Scott I. Lee, MD
Music, Amongst Other Things, Can Influence Your Surgical Outcome
Surgical outcomes are impacted by a variety of factors, a surprising number of which you and your surgeon can influence to ensure the best outcomes. What questions should you ask? What can you do before surgery to load the odds in your favor? What can be done once you are under anesthesia and your outcome is in the hands of your surgeon?
The decision to undergo surgery becomes a dance between pros and cons, weighing the possible risks against the proposed benefits. You, along with your surgeon, should do everything in your collective efforts to ensure a good surgical outcome. The decision to have surgery should always begin with a heart-to-heart conversation with yourself, your family and friends, and of course, your surgeon.
Pre-Surgery Factors Likely Have The Largest Influence On Outcomes
This is good news. It means that you and your surgeon have some control over your outcomes even before you get close to the operating room. Imagine hitting the blackjack table in Las Vegas with a couple Aces in your back pocket to use as you please. While the extra cards do not guarantee a win, most of us would welcome the extra assistance. Give yourself some "Aces" leading up to surgery:
1. What are the indications for surgery?
This is perhaps the most important question to ask yourself and your surgeon. In order for surgery to be successful, alignment is of paramount importance. And by alignment, I am referring to an alignment between your goals, your surgeon's expectations, and the potential benefits of surgery. If surgery is being offered for questionable reasons (e.g. you have not exhausted other treatment options) or surgery does not match your treatment goals, then I strongly encourage you to seek a second opinion. Your surgeon should be able to provide you with scientific evidence to support the proposed surgical plan, outline the risks of surgery, and reasonably estimate the chance that surgery will alleviate your symptoms. The point is, ask your surgeon questions!
2. Is surgery the only option?
There are certainly instances where spine surgery is the only option to preserve function. Fortunately, these instances are rare and most often involve traumatic injuries or a progressive loss of function. For the vast majority of spine issues, surgery is an elective procedure. There is good evidence that conservative treatment measures provide an excellent chance for relief of many spine issues. Unfortunately, not everyone experiences significant relief, and for some individuals, conservative treatment does not align with his/her goals. If despite physical therapy, medications, injections, and other treatment you are still experiencing debilitating symptoms, then surgery may be a great option for you.
With that said, if you have reached the decision to have surgery, there is profound benefit in continuing your exercise routine and physical therapy. The better your physical condition is before surgery, the better your base will be as you begin the process of post-operative rehabilitation. I refer to this as (P)re-habilitation.
3. Am I healthy enough for surgery?
This question requires coordination between your surgeon and your primary care provider. While not all surgeries are the same in terms of length of surgery, degree of invasiveness, and anticipated recovery time, your medical team should ensure that you are able to handle the physiologic stress of surgery. This may involve checking basic blood work, evaluating your heart function, as well as reviewing your current medications.
Here are some important things that you can do to help not only improve your health, but also will help ensure the best possible outcome with spine surgery:
Continue your current exercise routine
Control chronic medical conditions (e.g. blood pressure, diabetes, cholesterol)
Stop smoking, and if you do not smoke, be sure not to start!
There is a mountain of medical evidence that smoking/nicotine leads to increased risk of pain, infection, poor bone healing, and overall worse outcomes with spine surgery
Keep your weight under control
4. Am I a candidate for Minimally-Invasive Surgery (MIS)?
MIS techniques can reduce operative time, decrease blood loss and rates of infection, while also lowering post-operative pain when compared to open, traditional techniques. There is a large body of evidence that MIS techniques can significantly expedite your recovery. However, MIS techniques may not be the best option for certain patients or surgical issues. Here is an analogy I provide to my patients:
Imagine you hired a handyman/woman to do some repairs around your house. Unfortunately, he/she only knows how to use one tool -- a hammer. The hammer is great for nailing nails, but do you really think it will be effective in fixing a leaky faucet, unclogging a stubborn drain, or fixing an electrical outlet?
I am a huge proponent of MIS techniques. However, when applied broadly without regard to individual patient factors, these techniques can produce less than optimal results. If you are a candidate for MIS techniques and your surgeon is well-versed in them, that is fantastic. If you are not a candidate, do not fret. Open, traditional techniques have withstood the test of time because they work.
The take home point is, make sure your surgeon has both MIS and open techniques to properly use at his/her disposal.
Surgical Efficiency Can Expedite Your Recovery
Efficiency matters in the operating room. An efficient surgery minimizes your time under anesthesia, limits the time that your surgical wound is exposed, and has strongly been associated with improved surgical outcomes. Now before you envision your surgical team sprinting around the operating room, efficiency is not solely based on speed. Rather, operating room efficiency is most strongly dictated by familiarity between members of the operating room team, minimization of unnecessary steps, and avoidance of complications.
5. Does the hospital employ a specialized spine team in the operating room?
Due to the special nature of spine procedures, many hospitals employ a specialized spine team that has been specifically trained on spine procedures, instruments, and operating room set-up. Studies show that these specialized teams have immense value -- familiarity and repetition breed efficiency.
Your anesthesiologist can already anticipate the length of surgery and knows what medications to administer that will keep you safe and comfortable before, during, and after surgery
Your surgical nurse knows how to position you correctly for surgery, what equipment should be prepared, and who to call to begin coordinating your post-operative care
Your surgical scrub technician is familiar with each procedure, anticipating surgical steps, and oftentimes handing your surgeon the correct instrument without even being asked
Your surgeon is very familiar with everyone in the surgical team, has supreme confidence in their abilities, and knows that they all can be trusted to keep you safe during surgery
6. What music does my surgeon listen to in the operating room?
In a joint study published by Spotify and Figure 1, 90% of surgeons listen to music at some point during an operation. Believe it or not, there is considerable debate about playing music during surgery. The naysayers frequently point to music as a potential source of distraction that can impair communication between team members. Proponents for music in the operating room cite several studies that suggest the following:
increased speed and accuracy solving problems with reduced autonomic nervous system activity (e.g. sweating, increased heart rate -- indicative of a stress response)
improved efficiency and performance with more simple, surgical tasks (e.g. closing incisions)
And there is certainly a mountain of anecdotal evidence. Personally, I prefer playing relaxing music at a reasonable volume in the operating room. I feel that it keeps me calm and focused on-task while helping to keep the entire surgical team engaged.
However, my choice in music is in the minority. According to the Spotify and Figure 1 study, Rock rules! Ask your surgeon if he/she takes requests for your operating room soundtrack.
7. Does my surgeon look after his/her own health and performance?
A healthy surgeon is a happy surgeon, and a happy surgeon is an efficient surgeon. Surgery is both mentally and physically demanding, requiring sustained focus, hand-eye coordination, fine motor skill, quick problem solving, and stamina. After particularly long surgery days, I can feel drained and physically sore.
It is no wonder that there has been increasing focus on a surgeon's physical and mental health in optimizing surgical performance. In a 2011 New Yorker article, Dr. Atul Gawande explores the idea of a "performance coach" for surgeons to continuously evaluate and improve surgical technique. In a recently published Doximity article, Dr. Jonathan Cabin floats the idea of surgeons as high-performance athletes.
While I think it is a major stretch to compare surgeons to to the likes of Michael Jordan or Usain Bolt, I do think that Drs. Gawande and Cabin have some valid thoughts to improve surgeon performance.
In my own practice, here is how I help manage the physical and mental rigors of surgery:
Sleep - consistent and restful sleep helps maintain focus and energy levels
Nutrition - a low carbohydrate, high protein breakfast sets me up for the day. Small, balanced snacks with plenty of hydration between cases maintains my energy
Mental Rehearsal - I mentally rehearse each operation the night before. I find that this improves my efficiency and helps identify potential difficulties with each case. It also affords the opportunity to develop well-thought-out contingency plans
Performance Evaluation - reflection is an important aspect of improvement. How did we do on each step of the operation? What aspects did we excel at? Were there moments in the operation where we got bogged down?
What other questions do you think are important to ask before surgery? Comment down below!