we encourage the use of a lightweight headlight in rhinoplasty, while opting instead for a lighted retractor when possible in other cases because handheld retractors allow much more flexibility in terms of positioning your body, thereby reducing stress on the neck. Optimal ergonomics require optimized comfort. When you are donning the equipment, it is a good idea to put it on yourself before scrubbing into the case to ensure everything fits properly and the focus of the light is where you need it without having to contort your body to make up for poor placement. Use your own equipment when possible to better achieve comfortable habits. A professional golfer should not have to use a new driver each time he or she steps into the tee box, and you should not have to adjust to new equipment each time you step into the operating room.
Longer cases, such as in microsurgery, require significant muscle stamina to maintain position for hours, so make sure exercise is part of your regular routine. Focus on posture-improving exercises and core strength training such as pull-ups, dead lifts, and rowing-type exercises to focus on the often neglected back and erector spinae muscles. Incorporating abdominal core exercises will also help with posture and add variety to your workout routine. As with any training regimen, begin slowly with an instructor’s supervision and add to your routine over time, after you have the proper form and movements down pat. Outside of the operating room, remind yourself of good posture habits and sit with your neck neutral and shoulders back. Sleep, hygiene, and a healthy diet will also play a critical role in daily recovery and career-long stamina. Key points to maximize your musculoskeletal health in the operating room and are listed in Table 1 .
Table 1. - Description of Effective Methods for Protecting the Cervical and Lumbar Spine
Lumbar spine
Back-support stool
Limit hunching/flexing, which often occurs when standing and operating downward
Sit as often as possible and let the operating room table and stool do the work instead of your lower back
Keep moving throughout the day; during a long case of standing, make sure you flex and extend—and stretch every hour to limit stiffness and stationary muscle fatigue
Cervical spine
Good posture (shoulders, 90 degrees; neck, 90 degrees; 90/90 as much as possible)
Stools that rotate up and down can limit excessive flexion/extension of the cervical vertebrae
Active stretching for at least 15 min before your first case, and at least 15 min after your last case of the day (slow flexion and extension)
Newer-era ergodynamic instruments and lightweight headlight and loupes, when combined allow for less need to flex or extend the neck to focus light or attain focus
Sit whenever possible and remind yourself of your posture.
Stretching is not just for the gym; stretch frequently in the operating room.
The patient and operating room table should be positioned to make you comfortable ( Fig. 1 ). [ See Video (online) , which demonstrates proper operating room safe positioning at 90/90.]
Do not routinely rely on loupes and a headlight for every case.
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Fig. 1.:
Dr. Rohrich sitting “90/90” with legs parallel to floor, back perpendicular, and neck extended.
The correlation between athletic training and the longevity of a surgeon’s career cannot be overemphasized, just as any successful athlete recognizes that there is no substitute for proper physical training to maintain endurance and prevent injury. In our opinion, the three primary factors to consider are as follows.
Endurance. Regular cardiovascular exercise should be considered as a daily component of lifestyle both to increase endurance and to prevent long-term injury resulting from the stressful requirements of surgery. Improved endurance through cardiovascular exercises increases stamina and improves concentration during long or difficult procedures, allowing for quality and consistency in patient outcomes while not adversely effecting surgeon health.
Avoidance of overuse syndromes and arthritis. Repetitive motion and the positioning issues of surgery have long-term consequences that can be largely avoided with proper biomechanical maintenance. Although there are many choices available to prevent neck and back pain, we have found that 15 to 20 minutes of gentle stretching exercises before leaving home in the morning (before surgery) and nightly (after a long day of surgery) helps prevent injury. Finding a good physical therapist or massage therapist in your community, who understands biomechanical issues related to overuse, is critical to injury prevention. These professionals not only offer regular manual therapy to regions of muscular overuse but can also individualize your exercise routine to allow more precision during stretching, weight training, and endurance exercises.
Diet. All too often, the busy and stressful life of a surgeon leads to poor diet and poor weight control. Proper diet not only affects weight and endurance but also accelerates the degenerative effects of aging. There are many options for improving what one eats, but as a generalization, a greater emphasis on plant-based alternatives and a diet low in simple carbohydrates and saturated fats leads to better health and physical well-being. Fast food and hospital food all too often lack healthy choices. We have found that bringing food from home for lunch and opting for healthy snacks are useful in maintaining both a healthy diet and higher energy levels for consistent performance during surgery.
We strongly agree with Atul Gawande’s comparison of surgeons to athletes and singers who may, over time, unknowingly develop performance-hindering habits necessitating refinement through coaching. 2 Some points to consider further:
We may not be aware of our own bad habits of posture in the operating room and straining/struggling to maintain a position.
Just as your mother would correct your poor posture, you should correct the posture of your colleagues.
Without feedback to learn when we are most prone to become lax in our posture, we cannot improve.
Find a posture coach, manual therapist, or personal trainer knowledgeable in biomechanical maintenance and overuse prevention.
Work on conservation of movement and conservation of posture; both are vital to your longevity.
Incorporate both proper diet and cardiovascular exercise into your daily lifestyle to increase endurance and stamina in the operating room.
These chronic injuries can lead to decreasing surgical volume and even early retirement. Therefore, it is essential to identify poor surgical ergonomics and lifestyle habits early in your career and correct them. Actively develop a healthy lifestyle to include diet, sleep, and exercise. Developing good habits early leads to not only a long career but also a more successful practice that is pain-free and allows healthy alternatives for the stressful life of a surgeon.
ACKNOWLEDGMENT
The authors wish to acknowledge Mike Stokes, Vice President of Communications, American Society of Plastic Surgeons, for reviewing and copyediting this piece.
REFERENCES
1. Rohrich RJ. Why I hate the headlight … and other ways to protect your cervical spine. Plast Reconstr Surg. 2001;107:1037–1038.

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