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Ergonomics and Related Physical Symptoms Among Neurosurgeons
Journal Pre-proof Ergonomics and related physical symptoms among neurosurgeons Pravesh S. Gadjradj, MD, Kennedy Ogenio, MD, Istifari Voigt, BSc, Biswadjiet S. Harhangi, MD, PhD, MSc PII:
S1878-8750(19)32712-3
DOI:
https://doi.org/10.1016/j.wneu.2019.10.093
Reference:
WNEU 13564
To appear in:
World Neurosurgery
Received Date: 5 September 2019 Revised Date:
14 October 2019
Accepted Date: 15 October 2019
Please cite this article as: Gadjradj PS, Ogenio K, Voigt I, Harhangi BS, Ergonomics and related physical symptoms among neurosurgeons, World Neurosurgery (2019), doi: https://doi.org/10.1016/ j.wneu.2019.10.093. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.
Ergonomics and related physical symptoms among neurosurgeons Authors: Pravesh S. Gadjradj MD1 , Kennedy Ogenio MD2,3, Istifari Voigt BSc1, Biswadjiet S. Harhangi MD, PhD, MSc3 Affiliations 1 Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands 2 Department of Neurosurgery, Sint Elisabeth Hospitaal, Curacao 3 Department of Neurosurgery, Erasmus MC: University Medical Center Rotterdam, The Netherlands Word count: 2475 Abstract word count: 250 Conflict of interest: none Disclosure: none Figures: 2 Tables: 6 Supplementary material: none Short title: ergonomics among neurosurgeons Corresponding Author’s name and complete mailing address: Pravesh S. Gadjradj, Department of Neurosurgery, Leiden University Medical Center Albinusdreef 2 2333 ZA Leiden, The Netherlands Phone: 00316 34286813 Email: [email protected] Key Words: Ergonomics, Neurosurgery, Occupational Injury
Ergonomics and related physical symptoms among neurosurgeons Structured Abstract Objective Work-related musculoskeletal disorders (WMSD) among neurosurgeons can lead to consequences for themselves, the hospital and society. In the current study, the working conditions of neurosurgeons from an ergonomic point of view is evaluated, together with WMSD. Methods Members of the Congress of Neurological Surgeons were surveyed with an online survey covering 1) demographics, 2) working conditions, 3) ergonomic features during three neurosurgical procedures and 4) experienced WMSD. Multivariate logistic regression analysis was performed to identify factors associated with experiencing WMSD. Results A total of 417 replies were received. Respondents had a mean tenure of 21.9 years. 33.1% stated that the operating room (OR) is furnished ergonomically and 90.7% stated that ergonomics is an underexposed field in neurosurgery. The majority of the respondents (73.6%) had experienced WMSD. Performing long procedures and spine surgery were mentioned most often as cause for WMSD. Due to WMSD, 11.3% of the respondents had to take time off work and 14.2% considered changing their career. Analgesics were mostly used as treatment for WMSD (42.9%) and 7.4% underwent surgery. Having a tenure ≤15 years and having the (OR) furnished ergonomically were associated with less WMSD in univariate analysis, while only a tenure<15 years was in multivariate analysis (odds ratio 0.27 95%CI 0.085- 0.831). Conclusions Despite only a minority of the surgeons taking time off due to WMSD, the majority suffers from WMSD. Education of residents in ergonomics to prevent WMSD in their later careers, and ergonomic furnishing of surgical instrumentation and ORs seem to be area`s for improvement.
Introduction: Every job has its own burden, which can be divided into physical and mental. Depending on the job, the physical burden might be more prominent than mental burden and vice versa. This is no exception in medicine and it varies depending of the specialization. Sometimes the burden may exceed the limits, which can lead to a disorder. This disorder may bring consequences, for the physician, the institution and society. Consequences for society may include higher costs, longer waiting times for patients and performance of lesser quality by the physician. Work-related musculoskeletal disorders (WMSD) are injuries or disorders of the muscles, nerves, tendons, joints, cartilage, and spinal discs that the work environment and performance of work contribute significantly to1. In the literature there is a wide range of the prevalence of WMSD among surgeons, starting from 20% and can reach as high as 70%2, 3. Usually, the focus of health care and surgeons is on the patients and patient outcomes, rather than on the well-being of physicians themselves. To improve patient outcomes, less invasive techniques were introduced. Apart from causing less tissue trauma to patients, these techniques may put more physical strain on surgeons themselves4. The most important risk factors for developing WMSD include working overtimes, less time to rest, psychosocial factors and work environment5. Ergonometrics is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and methods to design in order to optimize human well-being and overall system performance6. Looking at the WMSD incidence in other disciplines, improving ergonometrics could play a role to reduce the burdens and improve the well-being of surgeons7. An example of this is the ergonomic furnishing of the operating room (OR). This might include an operating table which is adjustable to height, having chairs with back support and having adjustable screen monitors for endoscopic procedures. The aim of the current study is to assess the prevalence of WMSD among neurosurgeons, explore the type of WMSD and identify the risk factors to develop WMSD among neurosurgeons.
Methods Based on previously published literature and discussion between a neurosurgeon and two residents in neurosurgery, a draft survey was developed8-12. After pilot testing the survey, a final version was created (see table 1). The eventual survey consisted of 29 questions and covered: 1) Respondent`s demographics such as age, tenure and glove size; 2) Ergonomics such as case load and furnishing of the operation room; 3) Ergonomic features during the performance of three neurosurgical procedures: lumbar discectomy, ventriculoperitoneal shunt insertion and endoscopic third ventriculostomy; 4) Respondent`s experience with occupational musculoskeletal injury(MSI). The Institutional Review Board waived the need for approval because this study does not involve patients. Using the member directory of the Congress of Neurological Surgeons (CNS), email adresses of members were retrieved. The CNS is an international organization focused on progression of the neurosurgical care. At the time of inquiring the directory, 9007 members were enlisted. Of these members, 8457 had email addresses available of which 6458 were functional. SurveyMonkey (Palo Alto, CA, USA) was used to distribute the survey electronically. After digitalizing and testing the survey, the survey was distributed starting from May 2019. Two, four and six weeks after the initial survey mail, reminders were sent to improve the response rate. Participation was voluntary. Statistical analysis When depicting data, valid percentages were used. Categorical data were tested with for statistical significance using chi square test or Fisher`s exact test when appropriate. Statistical significance was set at a p-value < 0.05. To analyze factors influencing musculoskeletal injury, a logistic regression model was used to identify risk factors. Variables significantly associated with musculoskeletal injury (p<0.05) or trends (p<0.10) on univariate analysis were used in the logistic regression model. All data were analyzed using the Statistical Package for Social Sciences for Windows (version 21.0, SPSS Inc.).
Results: Demographics Of the total of 420 responses received, 417 were suitable for analysis, leading to a response rate of 6.5%. Table 2 gives an overview of the demographic data. The majority (83.9%) was male. Respondents had a mean age of 48.2 years with a mean tenure of 21.9 years. Spine, Neurooncology and Neuro-trauma were the most frequently followed subspecializations (73.1%, 59.7% and 57.8%). The majority (87.3%) was right-handed with 9.4% left handed and 3.4% having ambidexterity. 39.1% had 7.5 as a glove size, while 3.8% had a glove size <6.5 and 9.2% a size>8. Ergonomics When asked on the amount of surgical procedures performed yearly, 56.6% performed 100 to 300 cases per year. 32.7% performed 300-600 cases and 2.0% had a case load >600 per year (see table 3). The mean duration of the average surgical procedure was 3.4 hours (±1.2) with the majority (71.1%) between 3 – 5 hours. Respondents spent a mean of 21.9 hours (±12.0) performing surgery weekly with 5.3% spending >40 hours per week in the OR. Regarding type of procedures performed 92.8% performs open procedures, 49.4% performs endoscopic procedures, 88.5% performs microsurgery and 8.6% performs robotic surgery. Only a minority of the respondents (33.1%) stated that the OR is furnished ergonomically. Respondents (strongly) agreed that wearing a lead apron (90.3%) and that lifting patients on an OR table (61.6%) leads to physical discomfort. Answers on the influence of the shift towards more minimally invasive procedures on physical discomfort showed ambiguity with the majority selecting the neutral option. Majorities (strongly) agreed that hospital management should invest more in furnishing the OR more ergonomically (86.3%) and that ergonomics is an underexposed field in neurosurgery (90.7%). Ergonomic features during three procedures: lumbar discectomy, ventriculoperitoneal shunt placement and endoscopic third ventriculostomy Figure 1 gives an overview of physical complaints experienced among respondents who perform the above three procedures with different caseloads. Neck, shoulder and back complaints were the most prevalent throughout all three procedures. Neck complaints were the most prevalent in respondents performing lumbar discectomy. Table 4 gives an overview of ergonomic features of respondents during the performance of the three procedures. Occupational injury When asked to rate their own general well-being, 47.7% rated it as ‘excellent’ or ‘good’ and 16.2% as ‘fair’ or ‘poor’ (see table 5). 57.4% had experienced non-work related MSI in the past. When looking into MSI experienced during work, 73.6% stated to experience abnormal amounts of pain and/ or discomfort during work. Figure 2 gives an overview of this WMSD. During surgery the neck, back and shoulder area were the most problematic by 41.2%, 33.6% and 24.7% respectively. Similarly, after surgery the neck (40%), back (39.3%) and shoulders (27.3%) were the most problematic. Continuous complaints were rare with 13.4% having constant complaints
of the neck, 12.9% of the back and 8.4% of the lower extremities. Further specification of complaints showed that fatigue was the biggest physical complaint of the eyes and pain in the neck, shoulders, back, wrists, fingers and lower extremities. When asked performing which procedures were most likely causing physical complaints, degenerative spinal surgery such as microdiscectomy and laminectomy were mentioned most frequently. This was followed by performing “any long procedure”, microsurgery and skull base surgery. Except for one, all respondents continued working despite the physical complaints. 11.3%, however, took time off work because of the physical discomfort. This time taken off work was usually shorten than a few weeks. 14.2% considered changing their career path because of the physical complaints. When asked on the treatment of the physical complaints, 42.9% used analgesics and 23.0% underwent physical therapy. 7.4% underwent surgery. Most frequent performed surgical procedures were due to degenerative spinal conditions. 48.2% stated that their treatment solved the MSI. Table 6 gives an overview of univariate and multivariate analysis on experiencing abnormal amounts of pain and/or discomfort while working. Univariate testing shows that tenure and having the OR furnished ergonomically were significantly associated with having musculoskeletal discomfort (p=0.005 and p=0.012 respectively). In the multivariate testing model only tenure <15 years remained significantly associated (odds ratio 0.27 95% CI 0.0850.831) with less musculoskeletal discomfort. Height, gender, age, dominant hand, case load, average duration of the procedures and hours worked weekly in the OR were all nonsignificant factors.
Discussion: Summary The current study surveyed 417 neurosurgeons to evaluate the current field of ergonomics and to estimate the prevalence of WMSD. We hypothesized that, because neurosurgery is a specialization with long procedures using the microscope, that WMSD would be especially prevalent among neurosurgeons. Respondents had a mean age of 48.2 years and a mean tenure of 21.9 years. Spine, Neuro-oncology and Neuro-trauma were the most frequent subspecializations. The average surgical procedure lasted 3.4 hours and respondents spent a mean of 21.9 hours in the operating room per week. 33.1% stated that their OR is furnished ergonomically and 90.7% stated that ergonomics is an underexposed field in neurosurgery. The majority of the respondents (73.6%) had experienced WMSD. Neck, shoulders and back complaints were the most prevalent complaints among respondents. Performing long procedures and spine surgery were mentioned most often as cause for WMSD. Because of the WMSD, 11.3% of the respondents had to take time off work and 14.2% considered changing their career. Analgesics were mostly used as treatment for WMSD (42.9%) and 7.4% underwent surgery. Surgery on the spine and knee were mostly performed. Having a tenure ≤15 years and having the OR furnished ergonomically were significantly associated with less WMSD in univariate analysis, while only a tenure<15 years was in multivariate analysis. Height, gender, age, dominant hand, caseload, average duration of procedure, hours per week in the OR and having the OR furnished ergonomically were all nonsignificant factors. Comparison with other studies Conducting minimally invasive procedures, e.g. endoscopic or laparoscopic procedures, has been shown to be associated with an increase in WMSD3, 4, 11. Among the respondents, 49.4% performs endoscopic surgery. In other surgical disciplines, endoscopic and laparoscopic procedures have been more integrated. In a recent survey conducted among 113 bariatric surgeons, a 66% prevalence of musculoskeletal injury was reported9. Even tough neurosurgeons perform less endoscopic procedures than other disciplines, the surgeries that are performed are usually of longer duration and usually with the assistance of loupes or a microscope. This may explain the difference in prevalence (73.6%). From another point of view, the impact of WMSD is smaller among neurosurgeons (11.3%). More than a quarter of the bariatric surgeons had to decrease their case load due to WMSD, while almost a third reported that the injury affects their surgical performance. Another survey conducted among plastic surgeons showed a similar rate of WMSD (78.3%)8. WMSD are not only limited to medical occupations. Work-related neck disorders for example, has also been studied in other occupations such as nursing and office work. A large cross sectional study on office workers showed that the twelve month prevalence of neck pain was 45.5%13. This in comparison to the mean prevalence of neck pain in the general population of 23.1%14. Women, persons over 30 years of age were associated with a higher prevalence while being physical active was associated with a lower prevalence of neck pain. Another cross sectional study in the U.S. working population showed that military specific occupations,
occupations in the art, design, entertainment and sports, and jobs in the life, physical and social sciences had a significantly higher prevalence of neck pain15. Different studies have proposed solutions to reduce risks on WMSD8, 16. One solution is improving the posture while performing surgery. This may include the prevention of common errors like 1) forward leaning of the head, which increases the weight on the neck; 2) improper shoulder elevation and rotation; and 3) asymmetry of the pelvic griddle which can increase the weight on one side (e.g. back or leg) of the body. This shows the importance of proper set-up of the OR and operating table before surgery and proper adjustment during surgery8. Technical advances may also provide solutions17. An example is the use of deflection prismatic loupes which reduces neck flexion and therefore the physical strain on the neck. Another example is the increasing use of robotic surgery e.g. robot-assisted microscope, leading to more favorable ergonomics11. Some solutions inside the hospital may include training in ergonomic interventions, the use of arm supports, the use of an alternative mouse when using a computer and having breaks during work18, 19 . Other proposed solutions outside of the hospital were doing core-strengthening exercises and stretching exercises. Spine surgery was mentioned most often as the procedure most likely to cause WMSD. Frequently mentioned spinal procedures were spinal fusion, minimally invasive fusion and cervical and lumbar discectomy. Auerbach et al. surveyed orthopedic spine surgeons, specialized in deformity surgery. Deformity surgery can be characterized as long procedures with parts that require some strength20, which may be comparable to spinal fusion over smaller trajects but are more exhaustive as simple discectomy or laminectomy performed by neurosurgeons. In their survey, spinal disorders as WMSD were more prevalent with 31% reporting lumbar and 28% reporting cervical radiculopathy. Rotator cuff disease, varicose veins/ peripheral edema and lateral epicondylitis had prevalence’s of 24%, 20% and 18% respectively. In their regression analysis total caseload was correlated with neck pain and lower extremity edema. Tenure, however, was not correlated with any MSD in contrast to our results. Strengths and limitations Some limitations have to be acknowledged. One might be recall bias. As we asked for WMSD experienced during a career which varied from 1 to 50 years, some respondents may have forgotten WMSD or remembered it incorrectly. Furthermore, endoscopic third ventriculostomy seemed to be a more rarely performed technique, which warrants careful explanation of figure 2. Another limitation which is often an issue in survey research is the response rate. In this study, 6458 CNS members were approached which resulted in a response rate of 6.5%, which may lead to a distorted reflection of the actual situation. In a systematic review of 35 articles, representing 7112 respondents, showed that if all non-responders on the survey would not have any musculoskeletal complaints, that the prevalence of complaint would decrease from 74% to 22%, emphasizing cautious interpretation of our data3. Furthermore, our survey has a response rate comparable to those of modern online surveys among large member directories21, 22. The
importance of the response rate as indicator for the quality of surveys is, however, subject of debate23, 24. No demographic data was available of CNS members. Therefore no analyses could be made to compare responders versus nonresponders to assess generalizability of the data. Conclusion Despite only a minority of the surgeons taking time off due to WMSD, the majority suffers from WMSD. Complaints of the neck, back and shoulders are the most prevalent, while performing spine surgery seems to be the most problematic. A tenure longer than 15 year seems to be a risk factor in developing WMSD. Education of residents in ergonomics to prevent later WMSD and ergonomic furnishing surgical instrumentation and ORs seem to be area`s for improvement.
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Figure Legend: Figure 1: Heatmaps on 3 neurosurgical procedures Figure 2: physical discomfort experienced during surgery, after surgery and continuously per physical location. The chart below specifies the nature of the discomfort.
Ergonomics and related physical symptoms among neurosurgeons
Tables: Table 1: The 29-question survey. The options for multiple choice questions are in italic. Questions 1. What is your age? 2. How many years of clinical experience do you have? 3. What is your height ? 4. What is your gender? 5. What is your scope of practice? Spine, Neuro-oncology, Pediatric Neurosurgery, Neurovascular, Neurotrauma, Funtional, Epilepsy, Peripheral Nerve, Skull Base.
6. What is your dominant hand? Right, left, both, none
7. What is your glove size? 8. How many surgical cases do you perform every year? <100, 100-300, 300-600, >600
9. How long does the average surgical procedure take (in hours)?
10. How many hours per week do you perform surgery? 11. Do you perform open surgery/endoscopic surgery/ microsurgery/ robotic surgery?
12. Is the OR furnished ergonomically? 13. Please share your opinion on the following: •
• • • •
Wearing a lead apron while performing surgery leads to physical discomfort’ Lifting a patient on an OR table leads to physical discomfort The shift towards performing more minimally invasive procedures, leads to more physical discomfort Hospital management should invest more in furnishing the OR more ergonomically Ergonomics is an underexposed area in the neurosurgical field
Strongly agree/agree/neutral/disagree/strongly agree
14. Do you perform… and how many cases? Lumbar discectomy/VP-shunt placement/ETV
15. While performing Lumbar discectomy/VP-shunt placement/ETV, do you… Sit/stand, use arm supports, use foot pedals, wear loupes, use a microscope, gaze downward/straight ahead/upward through the microscope
16. How would you rate your general wellbeing? Poor/Fair/Good/Very good/Excellent
17. Have you had any non-work related musculoskeletal injury in the past? 18. Have you ever experienced abnormal amounts of pain or discomfort in the musculoskeletal area 19. If you have experienced abnormal amounts of pain or discomfort, please specify in which areas? Eyes/Neck/Shoulders/Back/Wrists/Fingers/Lower extremities During surgery/ After surgery/ Continuously
20. Please specify further: Fatigue/Pain/Stiffness/Numbness
21. Performing which procedure is the most likely to cause pain/discomfort? 22. Did you continue working despite the pain/discomfort? 23. Did this pain/discomfort cause you to decrease your case-volume? 24. Did this pain/discomfort cause you to take time off work? 25. If yes, how long did you take time off work? 26. Did you ever consider changing your career because of this? 27. Which of the following have you used as treatment: Analgesics/Physical Therapy/ Surgery/ Other
28. If you choose surgery above, what procedure was done? 29.Did the treatment solve the problem?
Table 2: Demographics of the respondents Gender Male Female
N (%) 417 350 (83.9%) 67 (16.1%)
Age (mean, range)
48.2 (25 – 85)
Tenure (mean, range)
21.9 (1 – 50)
Height >1.80 m 1.65 m – 1.80 m <1.65 m
417 125 (30.0%) 241 (57.8%) 51 (12.2%)
Specialties Epilepsy Functional Peripheral nerve Pediatrics Neuro-oncology Neurovascular Neuro-trauma Spine Skull base
64 (15.3%) 70 (16.8%) 112 (26.9%) 102 (24.5%) 249 (59.7%) 143 (34.3%) 241 (57.8%) 305 (73.1%) 148 (35.5%)
Dominant hand Right Left Both
N (%) 417 363 (87.3%) 39 (9.4%) 14 (3.4%)
Glove Size 5.5 6 6.5 7 7.5 8 8.5 9
414 1 (0.2%) 15 (3.6%) 36 (8.7%) 70 (16.9%) 162 (39.1%) 92 (22.2%) 33 (8.0%) 5 (1.2%)
Table 3: Person experience with and opinions on ergonomics Surgical cases performed yearly <100 100-300 300-600 >600
N (%) 401 35 (8.7%) 227 (56.6%) 131 (32.7%) 8 (2.0%)
Duration average surgical procedure 0 – 2 hours 3 – 5 hours >5 hours
401 96 (23.9%) 285 (71.1%) 20 (5.0%)
Hours weekly performing surgery 0 – 10 hours 11 – 20 hours 21- 40 hours >40 hours
396 66 (16.7%) 166 (41.9%) 134 (36.1%) 21 (5.3%)
Perform Open surgery Endoscopic surgery Microsurgery Robotic surgery
387 (92.8%) 206 (49.4%) 369 (88.5%) 36 (8.6%)
OR furnished ergonomically Yes No
399 132 (33.1%) 267 (66.9%)
Wearing a lead apron during surgery leads to physical discomfort Strongly agree Agree Neutral Disagree Strongly disagree
399
OR: operating room
177 (44.4%) 183 (45.9%) 25 (6.3%) 13 (3.3%) 1 (0.3%)
Lifting a patient on an OR table leads to physical discomfort Strongly agree Agree Neutral Disagree Strongly disagree The shift towards more min. invasive surgery leads to more physical discomfort Strongly agree Agree Neutral Disagree Strongly disagree
N (%) 401 101 (25.2%) 146 (36.4%) 84 (20.9%) 64 (16.0%) 6 (1.5%) 400 28 (7.0%) 98 (24.5%) 159 (39.8%) 99 (24.8%) 16 (4.0%)
Hospital management should invest more in furnishing the OR more ergonomically Strongly agree Agree Neutral Disagree Strongly disagree
400
Ergonomics is an underexposed area in the neurosurgical field Strongly agree Agree Neutral Disagree Strongly disagree
401
177 (44.3%) 168 (42.0%) 44 (11.0%) 9 (2.3%) 2 (0.5%)
205 (51.1%) 159 (39.7%) 29 (7.2%) 5 (1.2%) 3 (0.7%)
Table 4: an overview of ergonomic features during three procedures: lumbar discectomy, ventriculoperitoneal shunt placement (VP-shunt) and endoscopic third ventriculostomy (ETV) Procedure
Lumbar discectomy
VPshunting
ETV
I use arm supports I use foot pedals I sit in chair with back support I gaze downward through the microscope I gaze straight ahead through the microscope I gaze upward through the microscope I routinely wear loupes I stand while operating I sit while operating I operate via direct visualization through the endoscope I operate via visualization on a video monitor only The video monitor is above my eye level The video monitor is at my eye level The video monitor is below my eye level
8 (1.9%) 179 (42.9%) 6 (1.4%) 95 (22.8%) 213 (51.1%) 13 (3.1%) 160 (38.4%)
1 (0.2%) 6 (1.4%) 151 (36.2%) 105 (25.2%) 7 (1.7%)
193 (46.3%) 319 (76.5%) 210 (50.4%) 43 (10.3%) 11 (2.6%) 13 (3.1%) 174 (41.7%) 61 (14.6%) 141 (33.8%) 5 (1.2%)
Table 5: Occupational injury
Rate own general well-being Excellent Very good Good Fair Poor
N (%) 394 58 (14.7%) 130 (33.0%) 142 (36.0%) 62 (15.7%) 2 (0.5%)
Had any non-work related musculoskeletal injury in the past Yes No
394
Experienced abnormal amounts of pain or discomfort in the musculoskeletal area during work Yes No
394
226 (57.4%) 168 (42.6%)
290 (73.6%) 104 (26.4%)
Procedure mostly likely causing pain/discomfort* Any long cases Any craniotomy Degenerative spinal surgery Endoscopic surgery Microsurgery Posterior fossa surgery Skull base surgery Spinal deformity surgery Vascular (aneurysms and AVMs) Traumatic spinal cases Other
18 4 171 6 15 5 12 9 6 3 15
Continue working despite discomfort Yes No
276 275 (99.6%) 1 (0.4%)
Discomfort caused taking time off work Yes No
275 31 (11.3%) 244 (88.7%)
*More answers possible
N (%) Time taken off work 1-2 days 3 days- 1 week 1 -4 weeks 5- 12 weeks >12 weeks
14 3 7 6 1
Ever consider changing career because of this Yes No
274 39 (14.2%) 235 (85.8%)
Used as treatment… Analgesics Physical therapy Surgery None of the above Other… NSAIDs Excercise Steroid injections Massage therapy Rest Chiropraction Other
179 (42.9%) 96 (23.0%) 31 (7.4%) 59 (14.1%) 55 10 12 6 6 2 2 17
If surgery, what procedure was done? Cervical spine surgery Hip surgery Hand surgery Knee surgery Lumbar spine surgery Other
4 2 3 7 11 2
Did the treatment solve the problem? Yes No Other
191 92 (48.2%) 61 (31.9%) 38 (19.9%)
Table 6: Uni- and multivariate analysis of factors associated with feeling discomfort during surgery
Percentage of respondents experiencing abnormal amounts of pain/discomfort (N=386) Univariate Multivariate p-value Odds Ratio 95% CI of OR Height >1.80 m 29.0% NS 1.65-1.80 m 59.0% <1.65 m 12.1% 0.092
Gender Female Male
82.4% 17.6%
≤45 years >45 years
40.3% 59.7%
≤15 years >15 years
33.4% 66.6%
1.84 reference
0.593 - 5.684
0.27* reference
0.085 – 0.831
2.31 1.40 2.10 reference
0.752 – 7.106 0.525 – 3.739 0.779 – 5.650
0.64 reference
0.395 – 1.044
0.005
Tenure
*significant
0.869 – 3.761
0.061
Age
NS: Not significant
1.81 reference
Dominant hand Right Left Both
86.9% 10.3% 2.8%
Surgical cases performed yearly <100 100- 300 301- 600 >600
8.0% 58.1% 31.8% 2.1%
Duration average procedure 0-2 hours 3- 5 hours >5 hours
22.5% 72.3% 5.2%
Hours/week in OR 0-10 hours 11-20 hours 20-40 hours >40 hours
18.1% 40.4% 37.6% 3.8%
OR furnished ergonomically Yes No
29.2% 70.8%
NS
NS
NS
0.068
0.012
Ergonomics and related physical symptoms among neurosurgeons Abbreviations WMSD : Work-related musculoskeletal disorders OR: Operation room MSI: Musculoskeletal injury
S1878-8750(19)32712-3
DOI:
https://doi.org/10.1016/j.wneu.2019.10.093
Reference:
WNEU 13564
To appear in:
World Neurosurgery
Received Date: 5 September 2019 Revised Date:
14 October 2019
Accepted Date: 15 October 2019
Please cite this article as: Gadjradj PS, Ogenio K, Voigt I, Harhangi BS, Ergonomics and related physical symptoms among neurosurgeons, World Neurosurgery (2019), doi: https://doi.org/10.1016/ j.wneu.2019.10.093. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.
Ergonomics and related physical symptoms among neurosurgeons Authors: Pravesh S. Gadjradj MD1 , Kennedy Ogenio MD2,3, Istifari Voigt BSc1, Biswadjiet S. Harhangi MD, PhD, MSc3 Affiliations 1 Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands 2 Department of Neurosurgery, Sint Elisabeth Hospitaal, Curacao 3 Department of Neurosurgery, Erasmus MC: University Medical Center Rotterdam, The Netherlands Word count: 2475 Abstract word count: 250 Conflict of interest: none Disclosure: none Figures: 2 Tables: 6 Supplementary material: none Short title: ergonomics among neurosurgeons Corresponding Author’s name and complete mailing address: Pravesh S. Gadjradj, Department of Neurosurgery, Leiden University Medical Center Albinusdreef 2 2333 ZA Leiden, The Netherlands Phone: 00316 34286813 Email: [email protected] Key Words: Ergonomics, Neurosurgery, Occupational Injury
Ergonomics and related physical symptoms among neurosurgeons Structured Abstract Objective Work-related musculoskeletal disorders (WMSD) among neurosurgeons can lead to consequences for themselves, the hospital and society. In the current study, the working conditions of neurosurgeons from an ergonomic point of view is evaluated, together with WMSD. Methods Members of the Congress of Neurological Surgeons were surveyed with an online survey covering 1) demographics, 2) working conditions, 3) ergonomic features during three neurosurgical procedures and 4) experienced WMSD. Multivariate logistic regression analysis was performed to identify factors associated with experiencing WMSD. Results A total of 417 replies were received. Respondents had a mean tenure of 21.9 years. 33.1% stated that the operating room (OR) is furnished ergonomically and 90.7% stated that ergonomics is an underexposed field in neurosurgery. The majority of the respondents (73.6%) had experienced WMSD. Performing long procedures and spine surgery were mentioned most often as cause for WMSD. Due to WMSD, 11.3% of the respondents had to take time off work and 14.2% considered changing their career. Analgesics were mostly used as treatment for WMSD (42.9%) and 7.4% underwent surgery. Having a tenure ≤15 years and having the (OR) furnished ergonomically were associated with less WMSD in univariate analysis, while only a tenure<15 years was in multivariate analysis (odds ratio 0.27 95%CI 0.085- 0.831). Conclusions Despite only a minority of the surgeons taking time off due to WMSD, the majority suffers from WMSD. Education of residents in ergonomics to prevent WMSD in their later careers, and ergonomic furnishing of surgical instrumentation and ORs seem to be area`s for improvement.
Introduction: Every job has its own burden, which can be divided into physical and mental. Depending on the job, the physical burden might be more prominent than mental burden and vice versa. This is no exception in medicine and it varies depending of the specialization. Sometimes the burden may exceed the limits, which can lead to a disorder. This disorder may bring consequences, for the physician, the institution and society. Consequences for society may include higher costs, longer waiting times for patients and performance of lesser quality by the physician. Work-related musculoskeletal disorders (WMSD) are injuries or disorders of the muscles, nerves, tendons, joints, cartilage, and spinal discs that the work environment and performance of work contribute significantly to1. In the literature there is a wide range of the prevalence of WMSD among surgeons, starting from 20% and can reach as high as 70%2, 3. Usually, the focus of health care and surgeons is on the patients and patient outcomes, rather than on the well-being of physicians themselves. To improve patient outcomes, less invasive techniques were introduced. Apart from causing less tissue trauma to patients, these techniques may put more physical strain on surgeons themselves4. The most important risk factors for developing WMSD include working overtimes, less time to rest, psychosocial factors and work environment5. Ergonometrics is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and methods to design in order to optimize human well-being and overall system performance6. Looking at the WMSD incidence in other disciplines, improving ergonometrics could play a role to reduce the burdens and improve the well-being of surgeons7. An example of this is the ergonomic furnishing of the operating room (OR). This might include an operating table which is adjustable to height, having chairs with back support and having adjustable screen monitors for endoscopic procedures. The aim of the current study is to assess the prevalence of WMSD among neurosurgeons, explore the type of WMSD and identify the risk factors to develop WMSD among neurosurgeons.
Methods Based on previously published literature and discussion between a neurosurgeon and two residents in neurosurgery, a draft survey was developed8-12. After pilot testing the survey, a final version was created (see table 1). The eventual survey consisted of 29 questions and covered: 1) Respondent`s demographics such as age, tenure and glove size; 2) Ergonomics such as case load and furnishing of the operation room; 3) Ergonomic features during the performance of three neurosurgical procedures: lumbar discectomy, ventriculoperitoneal shunt insertion and endoscopic third ventriculostomy; 4) Respondent`s experience with occupational musculoskeletal injury(MSI). The Institutional Review Board waived the need for approval because this study does not involve patients. Using the member directory of the Congress of Neurological Surgeons (CNS), email adresses of members were retrieved. The CNS is an international organization focused on progression of the neurosurgical care. At the time of inquiring the directory, 9007 members were enlisted. Of these members, 8457 had email addresses available of which 6458 were functional. SurveyMonkey (Palo Alto, CA, USA) was used to distribute the survey electronically. After digitalizing and testing the survey, the survey was distributed starting from May 2019. Two, four and six weeks after the initial survey mail, reminders were sent to improve the response rate. Participation was voluntary. Statistical analysis When depicting data, valid percentages were used. Categorical data were tested with for statistical significance using chi square test or Fisher`s exact test when appropriate. Statistical significance was set at a p-value < 0.05. To analyze factors influencing musculoskeletal injury, a logistic regression model was used to identify risk factors. Variables significantly associated with musculoskeletal injury (p<0.05) or trends (p<0.10) on univariate analysis were used in the logistic regression model. All data were analyzed using the Statistical Package for Social Sciences for Windows (version 21.0, SPSS Inc.).
Results: Demographics Of the total of 420 responses received, 417 were suitable for analysis, leading to a response rate of 6.5%. Table 2 gives an overview of the demographic data. The majority (83.9%) was male. Respondents had a mean age of 48.2 years with a mean tenure of 21.9 years. Spine, Neurooncology and Neuro-trauma were the most frequently followed subspecializations (73.1%, 59.7% and 57.8%). The majority (87.3%) was right-handed with 9.4% left handed and 3.4% having ambidexterity. 39.1% had 7.5 as a glove size, while 3.8% had a glove size <6.5 and 9.2% a size>8. Ergonomics When asked on the amount of surgical procedures performed yearly, 56.6% performed 100 to 300 cases per year. 32.7% performed 300-600 cases and 2.0% had a case load >600 per year (see table 3). The mean duration of the average surgical procedure was 3.4 hours (±1.2) with the majority (71.1%) between 3 – 5 hours. Respondents spent a mean of 21.9 hours (±12.0) performing surgery weekly with 5.3% spending >40 hours per week in the OR. Regarding type of procedures performed 92.8% performs open procedures, 49.4% performs endoscopic procedures, 88.5% performs microsurgery and 8.6% performs robotic surgery. Only a minority of the respondents (33.1%) stated that the OR is furnished ergonomically. Respondents (strongly) agreed that wearing a lead apron (90.3%) and that lifting patients on an OR table (61.6%) leads to physical discomfort. Answers on the influence of the shift towards more minimally invasive procedures on physical discomfort showed ambiguity with the majority selecting the neutral option. Majorities (strongly) agreed that hospital management should invest more in furnishing the OR more ergonomically (86.3%) and that ergonomics is an underexposed field in neurosurgery (90.7%). Ergonomic features during three procedures: lumbar discectomy, ventriculoperitoneal shunt placement and endoscopic third ventriculostomy Figure 1 gives an overview of physical complaints experienced among respondents who perform the above three procedures with different caseloads. Neck, shoulder and back complaints were the most prevalent throughout all three procedures. Neck complaints were the most prevalent in respondents performing lumbar discectomy. Table 4 gives an overview of ergonomic features of respondents during the performance of the three procedures. Occupational injury When asked to rate their own general well-being, 47.7% rated it as ‘excellent’ or ‘good’ and 16.2% as ‘fair’ or ‘poor’ (see table 5). 57.4% had experienced non-work related MSI in the past. When looking into MSI experienced during work, 73.6% stated to experience abnormal amounts of pain and/ or discomfort during work. Figure 2 gives an overview of this WMSD. During surgery the neck, back and shoulder area were the most problematic by 41.2%, 33.6% and 24.7% respectively. Similarly, after surgery the neck (40%), back (39.3%) and shoulders (27.3%) were the most problematic. Continuous complaints were rare with 13.4% having constant complaints
of the neck, 12.9% of the back and 8.4% of the lower extremities. Further specification of complaints showed that fatigue was the biggest physical complaint of the eyes and pain in the neck, shoulders, back, wrists, fingers and lower extremities. When asked performing which procedures were most likely causing physical complaints, degenerative spinal surgery such as microdiscectomy and laminectomy were mentioned most frequently. This was followed by performing “any long procedure”, microsurgery and skull base surgery. Except for one, all respondents continued working despite the physical complaints. 11.3%, however, took time off work because of the physical discomfort. This time taken off work was usually shorten than a few weeks. 14.2% considered changing their career path because of the physical complaints. When asked on the treatment of the physical complaints, 42.9% used analgesics and 23.0% underwent physical therapy. 7.4% underwent surgery. Most frequent performed surgical procedures were due to degenerative spinal conditions. 48.2% stated that their treatment solved the MSI. Table 6 gives an overview of univariate and multivariate analysis on experiencing abnormal amounts of pain and/or discomfort while working. Univariate testing shows that tenure and having the OR furnished ergonomically were significantly associated with having musculoskeletal discomfort (p=0.005 and p=0.012 respectively). In the multivariate testing model only tenure <15 years remained significantly associated (odds ratio 0.27 95% CI 0.0850.831) with less musculoskeletal discomfort. Height, gender, age, dominant hand, case load, average duration of the procedures and hours worked weekly in the OR were all nonsignificant factors.
Discussion: Summary The current study surveyed 417 neurosurgeons to evaluate the current field of ergonomics and to estimate the prevalence of WMSD. We hypothesized that, because neurosurgery is a specialization with long procedures using the microscope, that WMSD would be especially prevalent among neurosurgeons. Respondents had a mean age of 48.2 years and a mean tenure of 21.9 years. Spine, Neuro-oncology and Neuro-trauma were the most frequent subspecializations. The average surgical procedure lasted 3.4 hours and respondents spent a mean of 21.9 hours in the operating room per week. 33.1% stated that their OR is furnished ergonomically and 90.7% stated that ergonomics is an underexposed field in neurosurgery. The majority of the respondents (73.6%) had experienced WMSD. Neck, shoulders and back complaints were the most prevalent complaints among respondents. Performing long procedures and spine surgery were mentioned most often as cause for WMSD. Because of the WMSD, 11.3% of the respondents had to take time off work and 14.2% considered changing their career. Analgesics were mostly used as treatment for WMSD (42.9%) and 7.4% underwent surgery. Surgery on the spine and knee were mostly performed. Having a tenure ≤15 years and having the OR furnished ergonomically were significantly associated with less WMSD in univariate analysis, while only a tenure<15 years was in multivariate analysis. Height, gender, age, dominant hand, caseload, average duration of procedure, hours per week in the OR and having the OR furnished ergonomically were all nonsignificant factors. Comparison with other studies Conducting minimally invasive procedures, e.g. endoscopic or laparoscopic procedures, has been shown to be associated with an increase in WMSD3, 4, 11. Among the respondents, 49.4% performs endoscopic surgery. In other surgical disciplines, endoscopic and laparoscopic procedures have been more integrated. In a recent survey conducted among 113 bariatric surgeons, a 66% prevalence of musculoskeletal injury was reported9. Even tough neurosurgeons perform less endoscopic procedures than other disciplines, the surgeries that are performed are usually of longer duration and usually with the assistance of loupes or a microscope. This may explain the difference in prevalence (73.6%). From another point of view, the impact of WMSD is smaller among neurosurgeons (11.3%). More than a quarter of the bariatric surgeons had to decrease their case load due to WMSD, while almost a third reported that the injury affects their surgical performance. Another survey conducted among plastic surgeons showed a similar rate of WMSD (78.3%)8. WMSD are not only limited to medical occupations. Work-related neck disorders for example, has also been studied in other occupations such as nursing and office work. A large cross sectional study on office workers showed that the twelve month prevalence of neck pain was 45.5%13. This in comparison to the mean prevalence of neck pain in the general population of 23.1%14. Women, persons over 30 years of age were associated with a higher prevalence while being physical active was associated with a lower prevalence of neck pain. Another cross sectional study in the U.S. working population showed that military specific occupations,
occupations in the art, design, entertainment and sports, and jobs in the life, physical and social sciences had a significantly higher prevalence of neck pain15. Different studies have proposed solutions to reduce risks on WMSD8, 16. One solution is improving the posture while performing surgery. This may include the prevention of common errors like 1) forward leaning of the head, which increases the weight on the neck; 2) improper shoulder elevation and rotation; and 3) asymmetry of the pelvic griddle which can increase the weight on one side (e.g. back or leg) of the body. This shows the importance of proper set-up of the OR and operating table before surgery and proper adjustment during surgery8. Technical advances may also provide solutions17. An example is the use of deflection prismatic loupes which reduces neck flexion and therefore the physical strain on the neck. Another example is the increasing use of robotic surgery e.g. robot-assisted microscope, leading to more favorable ergonomics11. Some solutions inside the hospital may include training in ergonomic interventions, the use of arm supports, the use of an alternative mouse when using a computer and having breaks during work18, 19 . Other proposed solutions outside of the hospital were doing core-strengthening exercises and stretching exercises. Spine surgery was mentioned most often as the procedure most likely to cause WMSD. Frequently mentioned spinal procedures were spinal fusion, minimally invasive fusion and cervical and lumbar discectomy. Auerbach et al. surveyed orthopedic spine surgeons, specialized in deformity surgery. Deformity surgery can be characterized as long procedures with parts that require some strength20, which may be comparable to spinal fusion over smaller trajects but are more exhaustive as simple discectomy or laminectomy performed by neurosurgeons. In their survey, spinal disorders as WMSD were more prevalent with 31% reporting lumbar and 28% reporting cervical radiculopathy. Rotator cuff disease, varicose veins/ peripheral edema and lateral epicondylitis had prevalence’s of 24%, 20% and 18% respectively. In their regression analysis total caseload was correlated with neck pain and lower extremity edema. Tenure, however, was not correlated with any MSD in contrast to our results. Strengths and limitations Some limitations have to be acknowledged. One might be recall bias. As we asked for WMSD experienced during a career which varied from 1 to 50 years, some respondents may have forgotten WMSD or remembered it incorrectly. Furthermore, endoscopic third ventriculostomy seemed to be a more rarely performed technique, which warrants careful explanation of figure 2. Another limitation which is often an issue in survey research is the response rate. In this study, 6458 CNS members were approached which resulted in a response rate of 6.5%, which may lead to a distorted reflection of the actual situation. In a systematic review of 35 articles, representing 7112 respondents, showed that if all non-responders on the survey would not have any musculoskeletal complaints, that the prevalence of complaint would decrease from 74% to 22%, emphasizing cautious interpretation of our data3. Furthermore, our survey has a response rate comparable to those of modern online surveys among large member directories21, 22. The
importance of the response rate as indicator for the quality of surveys is, however, subject of debate23, 24. No demographic data was available of CNS members. Therefore no analyses could be made to compare responders versus nonresponders to assess generalizability of the data. Conclusion Despite only a minority of the surgeons taking time off due to WMSD, the majority suffers from WMSD. Complaints of the neck, back and shoulders are the most prevalent, while performing spine surgery seems to be the most problematic. A tenure longer than 15 year seems to be a risk factor in developing WMSD. Education of residents in ergonomics to prevent later WMSD and ergonomic furnishing surgical instrumentation and ORs seem to be area`s for improvement.
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Figure Legend: Figure 1: Heatmaps on 3 neurosurgical procedures Figure 2: physical discomfort experienced during surgery, after surgery and continuously per physical location. The chart below specifies the nature of the discomfort.
Ergonomics and related physical symptoms among neurosurgeons
Tables: Table 1: The 29-question survey. The options for multiple choice questions are in italic. Questions 1. What is your age? 2. How many years of clinical experience do you have? 3. What is your height ? 4. What is your gender? 5. What is your scope of practice? Spine, Neuro-oncology, Pediatric Neurosurgery, Neurovascular, Neurotrauma, Funtional, Epilepsy, Peripheral Nerve, Skull Base.
6. What is your dominant hand? Right, left, both, none
7. What is your glove size? 8. How many surgical cases do you perform every year? <100, 100-300, 300-600, >600
9. How long does the average surgical procedure take (in hours)?
10. How many hours per week do you perform surgery? 11. Do you perform open surgery/endoscopic surgery/ microsurgery/ robotic surgery?
12. Is the OR furnished ergonomically? 13. Please share your opinion on the following: •
• • • •
Wearing a lead apron while performing surgery leads to physical discomfort’ Lifting a patient on an OR table leads to physical discomfort The shift towards performing more minimally invasive procedures, leads to more physical discomfort Hospital management should invest more in furnishing the OR more ergonomically Ergonomics is an underexposed area in the neurosurgical field
Strongly agree/agree/neutral/disagree/strongly agree
14. Do you perform… and how many cases? Lumbar discectomy/VP-shunt placement/ETV
15. While performing Lumbar discectomy/VP-shunt placement/ETV, do you… Sit/stand, use arm supports, use foot pedals, wear loupes, use a microscope, gaze downward/straight ahead/upward through the microscope
16. How would you rate your general wellbeing? Poor/Fair/Good/Very good/Excellent
17. Have you had any non-work related musculoskeletal injury in the past? 18. Have you ever experienced abnormal amounts of pain or discomfort in the musculoskeletal area 19. If you have experienced abnormal amounts of pain or discomfort, please specify in which areas? Eyes/Neck/Shoulders/Back/Wrists/Fingers/Lower extremities During surgery/ After surgery/ Continuously
20. Please specify further: Fatigue/Pain/Stiffness/Numbness
21. Performing which procedure is the most likely to cause pain/discomfort? 22. Did you continue working despite the pain/discomfort? 23. Did this pain/discomfort cause you to decrease your case-volume? 24. Did this pain/discomfort cause you to take time off work? 25. If yes, how long did you take time off work? 26. Did you ever consider changing your career because of this? 27. Which of the following have you used as treatment: Analgesics/Physical Therapy/ Surgery/ Other
28. If you choose surgery above, what procedure was done? 29.Did the treatment solve the problem?
Table 2: Demographics of the respondents Gender Male Female
N (%) 417 350 (83.9%) 67 (16.1%)
Age (mean, range)
48.2 (25 – 85)
Tenure (mean, range)
21.9 (1 – 50)
Height >1.80 m 1.65 m – 1.80 m <1.65 m
417 125 (30.0%) 241 (57.8%) 51 (12.2%)
Specialties Epilepsy Functional Peripheral nerve Pediatrics Neuro-oncology Neurovascular Neuro-trauma Spine Skull base
64 (15.3%) 70 (16.8%) 112 (26.9%) 102 (24.5%) 249 (59.7%) 143 (34.3%) 241 (57.8%) 305 (73.1%) 148 (35.5%)
Dominant hand Right Left Both
N (%) 417 363 (87.3%) 39 (9.4%) 14 (3.4%)
Glove Size 5.5 6 6.5 7 7.5 8 8.5 9
414 1 (0.2%) 15 (3.6%) 36 (8.7%) 70 (16.9%) 162 (39.1%) 92 (22.2%) 33 (8.0%) 5 (1.2%)
Table 3: Person experience with and opinions on ergonomics Surgical cases performed yearly <100 100-300 300-600 >600
N (%) 401 35 (8.7%) 227 (56.6%) 131 (32.7%) 8 (2.0%)
Duration average surgical procedure 0 – 2 hours 3 – 5 hours >5 hours
401 96 (23.9%) 285 (71.1%) 20 (5.0%)
Hours weekly performing surgery 0 – 10 hours 11 – 20 hours 21- 40 hours >40 hours
396 66 (16.7%) 166 (41.9%) 134 (36.1%) 21 (5.3%)
Perform Open surgery Endoscopic surgery Microsurgery Robotic surgery
387 (92.8%) 206 (49.4%) 369 (88.5%) 36 (8.6%)
OR furnished ergonomically Yes No
399 132 (33.1%) 267 (66.9%)
Wearing a lead apron during surgery leads to physical discomfort Strongly agree Agree Neutral Disagree Strongly disagree
399
OR: operating room
177 (44.4%) 183 (45.9%) 25 (6.3%) 13 (3.3%) 1 (0.3%)
Lifting a patient on an OR table leads to physical discomfort Strongly agree Agree Neutral Disagree Strongly disagree The shift towards more min. invasive surgery leads to more physical discomfort Strongly agree Agree Neutral Disagree Strongly disagree
N (%) 401 101 (25.2%) 146 (36.4%) 84 (20.9%) 64 (16.0%) 6 (1.5%) 400 28 (7.0%) 98 (24.5%) 159 (39.8%) 99 (24.8%) 16 (4.0%)
Hospital management should invest more in furnishing the OR more ergonomically Strongly agree Agree Neutral Disagree Strongly disagree
400
Ergonomics is an underexposed area in the neurosurgical field Strongly agree Agree Neutral Disagree Strongly disagree
401
177 (44.3%) 168 (42.0%) 44 (11.0%) 9 (2.3%) 2 (0.5%)
205 (51.1%) 159 (39.7%) 29 (7.2%) 5 (1.2%) 3 (0.7%)
Table 4: an overview of ergonomic features during three procedures: lumbar discectomy, ventriculoperitoneal shunt placement (VP-shunt) and endoscopic third ventriculostomy (ETV) Procedure
Lumbar discectomy
VPshunting
ETV
I use arm supports I use foot pedals I sit in chair with back support I gaze downward through the microscope I gaze straight ahead through the microscope I gaze upward through the microscope I routinely wear loupes I stand while operating I sit while operating I operate via direct visualization through the endoscope I operate via visualization on a video monitor only The video monitor is above my eye level The video monitor is at my eye level The video monitor is below my eye level
8 (1.9%) 179 (42.9%) 6 (1.4%) 95 (22.8%) 213 (51.1%) 13 (3.1%) 160 (38.4%)
1 (0.2%) 6 (1.4%) 151 (36.2%) 105 (25.2%) 7 (1.7%)
193 (46.3%) 319 (76.5%) 210 (50.4%) 43 (10.3%) 11 (2.6%) 13 (3.1%) 174 (41.7%) 61 (14.6%) 141 (33.8%) 5 (1.2%)
Table 5: Occupational injury
Rate own general well-being Excellent Very good Good Fair Poor
N (%) 394 58 (14.7%) 130 (33.0%) 142 (36.0%) 62 (15.7%) 2 (0.5%)
Had any non-work related musculoskeletal injury in the past Yes No
394
Experienced abnormal amounts of pain or discomfort in the musculoskeletal area during work Yes No
394
226 (57.4%) 168 (42.6%)
290 (73.6%) 104 (26.4%)
Procedure mostly likely causing pain/discomfort* Any long cases Any craniotomy Degenerative spinal surgery Endoscopic surgery Microsurgery Posterior fossa surgery Skull base surgery Spinal deformity surgery Vascular (aneurysms and AVMs) Traumatic spinal cases Other
18 4 171 6 15 5 12 9 6 3 15
Continue working despite discomfort Yes No
276 275 (99.6%) 1 (0.4%)
Discomfort caused taking time off work Yes No
275 31 (11.3%) 244 (88.7%)
*More answers possible
N (%) Time taken off work 1-2 days 3 days- 1 week 1 -4 weeks 5- 12 weeks >12 weeks
14 3 7 6 1
Ever consider changing career because of this Yes No
274 39 (14.2%) 235 (85.8%)
Used as treatment… Analgesics Physical therapy Surgery None of the above Other… NSAIDs Excercise Steroid injections Massage therapy Rest Chiropraction Other
179 (42.9%) 96 (23.0%) 31 (7.4%) 59 (14.1%) 55 10 12 6 6 2 2 17
If surgery, what procedure was done? Cervical spine surgery Hip surgery Hand surgery Knee surgery Lumbar spine surgery Other
4 2 3 7 11 2
Did the treatment solve the problem? Yes No Other
191 92 (48.2%) 61 (31.9%) 38 (19.9%)
Table 6: Uni- and multivariate analysis of factors associated with feeling discomfort during surgery
Percentage of respondents experiencing abnormal amounts of pain/discomfort (N=386) Univariate Multivariate p-value Odds Ratio 95% CI of OR Height >1.80 m 29.0% NS 1.65-1.80 m 59.0% <1.65 m 12.1% 0.092
Gender Female Male
82.4% 17.6%
≤45 years >45 years
40.3% 59.7%
≤15 years >15 years
33.4% 66.6%
1.84 reference
0.593 - 5.684
0.27* reference
0.085 – 0.831
2.31 1.40 2.10 reference
0.752 – 7.106 0.525 – 3.739 0.779 – 5.650
0.64 reference
0.395 – 1.044
0.005
Tenure
*significant
0.869 – 3.761
0.061
Age
NS: Not significant
1.81 reference
Dominant hand Right Left Both
86.9% 10.3% 2.8%
Surgical cases performed yearly <100 100- 300 301- 600 >600
8.0% 58.1% 31.8% 2.1%
Duration average procedure 0-2 hours 3- 5 hours >5 hours
22.5% 72.3% 5.2%
Hours/week in OR 0-10 hours 11-20 hours 20-40 hours >40 hours
18.1% 40.4% 37.6% 3.8%
OR furnished ergonomically Yes No
29.2% 70.8%
NS
NS
NS
0.068
0.012
Ergonomics and related physical symptoms among neurosurgeons Abbreviations WMSD : Work-related musculoskeletal disorders OR: Operation room MSI: Musculoskeletal injury