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Ergonomics and tremor control

Authors: Thomas Givskov Sørensen, Magnus Balslev Avstorp MD, Ahmad Makki MD and Gete Toft

Ergonomics is highly important in all surgical fields in order to optimize working conditions by minimizing tremor as well as to ensure the longevity of the surgeon by reducing the incidence of musculoskeletal injuries.

Awkward positioning, repetitive motions, hyperflexion of the cervical spine and limited recovery time between surgeries all contribute to the development of musculoskeletal injuries. Additionally an optimal working position with hands and forearms comfortably supported reduces fatigue and tremor.

Beneficial practices for optimizing ergonomics

The following should be considered during surgery:

  • Sit with your back straightened and maintain a neutral position in the spine
  • Relax your shoulders
  • Keep your elbows tucked in
  • Rest your wrists on a surface adjusted to the level of the surgical field
  • Implement short regular breaks

Additional actions to ensure longevity for the microvascular surgeon:

  • Perform Intraoperative stretching
  • Try to enhance physical fitness by performing moderate resistance
  • Try to incorporate and make good use of your assistants

Physiologic tremor is a high-frequency, low-amplitude tremor which is commonly seen in healthy individuals. This tremor has a more significant impact on the surgical procedure when performing microsurgery, where controlled and precise movements are required due to the size and magnification of the surgical field. Tremor will be less pronounced with experience, but additional internal and external factors may have an impact on physiologic tremor.

Factors that may influence hand tremor

Anxiety: Stress or anxiety may result in the secretion of catecholamines which increase heart rate and physiologic tremor. 

Exercise: Strong physical efforts and physical exertion increase hand tremor in up to 24 hours.

Caffeine: Caffeine consumption increases hand tremor. However, this effect seems to be smaller in individuals who consume caffeine on a regular basis, compared to individuals who consume caffeine on a more occasional basis.

Duration of the procedure: Prolonged time in the operating theatre may result in mental and physical fatigue which can increase hand tremor as described above.


  1. C. Lakhiani, S. M. Fisher, D. E. Janhofer, and D. H. Song, “Ergonomics in microsurgery,” J Surg Oncol, vol. 118, no. 5, pp. 840–844, 2018, doi: 10.1002/jso.25197.
  2. E. Belykh et al., “Systematic Review of Factors Influencing Surgical Performance: Practical Recommendations for Microsurgical Procedures in Neurosurgery,” World Neurosurg., vol. 112, pp. e182–e207, 2018, doi: 10.1016/j.wneu.2018.01.005.
  3. K. M. Fargen, R. D. Turner, and A. M. Spiotta, “Factors That Affect Physiologic Tremor and Dexterity during Surgery: A Primer for Neurosurgeons,” World Neurosurg., vol. 86, pp. 384–389, 2016, doi: 10.1016/j.wneu.2015.10.098.

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