A nationwide perspective on ergonomic gaps in spine surgery: modifiable risk factors and gender-based findings
Article information
Abstract
Study Design
Cross-sectional questionnaire-based study.
Purpose
To determine the prevalence, anatomical distribution, and modifiable ergonomic risk factors for work-related musculoskeletal disorders (MSDs) among early-career spine surgeons in India, with an emphasis on gender-based differences.
Overview of Literature
Although MSDs are a well-recognized occupational hazard for surgeons, a large portion of existing spine surgery literature originates from high-income countries, focuses on low back pain, and lacks targeted evaluation of early-career surgeons in low- and middle-income countries. Consequently, gender-specific ergonomic challenges remain underexplored.
Methods
A nationwide, cross-sectional online survey was conducted (January–June 2025) among spine surgeons with <10 years of independent practice experience. The questionnaire assessed the demographics, operative workload, ergonomic practices, equipment use, and MSD symptoms over the past 12 months. Associations were evaluated using χ2 or Fisher’s exact tests, as appropriate, and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) derived from multivariable exact logistic regression.
Results
A total of 764 surgeons (mean age, 35.4±4.5 years; 19.6% women) participated. MSD prevalence was 83.9%, with 96.1% of symptomatic surgeons reporting neck discomfort. All women reported MSD, whereas only 80.0% of men did so (p<0.001). Microscope use was significantly associated with neck discomfort (aOR, 1.65; 95% CI, 1.14–2.39; p=0.009), whereas loupe use was not. Consistent table height adjustment was associated with markedly decreased MSD prevalence (72.8% vs. approximately 100%; aOR, 0.21; 95% CI, 0.05–0.88; p=0.03). Only 6.7% of the respondents reported preoperative ergonomic planning, despite frequent assistant–surgeon height mismatch (63.8%).
Conclusions
This nationwide survey of young spine surgeons in India revealed an unprecedented neck-dominant MSD pattern, universal MSD prevalence among female surgeons, and a strong protective effect of consistent table height adjustment. These findings underscore the urgent need for targeted ergonomic training, visualization tool optimization, and integration of ergonomic planning into surgical workflows.
Introduction
Work-related musculoskeletal disorders (MSDs) are a well-recognized occupational hazard for surgeons, with reported prevalence rates ranging from 60% to over 90% across various specialties [1]. In the field of spine surgery, demands for prolonged static postures, use of visualization tools, and wearing of lead aprons place unique biomechanical stresses on the cervical spine, shoulders, and lower back [2,3]. Previous studies have predominantly described MSD distribution and general ergonomic risk factors, often focusing on lower back pain as the most common complaint [4,5]. Although emerging evidence suggests that microscope use, suboptimal table height, and inadequate preoperative ergonomic planning may significantly exacerbate discomfort, these associations remain underexplored in early-career spine surgeons, particularly in low- and middle-income countries (LMIC) [3,6]. Moreover, sex-specific ergonomic challenges have received little attention, despite growing gender diversity in the field [4,5].
Despite the increasing attention to the ergonomic risks of spine surgery, most of the available literature originates from high-income countries, involves cohorts with varying surgical experience, and emphasizes descriptive prevalence over actionable interventions [1,6,7].
Early-career surgeons who are in the formative stage of their surgical habits remain underrepresented in ergonomic research, despite being at a critical window for adopting preventive strategies. Moreover, gender-based ergonomic disparities, though occasionally mentioned, have seldom been investigated or statistically analyzed in spine surgery [4,5]. In LMICs like India, where operating room equipment customization is limited and ergonomic culture is less formalized, these gaps are even more pronounced [5,8].
This nationwide survey of young spine surgeons in India was therefore designed to determine the prevalence and anatomical distribution of MSDs, identify high-impact modifiable risk factors, and uncover gender-specific ergonomic disparities in hopes of informing the development of targeted, evidence-based preventive strategies.
Materials and Methods
Study design and participants
We conducted a nationwide, cross-sectional, questionnaire-based survey targeting spine surgeons across India (both orthopedic and neurosurgeons) with less than 10 years of independent practice experience. Surgeons with fewer than 10 years of independent practice experience were selected given that they were in a formative phase in their career wherein operative and ergonomic habits were still evolving and modifiable. This rationale is consistent with prior ergonomics studies in spine surgery and related surgical specialties, which focused on identifying preventable work-related musculoskeletal risks among surgeons within their first decade of practice [4,7,8]. The current study was conducted in accordance with the Declaration of Helsinki. The Institutional Review Board (IRB) approval was taken from the institute at which the study was primarily done, i.e., Dr. Vasantrao Pawar Medical College, Hospital and Research Centre, Nashik (IRB approval number: NDMVPEC;2024029). Participation was entirely voluntary, with survey completion implying informed consent. No identifiable personal data were collected. The survey was designed to evaluate the prevalence, anatomical distribution, and ergonomic risk factors for MSD, focusing on operative practices, equipment usage, and intraoperative ergonomics. Participants were recruited between January 2025 and June 2025 via professional spine societies, regional orthopedic associations, academic mailing lists, and social media networks. Participation was voluntary and anonymous.
Survey instrument
The questionnaire was developed following a literature review on ergonomic assessments in surgical specialties and adapting the findings to suite spine surgery-specific contexts [3,5,8]. The instrument consisted of 35 items divided into four domains: (1) demographic and professional profile (age, sex, dominant hand, body mass index [BMI], designation, practice setting, years in spine surgery), (2) operative workload and equipment usage (average number of cases, average case duration, posture during surgery, use of microscope, loupes, headlamps, lead aprons, adjustable tables, footrests, monitors), (3) ergonomic practices (table height adjustment frequency, break-taking habits, preoperative discussions regarding ergonomics, implementation of ergonomic aids, assistant–surgeon height disparity), and (4) musculoskeletal symptoms (presence, frequency, and anatomical location of discomfort within the past 12 months).
Where applicable, questions used fixed categorical responses (e.g., “always/often/sometimes/never”), and multiple response options were permitted for symptom locations.
Data collection and management
The survey was conducted using Google Forms (Google LLC, Mountain View, CA, USA), with technical restrictions allowing only one submission per device. No personal identifiers were collected, and IP addresses were not recorded. The survey link was disseminated via multiple open professional groups on social messaging platforms and shared through social media accounts of spine societies and individual surgeons. Collected responses were exported to Microsoft Excel (Microsoft Corp., Redmond, WA, USA) and subsequently analyzed using Python ver. 3.11 (https://www.python.org/) and IBM SPSS Statistics for Windows ver. 28.0 (IBM Corp., Armonk, NY, USA).
Outcome measures
The primary outcome was the prevalence of self-reported MSD within the previous 12 months. Secondary outcomes included the association between MSD and demographic factors, ergonomic practices, equipment usage, and specific intraoperative behaviors (e.g., table height adjustment and microscope or loupe use).
Statistical analysis
Categorical variables were expressed as numbers and percentages, whereas continuous variables were presented as mean±standard deviation (SD) or median with interquartile range (IQR), depending on distribution. Associations among categorical variables were assessed using the χ2 test or Fisher’s exact test, as appropriate. Adjusted odds ratios (aORs) with exact 95% confidence intervals (CIs) were calculated for significant associations. aORs were derived using multivariable exact logistic regression. The multivariable exact logistic regression model adjusted for sex, age, microscope use, loupe use, table height adjustment, and case duration (as specified). A p-value of <0.05 indicated statistical significance. Missing data were handled through case-wise exclusion for the relevant analysis.
Results
A total of 764 spine surgeons (mean age, 35.4±4.5 years; median=35) completed the survey, among whom 150 (19.6%) and 614 (80.4%) were women and men, respectively, and 711 (93.0%) were right-hand dominant. The majority of the respondents were consultants (40.2%) or junior consultants (18.8%) often working at private hospitals (34.4%), medical colleges (25.0%), or corporate hospitals (17.0%). The mean BMI was 28.6±4.6 kg/m2 (Table 1).
Demographic and practice characteristics of respondents
Among the 764 respondents, 641 (83.9%) reported suffering from MSD within the past 12 months. Among the symptomatic surgeons, 96.1% reported experiencing neck discomfort, substantially exceeding those who reported lower back pain (55.4%), wrist pain (47.9%), and upper back pain (25.7%). All 150 female respondents reported MSD, whereas only 491 (80.0%) of the male respondents did the same (p<0.001) (Fig. 1A).
(A) Musculoskeletal disorder (MSD) prevalence by gender. Bar chart showing universal reporting of MSDs among women (100%) compared with 80% among men (p<0.001). (B) Association of optical aids with neck pain. Comparison of microscope versus loupe usage. Surgeons using the microscope reported significantly higher prevalence of neck pain (adjusted odds ratio, 1.65; 95% confidence interval, 1.14–2.39) compared with those using loupes. (C) Prevalence of musculoskeletal disorders according to frequency of operating table height adjustment. Table height adjustment was recorded as a categorical variable based on self-reported frequency (never, sometimes, often, always). Surgeons who always adjusted table height had a lower prevalence of musculoskeletal disorders compared with those who adjusted often, sometimes, or never. For regression analysis, table height adjustment was dichotomized as always versus not always (often/sometimes/never).
Moreover, 362 (58.9%) male surgeons and 79 (52.7%) female surgeons reported using microscopes (p=6.89), whereas 77 (12.5%) male surgeons and 45 (30%) reported using surgical loupes (p=0.033). Sex was included as a covariate in the multivariable model to account for this distribution. Microscope usage was significantly associated with neck pain (aOR, 1.65; 95% CI, 1.14–2.39; p=0.009), whereas surgical loupe usage was not (aOR, 1.06; 95% CI, 0.74–1.54; p=0.78) (Fig. 1B). This neck-dominant symptom pattern contradicts prior ergonomic literature, which showed that low back pain often predominated.
Among the 529 surgeons who reported always adjusting the operating table height, 65.6% and 84% were male and female, respectively. Surgeons who always adjusted operating table height for ergonomic comfort demonstrated a lower prevalence of MSDs (72.8%) than did those who adjusted table height often, sometimes, or never (approximately 95%–99%). Multivariable exact logistic regression analysis showed that consistent table height adjustment was independently associated with a reduced likelihood of MSDs (aOR, 0.21; 95% CI, 0.05–0.88; p=0.03) (Fig. 1C).
Most surgeons performed surgeries while standing for 2–4 hours per typical case (73.2%), with 89.6% wearing a lead apron. During long surgeries, 30.6% (“yes”) and 21.8% (“sometimes”) of the surgeons reported taking breaks or position changes, whereas 47.5% never took breaks. Break-taking behavior was analyzed descriptively only and was not included in regression models given that reverse causation could not be excluded. Paradoxically, MSD prevalence was higher among those who took breaks than in those who did not (100% vs. 79.3%), suggesting reactive rather than preventive break-taking.
Height disparity with the assistant/surgeon was reported by 63.8% of the surgeons, among whom 416 (67.7%) and 72 (48%) were male and female, respectively. However, only 51 (6.7%) of respondents reported “always” discussing ergonomic principles preoperatively, and only 12.0% repeated fully implementing the same in operating rooms. Ergonomic planning was infrequently reported (n=51) and was therefore analyzed descriptively without further stratification. The most commonly used aids were adjustable operating tables (90.7%), microscopes (57.7%), surgical loupes (44.6%), headlamps (44.6%), and footrests (32.3%) (Tables 2, 3).
Ergonomic practices and challenges
Musculoskeletal disorders and associated factors
Discussion
This nationwide survey of early-career spine surgeons in India showed that 83.9% of respondents reported experiencing MSDs, highlighting its high prevalence. Three findings stand out. First, microscope use was paradoxically associated with a greater risk of neck discomfort than was loupe use. Second, consistent operating table height adjustment emerged as a strong protective factor against MSDs. Third, all female surgeons reported MSDs, underscoring the compounded ergonomic risks linked to anthropometric mismatches within surgical environments.
The association between microscope use and increased neck strain contradicts earlier studies suggesting loupes impose greater cervical load [3,4]. However, several explanations reconcile this divergence. Microscopes restrict posture unless ocular tilt and table height are meticulously adjusted. In our cohort, only 6.7% reported consistent ergonomic preparation, suggesting widespread suboptimal alignment. Occupational Safety and Health Administration and Society of American Gastrointestinal and Endoscopic Surgeons guidelines emphasize ocular adjustment to minimize cervical strain [9,10]; however, adoption rates remain low. Recent studies have demonstrated that exoscopes and heads-up displays place surgeons in a superior posture compared to conventional microscopes [7,8], reinforcing our observation of microscope-related ergonomic risk. Conversely, properly fitted loupes, particularly with optimized declination angle and working distance, can facilitate cervical neutrality [11,12], potentially explaining their lack of association with MSDs here. Favorable reports on microscope ergonomics often stem from idealized conditions, such as adjustable chairs, specialized tables, and structured training [12], which are rarely accessible to early-career surgeons practicing in India.
The strong protective effect of consistent table height adjustment (72.8% vs. approximately 100% MSD prevalence; (aOR, 0.21; p=0.03) aligns with established ergonomic data showing that suboptimal table height increases trunk flexion, shoulder abduction, and cervical extension, thereby inducing fatigue [11,12]. Although other surgical specialties have emphasized adjustable table height as critical to ergonomic optimization [13], this simple intervention remains underutilized. Our data support the recommendation that table height adjustment should be an inflexible preincision checklist item, similar to time-out protocols, and not merely an optional consideration.
Sex-based disparities were another striking finding. Specifically, all female surgeons reported MSDs, whereas only 80% of men did so. Although prior studies have attributed this to psychosocial burden or dual-role stressors [14,15], our data reinforce accumulating evidence suggesting anthropometric mismatch as a primary driver. Instruments such as rongeurs, drills, and retractors, which have been historically designed for male hand spans and grip strengths [9,16], create disproportionate strain for smaller hands. Fixed tables and nonadjustable microscope oculars further magnify this disadvantage.
Our results also revealed paradoxically higher MSD prevalence among surgeons who reported taking breaks. This likely reflects reverse causation, with symptomatic surgeons interrupting procedures for relief rather than breaks causing MSD. Prior evidence supports the preventive utility of scheduled micro-pauses [16], highlighting the need to transition from symptom-driven to proactive break protocols.
Finally, although over 60% of the respondents reported height disparity with assistants, preoperative only 6.7% consistently engaged in ergonomic planning. This low uptake suggests an under-recognition of team-based ergonomics as a determinant of individual surgeon comfort. Interventions such as adjustable stools, dual-height tables, and coordinated monitor positioning could alleviate these mismatches [17,18].
Our findings underscore the urgent need for structured ergonomic training during residency and fellowship, emphasizing non-negotiable adjustments, such as table height optimization. Institutional commitment to ergonomic checklists, similar to surgical time-outs, could also normalize preventive practices.
Moreover, our results emphasize the necessity of equipment redesign for female surgeons, which include lighter lead aprons, ergonomic instrument handles, adjustable stools and tables, and customizable ocular systems. With the growing female representation in spine surgery, ensuring ergonomic inclusivity is essential for workforce sustainability. Industry-driven solutions, supported by institutional advocacy, can mitigate anthropometric disadvantages and reduce attrition.
The study benefits from its large, nationally representative sample of 764 early-career spine surgeons, a large national database, and detailed symptom data. By incorporating gender-specific analysis and highlighting modifiable factors, it provides novel and actionable insights.
However, the following limitations need to be acknowledged: (1) Reliance on self-reported data, which may introduce recall or reporting bias, and the cross-sectional design, which precludes causal inference. (2) The open dissemination of the survey questionnaire through professional messaging groups and social media precluded calculation of response rates and may have introduced selection bias given that symptomatic surgeons may have been more inclined to participate. (3) Objective ergonomic measurements, such as posture analysis or motion tracking, were not performed. (4) Although risk factors and potential solutions were identified, the long-term effectiveness of interventions, such as table adjustment or ergonomic redesign, requires confirmation in prospective trials.
Conclusions
This national survey revealed a neck-dominant MSD pattern among young spine surgeons, which was strongly linked to microscope use, and a universal prevalence of MSD among female surgeons. Consistent table height adjustment emerged as a powerful protective factor, highlighting the need for its routine incorporation into surgical workflows. Addressing ergonomic risks, particularly those related to visualization tools, equipment design, and gender-specific needs, can help safeguard surgeon health and career longevity.
Key Points
Work-related musculoskeletal disorders were highly prevalent among spine surgeons, affecting over 80% of the respondents, with a universal prevalence among women.
Neck pain, the principal complaint, was strongly associated with prolonged microscope use and static postures, indicating modifiable risk factors in surgical ergonomics.
Operating table height adjustment emerged as a protective ergonomic factor that reduced the risk of musculoskeletal symptoms.
Our findings highlight the urgent need for ergonomic training, awareness, and gender-sensitive interventions in spine surgery practice.
Notes
Conflict of Interest
No potential conflict of interest relevant to this article was reported.
Acknowledgments
Interested readers may contact the corresponding author to access the survey instrument and response data.
Author Contributions
Conceptualization & study design: PK. Data collection & survey distribution: PK, MS, MN. Data analysis: PK, MN. Interpretation: PK, MN. Writing–original draft: PK. Writing–review & editing: MS, MN. Final approval of the manuscript: all authors.