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The Effect of Cigarette Smoking and Smoking Cessation on Spinal Fusion
Abstract
The effect of cigarette smoking and smoking cessation on spinal fusion was studied in a retrospective review of 357 patients who had undergone instrumented spinal fusion.
To document the widely assumed but unreported benefit of cigarette smoking cessation on fusion rate and clinical outcome after spinal fusion surgery.
Cigarette smoking has been shown to inhibit lumbar spinal fusion and to adversely effect outcome in treatment of lumbar spinal disorders. Prior reports have compared smokers and nonsmokers, as opposed to comparing smokers and quitters.
This study retrospectively identified 357 patients who underwent a posterior instrumented fusion at either L4-L5 or L4-S1 between 1992 and 1996. Analysis of the medical record and follow-up telephone surveys were conducted. Clinical outcome and fusion status was analyzed in relation to preoperative and postoperative smoking parameters.
In this study, the nonunion rate was 14.2% for nonsmokers and 26.5% for patients who continued to smoke after surgery (P < 0.05). Patients who quit smoking after surgery for longer than 6 months had a nonunion rate of 17.1%. The nonunion rate was not significantly affected by either the quantity that a patient smoked before surgery or the duration of preoperative smoking abatement. Return-to-work was achieved in 71% of nonsmokers, 53% of nonquitters, and 75% of patients who quit smoking for more than 6 months after surgery.
These results validate the hypothetical assumption that postoperative smoking cessation helps to reverse the impact of cigarette smoking on outcome after spinal fusion.
... Glassman et al reported that smokers had a significantly higher risk of pseudarthrosis following spinal fusion surgery, underscoring the broader implications of smoking on bone healing and surgical success. 7 Despite the clear evidence linking smoking to adverse outcomes in other orthopedic procedures, the specific impact of smoking on hip arthroscopy outcomes remains less well-defined. The minimally invasive nature of hip arthroscopy might suggest a different risk profile compared to more invasive procedures like total hip arthroplasty. ...
... Smoking has been shown to adversely affect the outcomes of various orthopedic surgeries, including spinal fusion, total joint arthroplasty, and fracture healing. 7,10,11 The negative impact of smoking on bone and soft tissue healing, coupled with increased inflammation and reduced immune response, contributes to poorer surgical outcomes. For instance, Glassman et al demonstrated that smokers had a higher rate of pseudarthrosis after lumbar spine fusion compared to nonsmokers. ...
... For instance, Glassman et al demonstrated that smokers had a higher rate of pseudarthrosis after lumbar spine fusion compared to nonsmokers. 7 The impact of smoking on hip arthroscopy outcomes specifically has been less well-studied. However, the available evidence aligns with the findings of this metaanalysis. ...
Hip arthroscopy is an increasingly utilized procedure for treating various hip pathologies. However, patient-related factors, such as smoking, may significantly impact postoperative outcomes. Smoking is known to impair tissue healing and increase the risk of complications, potentially leading to poorer surgical results. This meta-analysis aims to evaluate the effect of smoking on outcomes following hip arthroscopy, focusing on functional scores, pain levels, and patient satisfaction. A comprehensive search was conducted in PubMed, Web of Science, Scopus, Medline, the Cochrane Library, and Google Scholar to identify studies assessing hip arthroscopy outcomes in smokers and nonsmokers. After removing duplicates, screening titles and abstracts, and assessing full-text eligibility, five studies were included in the quantitative synthesis. Outcomes were pooled using a fixed-effect model to calculate mean differences and 95% confidence intervals (CIs). The meta-analysis included data from five studies with a total of 618 patients (234 smokers and 384 nonsmokers). The hip outcome score–sports specific (HOS-SS) was significantly lower in smokers, with a mean difference of -8.63 (95% CI: -12.71, -4.54), indicating worse sports-specific function. The modified Harris hip score (mHHS) was also significantly lower in smokers (mean difference: -4.47, 95% CI: -7.50, -1.44). Pain levels measured by the visual analog scale (VAS) were higher in smokers (mean difference: 0.62, 95% CI: 0.17, 1.06). However, there was no significant difference in satisfaction VAS scores between smokers and nonsmokers (mean difference: -0.13, 95% CI: -0.61, 0.34). In conclusion, smoking is associated with significantly worse functional outcomes and higher pain levels following hip arthroscopy. These findings highlight the importance of smoking cessation programs for patients undergoing hip arthroscopy to improve surgical outcomes. Despite the worse functional and pain outcomes, patient satisfaction did not differ significantly, which may indicate a disparity between objective outcomes and subjective satisfaction in smokers.
... The documented incidence of pseudarthrosis post lumbar fusion surgery (5-15%) [3] and its substantial contribution to revision fusion surgery (23.6%) [4] underscore the clinical pertinence of this complication. Nunna et al. 's revelations regarding smoking as a global risk factor for pseudarthrosis [5], coupled with Glassman et al. 's identification of a significant dichotomy in pseudarthrosis rates between smokers and nonsmokers, contributed to a nuanced understanding of the multifaceted nature of the condition [6]. ...
... The outcome was not changed whether 1-level or 2-level fusion, allograft, or autograft was utilized. Glassman et al. [6] detailed that the frequency of pseudarthrosis was not essentially impacted by either the amount that a patient smoked before surgery or the duration of preoperative smoking cessation. Conversely, postoperative smoking cessation for more than 6 months was related to a diminished risk of pseudarthrosis. ...
This study presents a systematic literature review and meta-analysis of pseudarthrosis risk factors following lumbar fusion procedures. The odds ratio (OR) and 95% confidence interval (95% CI) were used for outcome measurements. The objective of this study was to identify the independent risk factors for pseudarthrosis after lumbar spinal fusion, which is crucial for mitigating morbidity and reoperation. Systematic searches in PubMed, Embase, and Scopus (1990–July 2021) were conducted using specific terms. The inclusion criteria included prospective and retrospective cohorts and case‒control series reporting ORs with 95% CIs from multivariate analysis. The quality assessment utilized the Newcastle–Ottawa scale. Meta-analysis, employing OR and 95% CI, assessed pseudarthrosis risk factors in lumbar fusion surgery, depicted in a forest plot. Of the 568 abstracts identified, 12 met the inclusion criteria (9 retrospective, 2006–2021). The 17 risk factors were categorized into clinical, radiographic, surgical, and bone turnover marker factors. The meta-analysis highlighted two significant clinical risk factors: age (95% CI 1.02–1.11; p = 0.005) and smoking (95% CI 1.68–5.44; p = 0.0002). The sole significant surgical risk factor was the number of fused levels (pooled OR 1.35; 95% CI 1.17–1.55; p < 0.0001). This study identified 17 risk factors for pseudarthrosis after lumbar fusion surgery, emphasizing age, smoking status, and the number of fusion levels. Prospective studies are warranted to explore additional risk factors and assess the impact of surgery and graft type.
... The adverse effects of smoking on fracture healing have been reported before on various occasions. For instance, smoking has been seen to prolong the healing times of tibial fractures or spinal fusions, as well as elective knee and foot surgery [30,[32][33][34]. The same goes for conventional and vascularized bone grafts in upper and lower extremity reconstruction, where smoking was associated with a 75% decreased healing rate, and the number of pack-years correlated with longer healing times [24]. ...
... In fact, it has even been demonstrated that the amount of nicotine intake is closely correlated with healing times [34]. Conversely, smoking cessation after bone surgery for six months has been seen to reduce healing times so that it almost reaches non-smoker levels [33]. In our cohort, neither the amount cigarettes smoked nor the rate of smoking cessation after surgery were assessed. ...
The vascularized fibula transfer is a well-established technique for extremity reconstruction, but operative planning and patient selection remains crucial. Although recently developed techniques for bone reconstruction, such as bone segment transfer, are becoming increasingly popular, bone defects may still require vascularized bone grafts under certain circumstances. In this study, 41 cases, 28 (68%) men and 13 (32%) women (median age: 40 years), were retrospectively analyzed. Therapy-specific data (flap vascularity [free vs. pedicled] size in cm and configuration [single- vs. double-barrel], mode of fixation [internal/external]) and potential risk factors were ascertained. Indications for reconstruction were osteomyelitis at host site (n = 23, 55%), pseudarthrosis (n = 8, 20%), congenital deformity (n = 6, 15%), traumatic defect, and giant cell tumor of the bone (n = 2, 5% each). Complete healing occurred in 34 (83%) patients after a median time of 6 months. Confounders for prolonged healing were female gender (p = 0.002), reconstruction in the lower limb (p = 0.011), smoking (p = 0.049), and the use of an external fixator (p = 0.009). Six (15%) patients required secondary limb amputation due to reconstruction failure, and one patient had persistent pseudarthrosis at last follow-up. The only risk factor for amputation assessed via logistic regression analysis was preexisting PAOD (peripheral artery occlusive disease; p = 0.008) The free fibula is a reliable tool for extremity reconstruction in various cases, but time to full osseous integration may exceed six months. Patients should be encouraged to cease smoking as it is a modifiable risk factor.
... Department of Health and Human Services, 2020; Ikeda et al., 2019Ikeda et al., , 2021, equalized household income (U.S. Department of Health and Human Services, 2020; Ikeda et al., 2019Ikeda et al., , 2021, weekly engagement in mild, moderate or vigorous physical activity (Chiolero et al., 2008;, lung disease diagnosis (Thomson, 2004), asthma diagnosis (Thomson, 2004), osteoporosis diagnosis (Glassman et al., 2000), cancer diagnosis (U.S. Department of Health and Human Services, 2020), depressive symptoms (Ikeda et al., 2019;Murphy et al., 2003), handgrip strength (Ikeda, Cooray, Suzuki, et al., 2022;Kojima et al., 2015), body mass index (Dare et al., 2015;Ikeda, Cooray, Suzuki, et al., 2022) and back pain and its intensity. ...
... Although the mechanisms underlying the relationship between smoking and back pain have been previously reported (Glassman et al., 2000;Law & Hackshaw, 1997;Shi et al., 2010), those reported on the relationship between smoking cessation and back pain are limited. A possible explanation for this is the recovery from long-term nicotine consumption, that is the recovery of the central nervous system and a decrease in increased pain perception are caused by the cessation of nicotine exposure. ...
Background:
This study aimed to assess the impacts of smoking cessation and resumption over 4 years on the risk of back pain at the 6-year follow-up among older adults in England.
Methods:
We analysed 6467 men and women aged ≥50 years in the English Longitudinal Study of Aging. Self-reported smoking status, assessed in waves 4 (2008-2009) and 6 (2012-2013), was used as exposure for the study, whereas self-reported back pain of moderate or severe intensity, assessed in wave 7 (2014-2015), was used as the outcome. A targeted minimum loss-based estimator was used with longitudinal modified treatment policies to adjust for baseline and time-varying covariates.
Results:
Regarding the estimation of the effects of changes in smoking status on the risk of back pain, during the follow-up, individuals who resumed smoking within 4 years had a higher risk of back pain than those who avoided smoking for over 4 years, and the relative risk (RR) (95% confidence interval [CI]) was 1.536 (1.214-1.942). Regarding the estimation of effects of smoking cessation on the risk of back pain, smoking cessation over 4 years was associated with a significantly lower risk of back pain, as indicated by the originally observed data, and the RR (95% CI) was 0.955 (0.912-0.999).
Conclusions:
Older adults who avoided smoking for over 4 years had a lower risk of back pain. However, those who resumed smoking within 4 years had a higher risk of back pain.
Significance:
Older adults who avoided smoking for over 4 years had a lower risk of back pain. However, those who resumed smoking within 4 years had a higher risk of back pain. Our study data suggest the importance of maintaining smoking cessation to reduce the risk of back pain in the older population.
... In open posterior spine surgery, the long incision together with the extensive dissection of muscles from the posterior bony elements and continuous self-retaining retraction result in significant oedema of the paraspinal muscles, leading to significant soft tissue damage, denervation and eventually to the reduction in their cross-sectional area [34][35][36]. By preventing these effects, MIS spinal procedures enable the better preservation of soft tissue and promote the healing process after surgery. ...
... Smoking has been shown to interfere with the healing of wounds, soft tissues and bone through the vasoactive effect of nicotine on peripheral tissue blood flow and oxygenation, as well as on the attenuation of inflammatory cell infiltration in the wound [4,34,35]. In addition, on the molecular level, nicotine inhibits the gene expression of the fibroblast growth factor, vascular endothelial growth factors and bone morphogenic proteins [38]. ...
Background:
Tobacco smoking is a major cause of morbidity and mortality worldwide. Several authors reported a significant negative impact of smoking on the outcome of spinal surgeries. However, comparative studies on the effect of smoking on the outcome of minimally invasive (MIS) spinal decompression are rare with conflicting results. In this study, we aimed to evaluate clinical outcomes and postoperative complications following MIS decompression in current and former smoking patients compared to those of non-smoking patients.
Methods:
We used our prospectively collected database to retrospectively analyse the records of 188 consecutive patients treated with MIS lumbar decompression at our institution between November 2013 and July 2017. Patients were divided into groups of smokers (S), previous smokers (PS) and non-smokers (N). The S group and the PS group comprised 31 and 40 patients, respectively. The N group included 117 patients. The outcome measures included perioperative complications, revision surgery and length of stay. Patient-reported outcome measures included a visual analogue scale (VAS) for back pain and leg pain, as well as the Oswestry disability index (ODI) for evaluating functional outcomes.
Results:
Demographic variables, comorbidity and other preoperative variables were comparable between the three groups. A comparison of perioperative complications and revision surgery rates showed no significant difference between the groups. All groups showed significant improvement in their ODI and VAS scores at 12 and 24 months following surgery. As shown by a multivariate analysis, current smokers had lower chances of improvement, exceeding the minimal clinical important difference (MCID) in ODI and VAS for leg pain at 12 months but not 24 months postoperatively.
Conclusions:
Our findings show that except for a possible delay in improvement in leg pain and disability, tobacco smoking has no substantial adverse impact on complications and revision rates following MIS spinal decompressions.
... In another study, which followed nearly 60 000 teenagers for 11 years, smoking raised the likelihood of lumbar discectomy [8]. According to other research, smoking prolongs the healing process following disc surgery and aggravates pre-existing disc degeneration [9,10]. Despite this epidemiologic correlation, it is still unknown how smoking contributes to IVDD. ...
Aim
Through the use of network toxicology, the research sought to determine whether cellular senescence and associated molecular mechanisms in nicotine‐induced intervertebral disc degeneration (IVDD) were potentially harmful.
Methods
The primary chemical structure and 105 targets of action of nicotine were determined by using the Swiss Target Prediction, Cell Age, and PubChem databases. 855 IVDD senescence genes were found using the GEO and Cell Age datasets.
Results
After additional screening and Cytoscape development, 9 key targets were identified. Additionally, these targets' co‐expression pattern analysis and protein interactions were confirmed to be identical. The core targets of nicotine‐induced IVDD cellular senescence were found to be primarily enriched in the positive regulation of cell proliferation, telomere shortening, histone acetylation, and cellular senescence‐related processes, according to gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG). The KEGG signaling pathway also made it clear that the Apelin signaling route, nicotinate and nicotinamide metabolism, cell cycle, and apoptosis are all strongly linked to nicotine‐induced IVDD cellular senescence. We chose four genes associated with the cellular senescence pathway—HDAC1, HDAC4, and NAMPT, MYLK—for molecular docking with the toxic substance nicotine. The findings validated nicotine's strong affinity for the primary targets.
Conclusion
All things considered, the current research indicates that nicotine may contribute to cellular senescence in IVDD via controlling the histone deacetylation process, telomere shortening, the Apelin signaling pathway, and pathways linked to the metabolism of nicotinate and nicotinamide. The theoretical foundation for investigating the molecular mechanisms of nicotine‐induced senescence in IVDD is established.
... Collection procedures often require a second surgical site, which extends the time in surgery and increases the risk of potential blood loss, infection, pain, and morbidity for the patient [10][11][12]. In addition, there are limits on the amount of graft material that can be safely harvested from pediatric patients, and there is considerable variation in graft quality due to factors such as the age of the patient, comorbidity and smoking status, and osteoporosis [13,14]. Many of these factors also contribute to delays in bone healing, susceptibility to infection, and post-procedural complications with pain, gait disturbance, numbness, or iliac crest fracture [15,16]. ...
Bone graft materials are essential for achieving arthrodesis after spine surgery. Safe bone graft products, with osteoinductive, osteoconductive properties and the ability to monitor fusion in real-time, are highly desirable. A novel hyper-crosslinked carbohydrate polymer (HCCP) bone graft substitute was shown to aid in bone regeneration in critical-size defect studies in a rabbit model. These studies further evaluated the in vivo application of HCCP as a bone graft substitute in an ovine model of spinal fusion and a retrospective study in adult human spine surgery patients. Sheep studies demonstrated the safety and efficacy of HCCP with no evidence of adverse histopathology over 6 months of follow-up. In human studies, patients (N = 63) underwent posterolateral fusion with HCCP, with follow-up to assess fusion success. No adverse reaction related to the HCCP bone graft substitute was identified. Fusion success was noted to be non-inferior to other bone graft substitutes. HCCP appears to be a safe bone void filler adjunct for use in spinal fusion surgery for both trauma and degenerative disease. It has a good degradation profile for forming bone with the ability to provide new vasculature and may also function as a scaffold to carry cells, medications, and growth factors. Given the safety profile experienced in our preclinical and clinical studies, future investigation into its efficacy to achieve solid fusion is currently ongoing.
... This discrepancy may be explained by the relatively small number of smokers in our study, which could limit statistical power. Additionally, routine perioperative smoking cessation protocols for oral surgery patients might have mitigated the impact of smoking during the perioperative period [31,32]. These factors, combined with the short-term effects of smoking cessation, may explain the lack of significant findings in our analysis. ...
Objectives
This cross-sectional study aimed to assess the natural bone healing process in mandibular cystic cavities after enucleation surgery using three-dimensional (3D) analysis. By assessing key indicators, including bone cavity healing percentage, mean reduction in bone cavity radius, and mean bone volume increase, we sought to provide a detailed quantification of postoperative bone regeneration.
Methods
223 CT records from 84 patients with initial bone cavity volumes exceeding 1000 mm³ were included. 3D mandibular models were generated from the CT scans, and digital software was employed to measure cavity volume, surface area, and anatomical distances. The influence of cyst size, gender, and age on healing outcomes was evaluated at various intervals.
Results
Mandibular bone cavities healed most rapidly during the first three months, shrinking by approximately 1.14 mm/month (IQR: 0.66–1.53 mm/month) while bone volume increased by 0.61 mm/month (IQR: 0.39–1.12 mm/month). By three months, approximately 58.32% (IQR: 37.54–65.87%) of the cavity volume had healed. By 12 months post-operation, cavities were nearly healed with a healing rate of 90.23% (IQR: 80.69–94.45%). Bone accumulation was influenced by gender (P < 0.001), age (P = 0.014), cavity size (P = 0.004), and position (P = 0.029), with cavity shrinkage more significantly affected by the initial cavity size (P = 0.015) and gender (P = 0.004). Newly formed bone contributed to 63.28%(IQR:45.78–83.68%) of the total healing.
Conclusions
This study offers a comprehensive 3D evaluation of mandibular bone healing after cyst enucleation. Both bone formation and cavity shrinkage were key components of healing.
Clinical relevance
The study provides valuable insights for monitoring postoperative recovery and predicting bone healing.
... One study advocated for mandatory smoking cessation for at least four weeks postoperatively (8). Evidence shows that smokers have a significantly higher incidence of ASD following SF compared with non-smokers (79). While the direct effect of alcohol on ASD is less studied, it is known to lower bone density, increase fracture risk and impair bone healing and regeneration, all of which may indirectly elevate the risk of ASD (80). ...
Adjacent segment disease (ASD) is a significant clinical complication following cervical and lumbar spinal fusion surgery, characterized by the degeneration of spinal segments adjacent to the fused area. The present literature review aimed to elucidate the risk factors contributing to ASD and to evaluate current and emerging treatment strategies. Epidemiological data indicate that patient-related factors such as age, pre-existing spinal degeneration and comorbidities, along with surgical factors including the type of fusion, instrumentation and alignment correction, play pivotal roles in ASD development. Biomechanical alterations post-fusion further exacerbate the risk. The underlying mechanisms of ASD involve changes in spinal kinematics and disc degeneration, driven by inflammatory and degenerative processes. Diagnostic modalities, such as magnetic resonance imaging and computed tomography scans, are essential for early detection and accurate diagnosis. Preventive strategies emphasize meticulous preoperative planning, advanced surgical techniques and postoperative rehabilitation. Treatment approaches range from conservative methods such as physical therapy and pharmacological interventions to surgical solutions, including revision surgeries and the use of motion-preserving technologies. Emerging therapies, particularly in regenerative medicine, show promise in mitigating ASD. The present review underscored the necessity of a multidisciplinary approach to optimize patient outcomes and highlighted the need for ongoing research to address gaps in the current understanding of ASD in both cervical and lumbar regions.
... Among the preoperative patient characteristics examined in our cohort, smoking status was identified as a modifiable factor that was twice as common among those who ultimately developed high-grade UIV loosening, as well as among patients who ultimately required hardware revision, paralleling numerous other studies that have assessed the impact of smoking on fusion rates and adverse events after spine surgery. 30,31 In terms of surgical factors, the utilization of proximal hooks during ASD correction may influence the likelihood of developing UIV loosening. The impact of additional modifiable surgical factors, such as degree of deformity correction 32 or UIV screw angle, 33 on the development of screw loosening may be useful to explore in future studies. ...
OBJECTIVE
Surgical correction of adult spinal deformity (ASD) is associated with a high rate of hardware complication that can be challenging to predict. Hardware integrity and alignment after surgery are typically followed with standing radiography, where pedicle screw loosening may be incidentally identified but the clinical significance of which is often unclear. This study aimed to identify the incidence and implications of pedicle screw loosening at the upper instrumented vertebra (UIV) after surgical correction of ASD.
METHODS
A single-institution retrospective analysis was performed on a cohort of 217 patients who underwent long-segment fusion with pelvic fixation for correction of ASD between September 2013 and November 2021. Cases with a minimum 1-year follow-up were included. UIV pedicle screws were graded on radiographs for evidence of loosening with a 0- to 3-point scale: 0, no loosening; 1, lucency within screw threads; 2, lucency around screw threads; and 3, screw dislodgment/backout. Need for hardware revision surgery was assessed as the primary outcome. Patient-reported outcome measures (PROMIS and Oswestry Disability Index scores) were assessed as secondary outcomes among the patients with available scores.
RESULTS
Low-grade UIV screw loosening (grade 1) was identified in 37 patients (17.1%), and high-grade UIV loosening (grade 2 or 3) was identified in 23 patients (10.6%). Low-grade UIV loosening was not associated with eventual need for hardware revision (OR 0.52, 95% CI 0.17–1.61, p = 0.258); however, high-grade loosening was associated with increased odds of hardware revision (OR 5.17, 95% CI 1.74–15.36, p = 0.003), including specifically surgery for correction of proximal junctional kyphosis (OR 5.73, 95% CI 1.27–25.95, p = 0.024). Among patients with PROMIS T-scores, those requiring hardware revision reported worse Pain Interference (65.0 ± 5.1 vs 59.6 ± 7.7, p = 0.001) and Physical Function (33.3 ± 5.6 vs 37.4 ± 7.4; p = 0.011). Patients with high-grade UIV loosening reported higher Oswestry Disability Index scores than those without high-grade loosening (grade 0 or 1), although this failed to reach statistical significance (44.0 ± 8.5 vs 33.7 ± 18.5, p = 0.101).
CONCLUSIONS
Grade 1 UIV pedicle screw loosening may represent a benign incidental finding, whereas high-grade loosening is associated with significantly increased odds of hardware revision surgery. High-grade loosening may also be associated with worse patient-reported disability. The authors’ findings suggest that while low-grade UIV loosening may often be managed expectantly, identification of high-grade UIV pedicle screw loosening on follow-up imaging warrants increased attention and continued surveillance.
... Smoking is associated with less improvement in back pain, delayed wound healing, delayed bone growth and fusion, and increased complication rates. [64][65][66][67][68][69][70][71] Most studies on prognostic factors for the outcome of spine surgery are not specific for CLBP due to DDD, superiority of surgery over a cognitive-behavioural pain management program (CBPMP) is not evident, [31][32][33][34][35] and thus the advice from international and national guidelines is to primarily enroll patients with CLBP in specific exercise-based programs or a CBPMP. Our recommendation remains to only perform fusion surgery for single level DDD if all conservative treatment has failed. ...
Study Design
Systematic review.
Objective
This systematic review aims to identify prognostic factors, encompassing biomedical and psychosocial variables, linked to outcome of fusion surgery for chronic low back pain (CLBP) in single or two-level lumbar degenerative spinal disorders. Identifying these factors is crucial for decision making and therefore long-term treatment outcome.
Methods
A systematic search (PROSPERO ID: CRD4202018927) from January 2010 to October 2022 was conducted, utilizing Medline, Embase, and the Cochrane Database of Systematic Reviews (CDSR, CENTRAL). Prognostic factors associated with various outcomes, including functional status, back and leg pain, health-related quality of life, complications, return to work, and analgesic use, were assessed. Risk of bias was determined using QUIPS, and the quality of evidence was evaluated using GRADE approach.
Results
Of the 9852 initially screened studies, eleven studies (n = 16,482) were included in the analysis. In total, 161 associations were identified, with 67 prognostic factors showing statistical significance ( P < 0.05). Thirty associations were supported by two or more studies, and only eight associations were eligible for meta-analyses: female gender remained statistically significant associated with decreased postoperative back pain, but negatively associated with complication rates and functional status, and smoking with increased postoperative back pain.
Conclusion
Only female gender and smoking were consistently associated with outcome of fusion for CLBP. Most of the included studies exhibited low to moderate methodological quality, which may explain the relatively weak associations identified for the assessed prognostic factors.
... This meta-analysis showed that patients who smoked were at higher risk for fusion failure. The combined OR of 8 studies [32,36,38,41,44,46,48,49] was 1.57 (95% CI, 1.11 to 2.21; I 2 = 0.0%) (Fig 3). The trim-and-fill method was used to assess the robustness of the results, and we did not find potentially missing studies (S6 Table). ...
Purpose
We performed a meta-analysis to identify risk factors affecting spinal fusion.
Methods
We systematically searched PubMed, Embase, and the Cochrane Library from inception to January 6, 2023, for articles that report risk factors affecting spinal fusion. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using fixed-effects models for each factor for which the interstudy heterogeneity I² was < 50%, while random-effects models were used when the interstudy heterogeneity I² was ≥ 50%. Using sample size, Egger’s P value, and heterogeneity across studies as criteria, we categorized the quality of evidence from observational studies as high-quality (Class I), moderate-quality (Class II or III), or low-quality (Class IV). Furthermore, the trim-and-fill procedure and leave-one-out protocol were conducted to investigate potential sources of heterogeneity and verify result stability.
Results
Of the 1,257 citations screened, 39 unique cohort studies comprising 7,145 patients were included in the data synthesis. High-quality (Class I) evidence showed that patients with a smoking habit (OR, 1.57; 95% CI, 1.11 to 2.21) and without the use of bone morphogenetic protein-2 (BMP-2) (OR, 4.42; 95% CI, 3.33 to 5.86) were at higher risk for fusion failure. Moderate-quality (Class II or III) evidence showed that fusion failure was significantly associated with vitamin D deficiency (OR, 2.46; 95% CI, 1.24 to 4.90), diabetes (OR, 3.42; 95% CI, 1.59 to 7.36), allograft (OR, 1.82; 95% CI, 1.11 to 2.96), conventional pedicle screw (CPS) fixation (OR, 4.77; 95% CI, 2.23 to 10.20) and posterolateral fusion (OR, 3.63; 95% CI, 1.25 to 10.49).
Conclusions
Conspicuous risk factors affecting spinal fusion include three patient-related risk factors (smoking, vitamin D deficiency, and diabetes) and four surgery-related risk factors (without the use of BMP-2, allograft, CPS fixation, and posterolateral fusion). These findings may help clinicians strengthen awareness for early intervention in patients at high risk of developing fusion failure.
... Several studies have shown that financial compensation concerns inappropriately affect all outcomes, including postoperative pain severity, postoperative opioid use, postoperative functional improvement, and emotional stability [8][9][10]. Smoking is also associated with increased preoperative or postoperative complications such as impaired wound healing, increased infection rates, and increased spinal nonunion [11,12]. These results indicate that behavioral modification should also be recommended for successful surgery. ...
“Chronic pain after spinal surgery” (CPSS) is a nonspecific term for cases in which the end result of surgery generally does not meet the preoperative expectations of the patient and surgeon. This term has replaced the previous term i.e., failed back surgery syndrome. CPSS is challenging for both patients and doctors. Despite advancements in surgical techniques and technologies, a subset of patients continue to experience persistent or recurrent pain postoperatively. This review provides an overview of the multimodal management for CPSS, ranging from conservative management to revision surgery. Drawing on recent research and clinical experience, we aimed to offer insights into the diverse strategies available to improve the quality of life of CPSS patients.
... Although it is thought that smokers may have a negatively different pain perception compared to non-smokers, the exact effect of smoking on pain perception is still unclear (Shi, Weingarten, Mantilla, Hooten & Warner, 2010). Glassman et al. reported that smoking can cause degenerative changes in spinal structures such as intervertebral discs over time (Glassman et al., 2000). Therefore, these degenerative disorders that occur over time are a threat that has the potential to compress nerve structures and may pose a risk of neuropathic low back pain. ...
Chronic low back pain (CLBP) is theoretically low back pain experienced for more than 12 weeks or 3 months. The aim of this study was to investigate the relationship between pain perceptions, beliefs and symptom severity of individuals in different age groups with CLBP.The study was conducted between December 2022 and March 2023 with 210 individuals. Participants were divided into 3 groups according to age; 18-39, 40-56, 57-79. The Demographic Information, Pain Beliefs Scale (PBQ), Centrality of Pain Scale (COPS) and Numeric Rating Scale (NRS-11) questionare was used to record the personal information and to measure participant’s beliefs, pain perceptions, and the severity of pain experienced. One-Way MANOVA was used to evaluate the difference between age groups. NRS-11 was found significantly different between age groups of 18-39/40-56 and 18-39/57-79. Significant difference was observed in the Psychological PBQ among the age groups of 40-56/57-79 and 18-39/57-79. Organic PBQ was found significantly different in age group of 18-39/57-79. No significance was found in terms of COPS. In conclusion, increasing age was found to be directly proportional to pain intensity and the strength of pain beliefs. Also, age factor was not found to be effective on the pain centralization in individuals with CLBP.
... El hábito tabáquico se asocia a resultados quirúrgicos negativos como pseudoartrosis y retraso cicatrización; el abandono del hábito tabáquico es beneficioso en mejorar los resultados postquirúrgicos [30][31][32][33] . En un estudio observacional de 357 pacientes sometidos a artrodesis, la tasa de pseudoartrosis en quienes suspendieron el hábito tabáquico por 6 o más meses de la cirugía es similar a los no fumadores y significativamente menor a quienes persistieron fumando (17 vs 14 vs 26%) 34 . Los pacientes obesos tienen mayor riesgo de complicaciones intra y postoperatorias 35 pero interesantemente, tienen un beneficio de la cirugía comparable a pacientes no obesos [36][37][38][39] . ...
Lumbar spinal stenosis is a pathology that has been increasing along with the aging of the population. It is a degenerative disorder that produces a narrowing of the spinal canal with compression of the nerve structures that generate pain and disabling neurological deficit in advanced stages. The cause is multifactorial and its main pathogenesis is facet or yellow ligament hypertrophy, disc herniations or protrusions, osteophytic formations or the association with degenerative spondylolisthesis. Being the main cause of spinal surgery in those over 65 years of age, minimally invasive surgical techniques and lately spinal endoscopy, offers the advantage of producing less muscle and bone damage, less pain, less bleeding, less requirement for post-operative analgesia, enables early return to work, shortens hospital stay with a low rate of complications.
... Diabetes mellitus and smoking have been reported to be significant factors affecting bone fusion after lumbar Indicates statistically significant difference. fixation [22,23]; however, in our study, diabetes mellitus and smoking had no significant effect on bone fusion. Additionally, low nutritional status may have a negative effect on bone fusion. ...
Study design:
This study adopted a retrospective cohort study design.
Purpose:
This study aimed to clarify the influence of diffuse idiopathic skeletal hyperostosis (DISH) on bone fusion after transforaminal lumbar interbody fusion (TLIF).
Overview of literature:
The negative effects of DISH on lumbar degenerative diseases have been reported, and DISH may be involved in the onset and severity of lumbar spinal canal stenosis. Patients with DISH have significantly more reoperations after posterior lumbar fusion, including TLIF. However, the effects of DISH on bone fusion after TLIF have not been reported.
Methods:
The medical records of patients with intervertebral TLIF from 2012 to 2018 were retrospectively examined. The patients were divided into those with fusion and those with pseudoarthrosis, and the following data were compared: age, sex, DISH, diabetes mellitus, smoking, drinking, albumin levels, body mass index ≥30 kg/m2, and L5/S fixation. Statistical analyses were performed using regression models.
Results:
In this study, 180 patients (78.6%) had fusion and 49 patients (21.4%) had pseudoarthrosis. The number of patients with DISH was significantly higher in the pseudoarthrosis group than in the fusion group (36.7% and 21.7%, respectively; univariate p=0.031, multivariate p =0.019). No significant differences in age, sex, diabetes mellitus, smoking, drinking, albumin levels, body mass index ≥30 kg/m2, and L5/S fixation were observed between the two groups. The risk factors for bone fusion were statistically analyzed in 57 patients with DISH. DISH with a caudal end below Th11 was an independent risk factor for pseudoarthrosis (univariate p=0.011, multivariate p=0.033).
Conclusions:
DISH is an independent risk factor for pseudoarthrosis after one intervertebral TLIF, and DISH with a caudal end below Th11 is associated with a higher risk of pseudoarthrosis than DISH without a caudal end below Th11.
... Further studies should clearly indicate these information, and the types of multiple-rod constructs should be based on the lexicon by Ramey et al. [59]. Third, we did not consider the impact of smoking due to the missing data, which could overestimate the incidence of pseudoarthrosis [60]. Fourth, despite definite inclusion and exclusion criteria, there is not yet any study that was able to really benchmark the two strategies and create homogenous groups for BMD, alignment, surgical technique (array of rods, interbody fusion procedures at LSJ, SPF, 3CO vs. none etc.), and other clinically relevant factors (myopathy in frails, BMP-2 use, fusion quality etc.). ...
Background
The incidence of mechanical complications is high in patients undergoing posterior spinal fusion (PSF) for adult spinal deformity (ASD), especially for cases with severe sagittal malalignment or a prior spinal fusion requiring three-column osteotomy (3-CO) or spinopelvic fixation (SPF). The purpose of this systematic review and meta-analysis was to compare the complications, revisions, radiographic spinopelvic parameters, health-related quality of life (HRQoL), and surgical data of PSF using multiple-rod constructs to those of two-rod constructs for the treatment of ASD.
Methods
A comprehensive literature search was performed for relevant studies in PubMed, EMBASE, Web of Science, and the Cochrane Library. Complications, revisions, spinopelvic parameters, HRQoL, and surgical date were compared between patients with ASD who underwent PSF using multiple-rod constructs (multi-rod group) and two-rod constructs (two-rod group).
Results
Ten studies, comprising 797 patients with ASD (399 in the multi-rod group and 398 in the two-rod group), were included. All these studies were retrospective cohort studies. There were no significant differences in the surgical, wound-related, and systemic complications between the groups. In the multi-rod group, we noted a significantly lower incidence of rod fracture (RR, 0.43; 95% CI 0.33 to 0.57, P < 0.01), pseudoarthrosis (RR, 0.38; 95% CI 0.28 to 0.53, P < 0.01), and revisions (RR, 0.44; 95% CI 0.33 to 0.58, P < 0.01); a superior restoration of PI-LL (WMD, 3.96; 95% CI 1.03 to 6.88, P < 0.01) and SVA (WMD, 31.53; 95% CI 21.16 to 41.90, P < 0.01); a better improvement of ODI score (WMD, 6.82; 95% CI 2.33 to 11.31, P < 0.01), SRS-22 total score (WMD, 0.44; 95% CI 0.06 to 0.83, P = 0.02), and VAS-BP score (WMD, 1.02; 95% CI 0.31 to 1.73, P < 0.01).
Conclusion
Compared with the two-rod constructs, PSF using multiple-rod constructs was associated with a lower incidence of mechanical complications, a lower revision rate, a superior restoration of sagittal alignment, and a better improvement of HRQoL, without increasing surgical invasiveness. Multiple-rod constructs should be routinely considered to for ASD patients, especially for cases with severe sagittal malalignment or a prior spinal fusion requiring 3-CO or SPF.
... [33] The same stands as regards the effect of smoking, generally believed to be a negative prognostic factor in the spine literature. [34][35][36][37][38] While it has been established that comorbidities increase the risk of complications in spinal surgery, [39,40] the extent to which comorbidities affect patient outcomes is rather complex. Previous studies have found that comorbidities can lead to variability in PROMs, [39,41] specifically in relation to functional outcomes in spinal disorders. ...
Background:
Thoracolumbar junction fractures (TLJFs) attract controversy for several parameters, including surgery versus conservative treatment, fusion versus stabilization, open versus percutaneous surgery, construct length, and downstream metalwork extraction.
Aims and objectives:
The aim of this pilot study was to assess the effectiveness of surgical treatment in patients with burst (AO Classification Type A4) TLJFs using patient-reported outcome measures (PROMs) and evaluate and compare different PROMs in this clinical scenario.
Materials and methods:
Patient records of consecutive patients who underwent posterior stabilization surgery for TLJFs were retrospectively reviewed. Data were collected on demographics, medical and social history, neurological examination, and postoperative complications. Telephone interviews and a combined PROM methodology (Numerical Rating Scale [NRS], EuroQol [EQ]-5D-5L, and Oswestry Disability Index [ODI]) were utilized to assess the effectiveness of intervention. Descriptive statistics were used to analyze exposure variables and outcome measures. Spearman's rank correlation was used for the outcome measures.
Results:
Thirteen patients were included. The mean age was 42 ± 16 years; the male: female ratio was 8:5; the mean follow-up was 18.9 ± 6.4 months. The mean NRS score was 3.3 ± 2.5, in line with a median score of 2 (2) on EQ-5D-5L pain/discomfort scale. Statistically significant correlations were found between several PROMs: pain-EQ-5D-5L and NRS (rs = 0.8, P = 0.002), pain-EQ-5D-5L and ODI (rs = 0.8, P = 0.001), usual anxiety/depression-EQ-5D-5L, and ODI (rs = 0.7, P = 0.008).
Conclusion:
A combined PROM methodology showed supportive evidence for safety and efficacy in the surgical stabilization of burst TLJFs. This alleviated significant pain and prevented neurological deficit and major disability. The preliminary widespread correlation between these PROMs supports further larger studies of their combined use in clinical practice, to measure the outcomes of spine trauma patients.
... It subsequently interferes with neovascularization and the normal vascular supply, encouraging net bone resorption rather than net bone growth (245,247). Notably, after lumbar or cervical fusion surgery, pseudarthrosis occurs at a rate that is two times higher among smokers (245,(249)(250)(251)(252). Tobacco inhalation and nicotine caused vasoconstriction and decreased the exchange of nutrients and anabolic substances, resulting in inadequate IVD nourishment, ECM and NP cell development all contributing to the IVD's instability and degeneration (253)(254)(255)(256)(257)(258). ...
Degeneration of the intervertebral disc (IVD) is a normal part of aging. Due to the spine's declining function and the development of pain, it may affect one's physical health, mental health, and socioeconomic status. Most of the intervertebral disc degeneration (IVDD) therapies today focus on the symptoms of low back pain rather than the underlying etiology or mechanical function of the disc. The deteriorated disc is typically not restored by conservative or surgical therapies that largely focus on correcting symptoms and structural abnormalities. To enhance the clinical outcome and the quality of life of a patient, several therapeutic modalities have been created. In this review, we discuss genetic and environmental causes of IVDD and describe promising modern endogenous and exogenous therapeutic approaches including their applicability and relevance to the degeneration process.
... While smoking has not been previously identified as a risk factor for revision surgery in this specific patient population, it is a known independent risk factor for revision surgery following lumbar discectomy, decompression, and 1-and 2-level fusion. [28][29][30] All patients who smoked preoperatively were counseled extensively regarding the increased risks of complications according to evidence-based guidelines. 31 In a systematic review of decompression alone in the setting of DLS, other risk factors for additional surgery included preoperative severe lumbar coronal Cobb angle (mean 29.6°), increased preoperative PT (mean 28.3°), preoperative PI-LL (mean 35.5°), and poor facet preservation (approximately 50%) on the approach side of the concavity. ...
OBJECTIVE
Patients with degenerative lumbar scoliosis (DLS) and neurogenic pain may be candidates for decompression alone or short-segment fusion. In this study, minimally invasive surgery (MIS) decompression (MIS-D) and MIS short-segment fusion (MIS-SF) in patients with DLS were compared in a propensity score–matched analysis.
METHODS
The propensity score was calculated using 13 variables: sex, age, BMI, Charlson Comorbidity Index, smoking status, leg pain, back pain, grade 1 spondylolisthesis, lateral spondylolisthesis, multilevel spondylolisthesis, lumbar Cobb angle, pelvic incidence minus lumbar lordosis, and pelvic tilt in a logistic regression model. One-to-one matching was performed to compare perioperative morbidity and patient-reported outcome measures (PROMs). The minimal clinically important difference (MCID) for patients was calculated based on cutoffs of percentage change from baseline: 42.4% for Oswestry Disability Index (ODI), 25.0% for visual analog scale (VAS) low-back pain, and 55.6% for VAS leg pain.
RESULTS
A total of 113 patients were included in the propensity score calculation, resulting in 31 matched pairs. Perioperative morbidity was significantly reduced for the MIS-D group, including shorter operative duration (91 vs 204 minutes, p < 0.0001), decreased blood loss (22 vs 116 mL, p = 0.0005), and reduced length of stay (2.6 vs 5.1 days, p = 0.0004). Discharge status (home vs rehabilitation), complications, and reoperation rates were similar. Preoperative PROMs were similar, but after 3 months, improvement was significantly higher for the MIS-SF group in the VAS back pain score (−3.4 vs −1.2, p = 0.044) and Veterans RAND 12-Item Health Survey (VR-12) Mental Component Summary (MCS) score (+10.3 vs +1.9, p = 0.009), and after 1 year the MIS-SF group continued to have significantly greater improvement in the VAS back pain score (−3.9 vs −1.2, p = 0.026), ODI score (−23.1 vs −7.4, p = 0.037), 12-Item Short-Form Health Survey MCS score (+6.5 vs −6.5, p = 0.0374), and VR-12 MCS score (+7.6 vs −5.1, p = 0.047). MCID did not differ significantly between the matched groups for VAS back pain, VAS leg pain, or ODI scores (p = 0.38, 0.055, and 0.072, respectively).
CONCLUSIONS
Patients with DLS undergoing surgery had similar rates of significant improvement after both MIS-D and MIS-SF. For matched patients, tradeoffs were seen for reduced perioperative morbidity for MIS-D versus greater magnitudes of improvement in back pain, disability, and mental health for patients 1 year after MIS-SF. However, rates of MCID were similar, and the small sample size among the matched patients may be subject to patient outliers, limiting generalizability of these results.
... El hábito tabáquico se asocia a resultados quirúrgicos negativos como pseudoartrosis y retraso cicatrización; el abandono del hábito tabáquico es beneficioso en mejorar los resultados postquirúrgicos [30][31][32][33] . En un estudio observacional de 357 pacientes sometidos a artrodesis, la tasa de pseudoartrosis en quienes suspendieron el hábito tabáquico por 6 o más meses de la cirugía es similar a los no fumadores y significativamente menor a quienes persistieron fumando (17 vs 14 vs 26%) 34 . Los pacientes obesos tienen mayor riesgo de complicaciones intra y postoperatorias 35 pero interesantemente, tienen un beneficio de la cirugía comparable a pacientes no obesos [36][37][38][39] . ...
La raquiestenosis lumbar es una patología que ha ido aumentando a la par con el envejecimiento de la población. Es un trastorno degenerativo que produce una estrechez del canal raquídeo con la compresión de las estructuras nerviosas que generan dolor y déficit neurológico incapacitante en los estados avanzados. La causa es multifactorial y su patogenia principal es hipertrofia facetaría o del ligamento amarillo, herniaciones o protrusiones discales, formaciones osteofíticas o la asociación con la espondilolistesis degenerativa. Siendo la principal causa de cirugía de columna en los mayores de 65 años las técnicas de cirugía mínimamente invasivas y últimamente la endoscopía de columna, ofrece la ventaja de producir menos daño muscular y óseo, menos dolor, menos sangramiento, menor requerimiento de analgesia postoperatoria, posibilita la reincorporación laboral precoz, acorta la estadía hospitalaria con un bajo índice de complicaciones.
... In contrast to previous reports in which BMI, osteopo- rosis, and tobacco use have been associated with an increased risk of RF, 12,[27][28][29][30] in the present study no definite modifiable risk factors were identified. Multivariate analysis revealed that one of the strongest preoperative clinical variables predictive of RF was diabetes; however, this association did not reach statistical significance. ...
OBJECTIVE
Previous reports of rod fracture (RF) in adult spinal deformity are limited by heterogeneous cohorts, low follow-up rates, and relatively short follow-up durations. Since the majority of RFs present > 2 years after surgery, true occurrence and revision rates remain unclear. The objectives of this study were to better understand the risk factors for RF and assess its occurrence and revision rates following primary thoracolumbar fusions to the sacrum/pelvis for adult symptomatic lumbar scoliosis (ASLS) in a prospective series with long-term follow-up.
METHODS
Patient records were obtained from the Adult Symptomatic Lumbar Scoliosis–1 (ASLS-1) database, an NIH-sponsored multicenter, prospective study. Inclusion criteria were as follows: patients aged 40–80 years undergoing primary surgeries for ASLS (Cobb angle ≥ 30° and Oswestry Disability Index ≥ 20 or Scoliosis Research Society-22r ≤ 4.0 in pain, function, and/or self-image) with instrumented fusion of ≥ 7 levels that included the sacrum/pelvis. Patients with and without RF were compared to assess risk factors for RF and revision surgery.
RESULTS
Inclusion criteria were met by 160 patients (median age 62 years, IQR 55.7–67.9 years). At a median follow-up of 5.1 years (IQR 3.8–6.6 years), there were 92 RFs in 62 patients (38.8%). The median time to RF was 3.0 years (IQR 1.9–4.54 years), and 73% occurred > 2 years following surgery. Based on Kaplan-Meier analyses, estimated RF rates at 2, 4, 5, and 8 years after surgery were 11%, 24%, 35%, and 49%, respectively. Baseline radiographic, clinical, and demographic characteristics were similar between patients with and without RF. In Cox regression models, greater postoperative pelvic tilt (HR 1.895, 95% CI 1.196–3.002, p = 0.0065) and greater estimated blood loss (HR 1.02, 95% CI 1.005–1.036, p = 0.0088) were associated with increased risk of RF. Thirty-eight patients (61% of all RFs) underwent revision surgery. Bilateral RF was predictive of revision surgery (HR 3.52, 95% CI 1.8–6.9, p = 0.0002), while patients with unilateral nondisplaced RFs were less likely to require revision (HR 0.39, 95% CI 0.18–0.84, p = 0.016).
CONCLUSIONS
This study provides what is to the authors’ knowledge the highest-quality data to date on RF rates following ASLS surgery. At a median follow-up of 5.1 years, 38.8% of patients had at least one RF. Estimated RF rates at 2, 4, 5, and 8 years after surgery were 11%, 24%, 35%, and 49%, respectively. Greater estimated blood loss and postoperative pelvic tilt were significant risk factors for RF. These findings emphasize the importance of long-term follow-up to realize the true prevalence and cumulative incidence of RF.
... In another study by Møller et al. 27 , the overall complication rate was 18% in the smoking cessation intervention group and 52% in the control group, and the median length of hospital stay was 11 and 13 days, respectively. Glassman et al. 28 have shown that smoking cessation for longer than six months after a posterior instrumented lumbar spinal fusion reduces the rate of nonunion to 17% compared with 26% for those who continued to smoke after surgery. The nonunion rate was 14% among non-smokers. ...
The aim of the study is to analyze the effect of smoking and smoking cessation on
the incidence of complications among orthopedic and hand surgery patients, and
to determine the feasibility of smoking cessation intervention, as well as factors
predicting success in smoking cessation. Orthopedic and hand surgery patients will
be invited to participate in the study, which will recruit 550 participants (at least
20% daily smokers). A participant will be defined as a daily smoker if he/she reports
daily smoking and/or laboratory tests show active smoking. Data will be collected
using a self-reported questionnaire and from medical records. Smokers will receive
information about the benefits of smoking cessation and will be encouraged to
quit. Medication or nicotine replacement therapy will be prescribed. Laboratory
tests will be taken two weeks before and two weeks after surgery. Follow-up phone
calls will be made at 3, 6, and 12 months after surgery. The primary outcome is
any complication, defined as a prolonged stay in hospital or any additional visit
to or measure taken by a health service during the 12 months after surgery. Data
on complications are mainly obtained from personal health records and from the
information received at the follow-up; the rest of the data will be collected from the
register of healthcare-associated infections. Secondary outcomes are the number
and types of complications. The sample (n=550) was calculated to observe a 10%
difference in complications between smokers and non-smokers (5% alpha level and
80% power), considering a 10% drop-out rate. Logistic regression and log-linear
models will be used for data analyses.
» Although spine surgery is effective in reducing pain and improving functional status, it is associated with unacceptably high rates of complications, thus necessitating comprehensive preoperative patient optimization.
» Numerous risk factors that can impact long-term surgical outcomes have been identified, including malnutrition, cardiovascular disease, osteoporosis, substance use, and more.
» Preoperative screening and personalized, evidence-based interventions to manage medical comorbidities and optimize medications can enhance clinical outcomes and improve patient satisfaction following spine surgery.
» Multidisciplinary team-based approaches, such as enhanced recovery after surgery protocols and multidisciplinary conferences, can further facilitate coordinated care from across specialties and reduce overall hospital length of stay.
Introduction
Cervical fusion surgeries are commonly performed to stabilize the spine and relieve pain from various conditions. Recent increases in nontobacco nicotine product use, such as electronic cigarettes, present new challenges because of their unknown effects on spinal fusion outcomes. Our study aims to explore the effect of nontobacco nicotine dependence (NTND) on the success of cervical spinal fusions.
Methods
We analyzed TriNetX database data for patients undergoing primary anterior cervical diskectomy and fusion, identified by specific Current Procedural Terminology codes, and categorized into cohorts based on a preoperative diagnosis of nicotine dependence, excluding those with tobacco use or dependence. Propensity matching in the ratio of 1:1 was done to control for demographics and body mass index. We analyzed 90-day medical and 2-year implant complications using chi-squared exact tests and univariate regressions within the matched cohorts.
Results
The NTND and control cohorts comprised 5,331 and 43,033 patients, respectively. Five thousand two hundred thirty-two matched pairs of patients were included from each cohort as shown in Table 1. Our results indicate notable disparities in complications within 90 days postoperation between the cohorts. The NTND cohort had higher risks for opioid use (85.6% vs. 80.3%, P < 0.001), emergency department visits (13.0% vs. 8.40%, P < 0.001), opioid abuse (0.4% vs. 0.2%, P < 0.001), inpatient hospitalizations (20.0% vs. 17.4%, P < 0.001), and sepsis (1.40% vs. 0.80%, P = 0.01). At the 2-year follow-up, increases were observed in pseudarthrosis (14.0% vs. 9.60%, P < 0.001), adjacent segment disease (3.70% vs. 2.20%, P < 0.001), dysphagia (8.90% vs. 6.3%, P = 0.001), and revision surgery (2.00% vs. 1.40%, P = 0.02).
Conclusion
This study highlights notable postoperative complications in patients with NTND undergoing cervical spinal fusion.
OBJECTIVE
Smoking has been shown to negatively impact spinal health, as well as the outcomes of spinal fusion. Published reports show conflicting data regarding whether smoking negatively impacts patient outcomes following lumbar decompression. The objective of this study was to investigate whether smoking affects the outcomes of patients undergoing lumbar decompression for spinal stenosis or herniated disc.
METHODS
The Quality Outcomes Database was queried for patients with spinal stenosis or lumbar disc herniation who underwent one- or two-level lumbar decompression without fusion. All patients had preoperative and 12-month outcome measures and were divided into groups of nonsmokers and current smokers. Outcomes were compared between the two groups, as well as the percentage of patients reaching the minimal clinically important difference (MCID) threshold for numeric rating scale (NRS) back and leg pain scores and the Oswestry Disability Index (ODI).
RESULTS
Of 17,271 patients, 14,233 were nonsmokers and 3038 were current smokers. Smokers had worse baseline NRS back and leg pain, ODI, and EQ-5D scores and experienced slightly less improvement in all measures following lumbar decompression (p ≤ 0.009), although changes were largely similar, and a high percentage of patients achieved the MCID thresholds for NRS back pain (78% nonsmokers vs 75% smokers), NRS leg pain (79% nonsmokers vs 73% smokers), and ODI (74% nonsmokers vs 68% smokers). Comparison of propensity-matched cohorts did not identify any difference in outcomes in smokers versus nonsmokers.
CONCLUSIONS
In patients undergoing lumbar decompression for spinal stenosis or herniated disc, smokers demonstrated slightly less improvement in outcomes compared with nonsmokers, and a high proportion of both groups achieved meaningful improvement with surgery. While smoking cessation should be strongly encouraged in all patients, lumbar decompression procedures for spinal stenosis and herniated disc should not be denied to smokers.
Improvements in healthcare management have led to a decrease in perioperative and postoperative complications. However, perioperative medical complications and mortality rates continue to increase in patients undergoing elective spinal surgeries. This trend is driven by the increase in the older population and the rise in the number of patients with more than two comorbidities. Managing patients with multiple comorbidities requires additional resources, augmenting the financial and societal burden. Despite the high risk of complications and mortality, patients with multiple comorbidities undergo spinal surgery for degenerative spinal conditions daily. These findings highlight the need for heightened awareness, patient education, and management of comorbidities before elective spinal surgeries. This article comprehensively reviews literature on the effects of medical comorbidities on spinal fusion surgery outcomes to increase awareness of the surgical complications associated with comorbidities. In addition, suggested preoperative and postoperative comorbidity management strategies are outlined.
Background:
Cerebrospinal fluid (CSF) leakage is one of the common complications of spine surgery and is largely caused by intraoperative or postoperative dural tears. Associations of different factors with postoperative CSF leakage have not been consistent. In this study we aimed to identify demographic, disease-related, and surgical risk factors for CSF leakage after extradural spine surgery in a systematic review and meta-anlysis.
Methods:
The PubMed, EMBASE, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Chinese Wanfang data, Chinese Weipu Database, and SinoMed databases were searched from inception until October 24, 2022. Fixed-effects or random-effects models were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). The quality of observational studies was evaluated using the Newcastle-Ottawa scale instrument.
Results:
A total of 15 observational studies with 1,719,923 participants were included in this systematic review. All studies had a Newcastle-Ottawa scale score greater than or equal to 6. Age older than 70 years, smoking, ossification of the posterior longitudinal ligament, adhesion of spinal dura, spinal canal stenosis, cervical fracture, spondylolisthesis, revision surgery, and multiple surgical segments were all related to CSF leakage in the pooled analysis. Obesity and disease duration>1 year were not associated with the leakage of CSF.
Conclusions:
This study will provide a reference for the identification of patients at high risk of developing CSF leakage, which suggests clinicians to strengthen the observation of drainage fluid in high-risk groups.
PurposeThe natural history of adolescent idiopathic scoliosis (AIS) has been well documented, but the impact of age at the time of surgical correction is relatively understudied. In this study, we matched patients undergoing surgical correction of adult idiopathic scoliosis (AdIS) with a cohort of AIS patients to compare: (1) coronal and sagittal radiographic correction, (2) operative variables, and (3) postoperative complications.MethodsA single-institution scoliosis registry was queried for patients undergoing idiopathic scoliosis surgery from 2000–2017. Inclusion criteria: patients with idiopathic scoliosis, no previous spine surgery, and 2-year follow-up. AdIS patients were matched 1:2 with AIS patients based on Lenke classification and curve characteristics. Independent sample t-test and Chi-square test was used to analyze the data.Results31 adults underwent surgical correction of idiopathic scoliosis and were matched with 62 adolescents. Mean age of adults was 26.2 ± 11.05, mean BMI was 25.6 ± 6.0, and 22 (71.0%) were female. Mean age of adolescents was 14.2 ± 1.8, mean BMI was 22.7 ± 5.7, and 41(66.7%) were female. AdIS had significantly less postoperative major Cobb correction (63.9% vs 71.3%, p = 0.006) and final major Cobb correction (60.6% vs 67.9%, p = 0.025). AdIS also had significantly greater postoperative T1PA (11.8 vs 5.8, p = 0.002). AdIS had longer operative times (p = 0.003), higher amounts of pRBCs transfused (p = 0.005), longer LOS (p = 0.016), more ICU requirement (p = 0.013), higher overall complications (p < 0.001), higher rate of pseudarthrosis (p = 0.026), and more neurologic complications (p = 0.013).Conclusion
Adult patients undergoing surgical correction of idiopathic scoliosis had significantly worse postoperative coronal and sagittal alignment when compared with adolescent patients. Adult patients also had higher rates of complications, longer operative times, and longer hospital stays.Level of evidence: III.
Background context:
High serum nicotine levels increase the risk of non-union after spinal fusion. Varenicline, a pharmaceutical adjunct for smoking cessation, is a partial agonist designed to displace and outcompete nicotine at its receptor binding site, thereby limiting downstream activation. Given its mechanism, varenicline may have therapeutic benefits in mitigating non-union for active smokers undergoing spinal fusion.
Purpose:
To compare fusion rate and fusion mass characteristics between cohorts receiving nicotine, varenicline, or concurrent nicotine and varenicline after lumbar fusion.
Study design:
Rodent non-instrumented spinal fusion model.
Methods:
Sixty eight-week-old male Sprague-Dawley rats weighing approximately 300 grams underwent L4-5 posterolateral fusion (PLF) surgery. Four experimental groups (control: C, nicotine: N, varenicline: V, and combined: NV [nicotine and varenicline]) were included for analysis. Treatment groups received nicotine, varenicline, or a combination of nicotine and varenicline delivered through subcutaneous osmotic pumps beginning two weeks before surgery until the time of sacrifice at age 14 weeks. Manual palpation testing, microCT imaging, bone histomorphometry, and biomechanical testing were performed on harvested spinal fusion segments.
Results:
Control (p=0.016) and combined (p=0.032) groups, when compared directly to the nicotine group, demonstrated significantly greater manual palpation scores. The fusion rate in the control (93.3%) and combined (93.3%) groups were significantly greater than that of the nicotine group (33.3%) (p=0.007, both). Biomechanical testing demonstrated greater Young's modulus of the fusion segment in the control (17.1 MPa) and combined groups (34.5 MPa) compared to the nicotine group (8.07 MPa) (p<0.001, both). MicroCT analysis demonstrated greater bone volume fraction (C:0.35 vs N:0.26 vs NV:0.33) (p<0.001, all) and bone mineral density (C:335 vs N:262 vs NV:328 mg Ha/cm3) (p<0.001, all) in the control and combined groups compared to the nicotine group. Histomorphometry demonstrated a greater mineral apposition rate in the combined group compared to the nicotine group (0.34 vs 0.24 μm/day, p=0.025).
Conclusion:
In a rodent spinal fusion model, varenicline mitigates the adverse effects of high nicotine serum levels on the rate and quality of spinal fusion.
Clinical significance:
These findings have the potential to significantly impact clinical practice guidelines and the use of pharmacotherapy for active nicotine users undergoing fusion surgery.
Study design:
Retrospective study.
Objective:
This study evaluated the impact of chewing tobacco on both medical and spine-related complication rates after spinal lumbar fusions in comparison to both a control cohort and a smoking cohort.
Summary of background data:
Smoking is a prevalent modifiable risk factor that has been demonstrated to be associated with increased complications after lumbar fusion. Although smoking rates have decreased in the United States, chewing tobacco use has not similarly reduced. Despite chewing tobacco delivering up to 4 times the dose of smoking, the impact of chewing tobacco is incompletely understood.
Methods:
A retrospective cohort study was conducted using the PearlDiver database. Patients who underwent lumbar spine fusion and used chewing tobacco were matched with a control cohort and a smoking cohort. Medical complications within 90 days after primary lumbar fusion were evaluated, including deep venous thrombosis, acute kidney injury, pulmonary embolism, transfusion, acute myocardial infarction, and inpatient readmission. Spine-related complications were evaluated at 2 years postoperatively, including pseudoarthrosis, incision and drainage (I&D), instrument failure, revision, and infection.
Results:
After primary lumbar fusion, the chewing tobacco cohort demonstrated significantly higher rates of pseudoarthrosis [odds ratio (OR): 1.41], revision (OR: 1.57), and any spine-related complication (OR: 1.32) compared with controls. The smoking cohort demonstrated significantly higher rates of pseudoarthrosis (OR: 1.88), I&D (OR: 1.27), instrument failure (OR: 1.39), revision (OR: 1.54), infection (OR: 1.34), and any spine-related complication (OR: 1.77) compared with controls. The chewing tobacco cohort demonstrated significantly lower rates of pseudoarthrosis (OR: 0.84), I&D (OR: 0.49), infection (OR: 0.70), and any spine-related complication (OR: 0.81) compared with the smoking cohort.
Conclusions:
This study demonstrated that chewing tobacco is associated with higher rates of both spine-related and medical complications after primary lumbar fusion. However, chewing tobacco use is associated with less risk of complications compared with smoking.
Level of evidence:
Level III.
Despite the increasing popularity of total ankle replacement, ankle arthrodesis remains the gold standard for the treatment of end-stage ankle arthritis. Historically, open techniques have been utilized for ankle arthrodesis. There have been many variations and techniques described, including transfibular, anterior, medial, and miniarthrotomy. Inherent disadvantages to these open techniques include postoperative pain, delayed or nonunion, wound complications, shortening, prolonged healing times, and prolonged hospital stays. Arthroscopic ankle arthrodesis provides the foot and ankle surgeon with an alternative to the traditional open techniques. Arthroscopic ankle arthrodesis has demonstrated faster union rates, decreased complications, reduced postoperative pain, and shorter hospital stays.
Background:
Nicotine in tobacco products is known to impair bone and tendon healing and smoking has been associated with an increased rate of retear and reoperation following rotator cuff repair (RCR). While smoking is known to increase the risk of failure following rotator cuff repair, former smoking status and the timing of preoperative smoking cessation has not previously been investigated.
Methods:
A national, all-payer database was queried for patients undergoing RCR between 2010 and 2020. Patients were stratified into 5 mutually exclusive groups according to smoking history: (1) never-smokers (n = 50,000), (2) current smokers (n = 28,291), (3) former smokers with smoking cessation 3 - 6 months preoperatively (n = 34,513), (4) former smokers with smoking cessation 6 - 12 months preoperatively (n = 786) and (5) former smokers with smoking cessation >12 months preoperatively (n = 1,399). The risks of postoperative infection and revision surgery were assessed at 90 days, 1 year, and 2 years following surgery. Multivariate logistic regressions were used to isolate and evaluate risk factors for postoperative complications.
Results:
The rate of 90-day infection following RCR was 0.28% in never-smokers compared to 0.51% in current smokers and 0.52% in former smokers who quit smoking 3 - 6 months prior to surgery (P < 0.001). Multivariate logistic regression identified smoking (OR, 1.49; P < 0.001) and smoking cessation 3 - 6 months prior to surgery (OR, 1.56; P < 0.001) as risk factors for 90-day infection. The elevated risk in these groups persisted at 1 and 2 years postoperatively. However, smoking cessation > 6 months prior to surgery was not associated with a significant elevation in infection risk. Similarly, smoking was associated with an elevated 90-day revision risk (OR, 1.22; P = 0.038), as was smoking cessation between 3 and 6 months prior to surgery (OR, 1.19; P = 0.048). The elevated risk in these groups persisted at 1 and 2 years postoperatively. Smoking cessation > 6 months prior to surgery was not associated with a statistically significant elevation in revision risk.
Conclusion:
Current smokers and former smokers who quit smoking within 6 months of RCR are at an elevated risk of postoperative infection and revision surgery at 90 days, 1 year and 2 years postoperatively compared to never-smokers. Former smokers who quit > 6 months prior to RCR are not at a detectably elevated risk of infection or revision surgery compared to those who have never smoked.
Introduction/Background: Cervical spondylotic myelopathy (CSM) is a spinal degenerative disorder that can ultimately lead to compression of the vertebral column with neurological sequelae. Although CSM is the most common spine pathology in the elderly American population, it remains a challenging disorder to treat among older patients.
Objectives: CASE PRESENTATION: We report an 86-yearold female patient with CSM with a history of posterior cervical fusion attempt on C3-C6 that progressed to C3-C6 nonunion with loose instrumentation. The patient had severe osteoporosis. With these indications, the patient underwent a combined anterior-posterior decompression and fusion (CAPDF) consisting of anterior cervical discectomy and fusion (ACDF) of the C3-C5, corpectomy of C6 and C7 with off FDA label use of polymethy methacrylate augmentation (PMMA) fixation of T1 screws anteriorly for C3T1 plate fixation and second stage instrumented posterior spinal fusion (PS) of C3-T3. The patient had a successful fusion and reduction of her cervical spine pain with preservation of her neurological status.
Methods: We report this case of multi-stage combined anterior and posterior fusion as a corrective measure for pseudarthrosis of a prior posterior cervical spinal fusion attempt. In the event of posterior spinal fusion instrumentation failure in patients with severe osteoporosis, combined multi-stage anterior-posterior fusion is a viable corrective intervention in octogenarians. This case also illustrated the utility of using PMMA for anterior cervical plate and screw stabilization in osteoporotic bone. The authors are not aware of the prior use of PMMA for screw fixation augmentation in the anterior cervical spine.
Background:
Many clinicians associate nicotine as the causative agent in the negative and deleterious effects of smoking on bone growth and spine fusion. Although nicotine is the primary driver of physiological addiction in smoking, isolated and controlled use of nicotine is one of the most effective adjuncts to quitting smoking.
Objective:
To explore the relationship between nicotine and noncombustion cigarette products on bone growth.
Methods:
One thousand five studies were identified, of which 501 studies were excluded, leaving 504 studies available for review. Of note, 52 studies were deemed to be irrelevant. Four hundred fifty-two studies remained for eligibility assessment. Of the remaining 452, 218 failed to assess study outcomes, 169 failed to assess bone biology, 13 assessed 5 patients or fewer, and 12 were deemed to be ineligible of the study criteria. Forty studies remained for inclusion within this systematic review.
Results:
Of the 40 studies identified for inclusion within the study, 30 studies were classified as "Animal Basic Science," whereas the remaining 10 were categorized as "Human Basic Science." Of the 40 studies, 11 noted decreased cell proliferation and boney growth, whereas 8 showed an increase. Four studies noted an increase in gene expression products, whereas 11 noted a significant decrease.
Conclusion:
The results of this study demonstrate that nicotine has a variety of complex interactions on osteoblast and osteoclastic activities. Nicotine demonstrates dose-dependent effects on osteoblast proliferation, boney growth, and gene expression. Further study is warranted to extrapolate the effects of solitary nicotine on clinical outcomes.
Background
Compared with posterior interbody fusion techniques, oblique lateral interbody fusion (OLIF) offers a larger fusion bed with greater intervertebral space access, use of larger cages, more sufficient discectomy, and better end-plate preparation. However, the fusion rate of OLIF is similar to that of other interbody fusions. This study aimed to examine the factors associated with nonunion in OLIF.
Methods
This study examined 201 disc levels from 124 consecutive patients who underwent OLIF for lumbar degenerative diseases with 1-year regular follow-up. Demographic and surgical factors were reviewed from the medical records. Radiological factors measured were sagittal parameters, intervertebral disc angle (DA) before surgery and at the final follow-up, presence of vertebral end-plate lesions, and cage subsidence. Multivariable logistic regression analysis was performed to identify the factors associated with nonunion.
Results
Among the 201 discs, 185 (92.0%) achieved union at 1-year followed up. Smoking, surgery at the L5-S1 level, not performing laminectomy, and a large intervertebral DA were factors associated with nonunion in OLIF (all P < 0.05). Multivariable logistic regression analysis showed two independent variables (surgery at L5-S1 level and not performing laminectomy) as risk factors for nonunion in OLIF.
Conclusions
Not performing laminectomy and surgery at the L5-S1 level were risk factors for nonunion in OLIF. To reduce the nonunion rate, surgeons should consider additional stabilization strategies for the L5-S1 OLIF and perform laminectomy.
Tobacco use will kill a projected 1 billion people in the 21st century in one of the deadliest pandemics in history. Tobacco use disorder is a disease with a natural history, pathophysiology, and effective treatment options. Anesthesiologists can play a unique role in fighting this pandemic, providing both immediate (reduction in perioperative risk) and long-term (reduction in tobacco-related diseases) benefits to their patients who are its victims. Receiving surgery is one of the most powerful stimuli to quit tobacco. Tobacco treatments that combine counseling and pharmacotherapy (e.g., nicotine replacement therapy) can further increase quit rates and reduce risk of morbidity such as pulmonary and wound-related complications. The perioperative setting provides a great opportunity to implement multimodal perianesthesia tobacco treatment, which combines multiple evidence-based tactics to implement the four core components of consistent ascertainment and documentation of tobacco use, advice to quit, access to pharmacotherapy, and referral to counseling resources.
Cigarette smoking and its ramifications are coming under increasing scrutiny in the field of orthopedic surgery. Smoking has been implicated in impeding bone metabolism and fracture repair, and increasing the rate of postoperative infection and the incidence of nonunion. This article reviews the current body of knowledge on these topics, as well as the potential adverse effects of smoking on wound healing and microsurgical procedures. An in-depth discussion on the pathophysiologic mechanisms of nicotine is also included.
The dangers of smoking during pregnancy are widely established.1 The Health of the Nation set the following target: “In addition to the overall reduction in [smoking] prevalence, at least a third of women smokers to stop smoking at the start of their pregnancy by the year 2000.”2 As part of a smoking and pregnancy initiative, the Health Education Authority for England carried out a series of annual surveys of pregnant women starting in 1992 to measure knowledge, attitudes, and behaviour in relation to smoking during pregnancy.
Two hundred chronic low-back pain patients entering a functional restoration program were assessed for current and lifetime psychiatric syndromes using a structured psychiatric interview to make DSM-III-R diagnoses. Results showed that, even when the somewhat controversial category of somatoform pain disorder was excluded, 77% of patients met lifetime diagnostic criteria and 59% demonstrated current symptoms for at least one psychiatric diagnosis. The most common of these were major depression, substance abuse, and anxiety disorders. In addition, 51% met criteria for at least one personality disorder. All of the prevalence rates were significantly greater than the base rate for the general population. Finally, and most importantly, of these patients with a positive lifetime history for psychiatric syndromes, 54% of those with depression, 94% of those with substance abuse, and 95% of those with anxiety disorders had experienced these syndromes before the onset of their back pain. These are the first results to indicate that certain psychiatric syndromes appear to precede chronic low-back pain (substance abuse and anxiety disorders), whereas others (specifically, major depression) develop either before or after the onset of chronic low-back pain. Such findings substantially add to our understanding of causality and predisposition in the relationship between psychiatric disorders and chronic low-back pain. They also clearly reveal that clinicians should be aware of potentially high rates of emotional distress syndromes in chronic low-back pain and enlist mental health professionals to help maximize treatment outcomes.
Patients who smoke cigaretters are believed to have a non union rate that is 3 to 4 times higher than that in nonsmokers undergoing spine Dr. Whitesides is emphatic that patients must take an active role in their care and be willing to stop smoking; Dr. Hanley feels that this strong of a prosition is not practical in many instances, and he offers a more tempered opinion.
Objective
—To estimate the overall efficacy and optimal use of the nicotine patch for treating tobacco dependence.Data Sources.
—Nicotine patch efficacy studies published through September 1993, identified through MEDLINE, Psychological Abstracts, and Food and Drug Administration new drug applications.Study Selection.
—Double-blind, placebo-controlled nicotine patch studies of 4 weeks or longer with random assignment of subjects, biochemical confirmation of abstinence, and subjects not selected on the basis of specific diseases (eg, coronary artery disease).Data Extraction.
— Pooled abstinence rates and combined odds ratios (ORs) at end of treatment and 6-month follow-up were examined overall and in terms of patch type (16-hour vs 24-hour), patch treatment duration, dosage reduction (weaning), counseling format (individual vs group), and intensity of adjuvant behavioral counseling.Data Synthesis.
—Across 17 studies (n=5098 patients) meeting inclusion criteria, overall abstinence rates for the active patch were 27% (vs 13% for placebo) at the end of treatment and 22% (vs 9% for placebo) at 6 months. The combined ORs for efficacy of active patch vs placebo patch were 2.6 at the end of treatment and 3.0 at 6 months. The active patch was superior to the placebo patch regardless of patch type (16-hour vs 24-hour), patch treatment duration, weaning, counseling format, or counseling intensity. The 16-hour and 24-hour patches appeared equally efficacious, and extending treatment beyond 8 weeks did not appear to increase efficacy. The pooled abstinence data showed that intensive behavioral counseling had a reliable but modest positive impact on quit rates.Conclusions.
—The nicotine patch is an effective aid to quitting smoking across different patch-use strategies. Active patch subjects were more than twice as likely to quit smoking as individuals wearing a placebo patch, and this effect was present at both high and low intensities of counseling. The nicotine patch is an effective smoking cessation aid and has the potential to improve public health significantly.(JAMA. 1994;271:1940-1947)
Nicotine (0.16–0.50 mg/kg, SC) was found to exert a potent antinociceptive action on thermal stimuli as measured by the tail-flick test. This antinociceptive action of nicotine could be blocked by centrally active nicotinic or muscarinic blockers implicating both classes of cholinergic receptors in this effect. Quaternary blockers, however, failed to prevent nicotine-induced antinociception. This finding, together with the ability of small doses of nicotine (25 g) to induce potent antinociceptive effects when administered centrally, suggests a central site of action for the antinociceptive action of nicotine. The present results also support the suggestion that nicotine may selectively reduce sensitivity to certain classes of pain stimuli, perhaps through a central releasing action on acetylcholine.
The effect on spinal fusion of an osteoinductive bone protein extract in the presence of a known inhibitor of spinal fusion (systemic nicotine) was studied prospectively in an animal model of posterolateral lumbar fusion.
To evaluate the ability of a bovine-derived osteoinductive bone protein extract to overcome the inhibitory effect of nicotine in a rabbit spine fusion model.
Multiple studies have demonstrated the ability of a variety of osteoinductive growth factors to serve as a bone graft substitute for lumbar spinal fusion under "normal" healing conditions.
Forty-eight adult female New Zealand white rabbits underwent spine arthrodesis at L5-L6 while receiving systemic nicotine through a subcutaneous miniosmotic pump. Arthrodesis was performed using one of the following three graft materials: 1) autogenous iliac crest, 2) osteoinductive bone protein delivered in an allogeneic demineralized bone matrix/ collagen carrier, or 3) osteoinductive bone protein delivered with autogenous iliac crest. Fusions were assessed by blinded manual palpation, radiography, and biomechanical testing.
Of the 44 rabbits manually tested by blinded observers, all 14 in the osteoinductive bone protein plus autogenous iliac crest bone group had solid fusions (14 of 14), whereas the fusion rate was less in the osteoinductive bone protein plus demineralized bone matrix group (nine of 14, 64%; P = 0.02), and there were no fusions in the autogenous iliac crest only group (0 of 16, 0%; P = 0.000001). The use of osteoinductive bone protein with autogenous bone produced stronger and stiffer fusions compared with those using autogenous bone alone or osteoinductive bone protein with allograft bone.
Cigarette smoking and nicotine are inhibitory factors in the healing of fractures and spine fusions. This study shows that the inhibitory effect of nicotine can be overcome with an osteoinductive bone growth factor in an animal model.
The results of a prospective study of 134 patients with lower back pain suggest that nonorganic factors are better predictors of return to work than organic findings. Patients who returned to work had fewer job, personal, or family related problems. There were no significant differences between patients who returned to work and those who did not when comparing myelograms, computed tomographic scans, or roentgenographs. The only significant difference in physical organic findings was for muscle atrophy. Patients who did not return to work had a statistically higher incidence rate of muscle atrophy. Length of time off from work was significantly related to outcome, but when patients were categorized according to time off the job, different factors predicted failure to return for patients off work for less than 6 months and patients off for more than 6 months. For patients off for less than 6 months, important predictors were a high Oswestry score, history of leg pain, family relocation, short tenure on the job, verbal magnification of pain, reports of moderate to severe pain on superficial palpation, and positive reaction to a "sham" sciatic tension test. None of these was a significant predictor for the group off for more than 6 months. For the group off work for more than 6 months, previous injuries, and stability of family living arrangements were among the significant predictors not significant for the group off less than 6 months. Using 21 factors selected from a larger group of 92 factors, three statistically significant (P less than or equal to 0.001) predictive measures were developed. These measures predicted return to work for the total sample, and for the two subgroups (off more than, or less than 6 months) more accurately than did the total set of 92 factors.
Sciatica is a common symptom that affects as many as 40% of the adult population at some time. However, clinically significant sciatica is much less common and occurs in only 4% to 6% of the population. Exactly how often the symptom is caused by lumbar disk herniation is uncertain; it is known that herniation can occur independent of symptoms. Among the factors associated with its occurrence are age, gender, occupation, cigarette smoking, and exposure to vehicular vibration. The contribution of other factors such as height, weight, and genetics is less certain. The majority of patients with sciatica appear to recover. Approximately 20% of patients with sciatica caused by lumbar herniation have a strong indication for surgical intervention. In the remainder, indications are based primarily on pain rather than functionally significant neurologic deficits. Because pain is the principle indication, there are wide variations in the rates of surgical intervention between countries, and, even within countries, there are significant regional variations. These variations appear to be driven less by specific medical factors and more by gender, occupation, income, education, and the surgeon's preference. Although the contribution of sciatica to low back pain disability remains uncertain, disability caused by low back pain and sciatica appears to be increasing at a rate disproportionate to population growth. To what degree surgery now contributes to that disability is uncertain, but limited information suggests that it may be substantial.
The primary objective of this study was to determine whether disc degeneration, as assessed through magnetic resonance imaging, is greater in smokers than in nonsmokers. To control for the maximum number of potentially confounding variables, pairs of identical twins highly discordant for cigarette smoking were selected as study subjects. Data analyses revealed 18% greater mean disc degeneration scores in the lumbar spines of smokers as compared with nonsmokers. The effect was present across the entire lumbar spine, implicating a mechanism acting systemically. This investigation demonstrates the efficiency of using carefully selected controls in studying conditions of multifactorial etiology, such as disc degeneration.
Fifty consecutive patients underwent standardized surgical treatment for isthmic lumbosacral spondylolisthesis. Twenty-two (44%) had mechanical symptoms only and were treated with in situ fusion. Twenty-eight (56%) had back and radicular symptoms and underwent decompression and fusion. Follow-up averaged 40.4 months. Satisfactory results were achieved in 30 (60%). Patients under 30 and over 50 appeared to do better. Success rate was not related to degree of slippage. Success rate in compensation cases was 39%, versus 83% in non-compensation cases (P less than 0.001); males, 53%, versus females, 78% (0.05 less than P less than 0.1); back pain only, 73%, versus radiculopathy, 50% (0.05 less than P less than 0.1); smokers, 48%, versus nonsmokers, 74% (0.05 less than P less than 0.1). Pseudoarthrosis rate was 12%, and this correlated with failure (P less than 0.002). Thus, a trend towards an unsatisfactory outcome was seen in males, middle-aged individuals, those with a smoking habit, and patients with radicular symptoms. A compensable work situation and pseudoarthrosis had a profoundly negative influence on outcome.
This is a report of 85 patients who underwent anterior lumbar interbody fusion (ALIF) for treatment of painful disc disruption (PDD) or symptomatic pseudarthrosis. The fusion rate was 80% by disc. The pseudarthrosis rate increased from 16% at L5-S1 to 21% and 31% at L4-5 and L3-4, respectively. There was a significant increase in pseudarthrosis rate in patients who smoked more than one pack per day. There was no difference in the fusion rate whether autogenous or cadaveric iliac crest graft or dowel versus tricortical block graft was used. Sixty-eight percent of patients were "able to work" after ALIF. The complication rate was low and retrograde ejaculation occurred in only one patient.
To investigate the relationship of smoking with the rate of pseudarthrosis (surgical nonunion), 50 patients, who were smokers, and 50 patients, who were not, and who had had a two-level laminectomy and fusion during 1977 and 1978 were randomly selected for this study. Most of those participating had sustained job-related injuries whereas the others had no common etiology for their back dysfunction. Most of the patients were from the southeastern United States. Ages ranged from 23 to 62 years, with a mean age of 42.4 years for smokers and 42.7 years for nonsmokers. There was an equal representation of males and females, with minorities represented according to their general percentage in the population. Examination 1 to 2 years after surgery revealed that 40% (20) of the smokers had developed a pseudarthrosis, whereas among nonsmokers, the rate was 8% (4). This finding appears to be independent of age, sex, or race and was statistically significant (chi 2 = 14.035, P = .001). It was hypothesized that the higher incidence of surgical nonunion among smokers may be related to blood gas levels. Nonsmokers showed no significant deficiencies, whereas smokers showed a mean PO2 level of 78.5% (normal = 95-97) and a mean O2 saturation level of 92.9% (normal = 95 or above). Implications and suggestions for further research are also discussed.
In 24 rabbits, the authors transplanted autologous cancellous bone to the anterior chamber of the eye. Half of the rabbits received nicotine and half received placebo (albumin) from mini-osmotic pumps that were implanted subcutaneously. Revascularization of the bone graft was evaluated postoperatively using ophthalmology slit-lamp and fluorescein angiography, and after sacrifice using microvascular silicone injection and histology.
The hypothesis that nicotine inhibits the revascularization of bone graft because of its pharmacologic action on the microvasculature was tested.
Pseudoarthrosis after spinal fusion occurs more frequently in smokers as compared with nonsmokers.
Observations of the bone graft were made regarding the time after implantation when vessels within the graft were noted and the pattern of these vessels. Revascularization of the graft was graded based on the observed percent area of fluorescence after injection of fluorescein. Serum levels of nicotine were measured weekly. Colored silicone was injected at sacrifice to fix the vasculature of the bone graft. Histologic analysis of undecalcified sections was performed.
Nicotine, as compared with placebo, was associated with delayed revascularization within the graft, a smaller percent area of revascularization, and a larger number of grafts showing necrosis.
Nicotine inhibits, but does not prevent, the revascularization of cancellous bone grafts. Inhibition of early revascularization by nicotine is proposed as the pathophysiologic mechanism by which smoking may adversely affect the healing of spinal fusions.
An animal model of posterior lateral intertransverse process fusion healing in the face of systemic nicotine.
To evaluate the effect of systemic nicotine on the success of spinal fusion and its effect on the biomechanic properties of a healing spinal fusion in an animal model.
Clinical observations suggested that cigarette smoking interferes with the healing of bony fusion. No direct link has been made to implicate nicotine as a cause for impaired healing of spinal fusions or fractures.
Twenty-eight adult female New Zealand white rabbits underwent single level lumbar posterior lateral intertransverse process fusion using autologous iliac bone graft. Animals were randomly assigned to either receive systemic nicotine or receive no nicotine. Animals were killed 35 days after surgery. Manual testing of the fusion mass was performed to determine the fusion status. Each fusion mass underwent biomechanic testing.
Fifty-six percent of the control animals were judged to have solidly fused lumbar spines, and there were no solid fusions in the nicotine group (P = 0.02). The mean relative fusion strength in the control group was greater (P = 0.09) than in the nicotine group. For the comparable stiffness figures, the control group was greater than the nicotine group (P = 0.08).
This animal model established a direct relationship between the development of a nonunion in the presence of systemic nicotine. The results suggested that bone formed in the face of systemic nicotine may have inferior biomechanic properties.
Although the etiology of most degenerative changes in the lumbar spine is unclear, genetic factors may play an important role. To investigate this link, we reviewed magnetic resonance images of the lumbar spines of identical twins to assess the degree of similarities in degenerative findings in the discs. Observers who were blinded to twinship evaluated sagittal T1-weighted and T2-weighted magnetic resonance images of the lumbar spines of forty male identical twins (twenty pairs) with respect to changes in the end plates, desiccation of the discs, bulging or herniated discs, and decrease in the height of the disc space. Similarities between co-twins were significantly greater than would be expected by chance. Whereas smoking status and age explained 0 to 15 per cent of the variability in the various degenerative findings in the discs, 26 to 72 per cent of the variability was explained with the addition of a variable representing co-twin status. These findings are compatible with a marked genetic influence and warrant further investigation.
There have been numerous studies that implicate cigarette smoking as a risk factor for the development of back pain or disc disease. The purpose of this article is to review patients who underwent surgery for cervical or lumbar radiculopathy and to investigate the relationship between cigarette smoking and development of surgical disc disease. A cigarette smoking study of 205 surgical patients with lumbar and cervical disc diseases was done, with the surgical patients compared to 205 age-sex-matched inpatient controls during 1987-1988. This study was conducted at the Pennsylvania Hospital in Philadelphia, Pennsylvania. There were 163 patients with lumbar disc disease and 42 patients with cervical disc disease. The ratio of men to women was 1.5:1 for lumbar disc and 2.5:1 for cervical disc disease. Smoking history (current and ex-smokers) was strikingly increased in both prolapsed lumbar intervertebral disc (56% vs. 37% of controls, p = 0.00029) and cervical disc disease (64.3% vs. 37% of controls, p = 0.0025). Calculated relative risks for smokers were 2.2 for lumbar disc and 2.9 for cervical disc diseases. This association between cigarette smoking and disc disease was more significant when comparing between current smokers versus nonsmokers (p = 0.000011 for lumbar disc disease, and p = 0.00064 for cervical disc disease). Relative risks for current smokers were 3.0 for lumbar disc and 3.9 for cervical disc diseases. This correlation was significant for both males (p = 0.000068 for lumbar disc disease, p = 0.043 for cervical disc disease) and females (p = 0.018 for lumbar disc disease, p = 0.006 for cervical disc disease).(ABSTRACT TRUNCATED AT 250 WORDS)
The role of spinal mechanisms in subcutaneous (s.c.) nicotine-induced antinociception was examined in male Sprague-Dawley rats using the hot-plate and tail-flick tests. Nicotine (0.125, 0.25, 0.375 or 0.5 mg/kg s.c.) produced a dose-related inhibition of nociception in both tests. Although increasing negative geotaxis response times slightly, no significant alteration of other motor reflexes was observed with 0.375 mg/kg of s.c. nicotine. Microinjection of 7 nmol of the high-affinity choline uptake inhibitor hemicholinium-3 into the rostral ventral medulla completely inhibited the antinociception produced by 0.375 mg/kg of s.c. nicotine. Intrathecal (i.t.) injection of 61 nmol of nicotine (in 10 microliter buffer) produced no changes in hot-plate or tail-flick test response latencies. Nicotine-induced antinociception was blocked by a variety of i.t. antagonists injected 12 min before s.c. injection of 0.375 mg/kg of nicotine. In both tests, i.t. pretreatment with 0.1 mumol (in 10 microliter buffer) of scopolamine, methysergide, yohimbine, idazoxan, mecamylamine or 0.2 mumol of atropine attenuated nicotine-induced increases in test response latencies. Pretreatment with 0.1 mumol of atropine attenuated nicotine-induced increases in tail-flick test, but not in the hot-plate test. Pretreatment with 0.1 mumol of i.t. prazosin or naloxone produced no changes in nicotine-induced increases in test response latencies in either test. These data suggest that the antinociception produced by s.c. nicotine is mediated via a number of sites in the spinal cord, including alpha-2 adrenergic, serotonergic and muscarinic cholinergic.(ABSTRACT TRUNCATED AT 250 WORDS)
To estimate the overall efficacy and optimal use of the nicotine patch for treating tobacco dependence.
Nicotine patch efficacy studies published through September 1993, identified through MEDLINE, Psychological Abstracts, and Food and Drug Administration new drug applications.
Double-blind, placebo-controlled nicotine patch studies of 4 weeks or longer with random assignment of subjects, biochemical confirmation of abstinence, and subjects not selected on the basis of specific diseases (eg, coronary artery disease).
Pooled abstinence rates and combined odds ratios (ORs) at end of treatment and 6-month follow-up were examined overall and in terms of patch type (16-hour vs 24-hour), patch treatment duration, dosage reduction (weaning), counseling format (individual vs group), and intensity of adjuvant behavioral counseling.
Across 17 studies (n = 5098 patients) meeting inclusion criteria, overall abstinence rates for the active patch were 27% (vs 13% for placebo) at the end of treatment and 22% (vs 9% for placebo) at 6 months. The combined ORs for efficacy of active patch vs placebo patch were 2.6 at the end of treatment and 3.0 at 6 months. The active patch was superior to the placebo patch regardless of patch type (16-hour vs 24-hour), patch treatment duration, weaning, counseling format, or counseling intensity. The 16-hour and 24-hour patches appeared equally efficacious, and extending treatment beyond 8 weeks did not appear to increase efficacy. The pooled abstinence data showed that intensive behavioral counseling had a reliable but modest positive impact on quit rates.
The nicotine patch is an effective aid to quitting smoking across different patch-use strategies. Active patch subjects were more than twice as likely to quit smoking as individuals wearing a placebo patch, and this effect was present at both high and low intensities of counseling. The nicotine patch is an effective smoking cessation aid and has the potential to improve public health significantly.
Two hundred chronic low-back pain patients entering a functional restoration program were assessed for current and lifetime psychiatric syndromes using a structured psychiatric interview to make DSM-III-R diagnoses. Results showed that, even when the somewhat controversial category of somatoform pain disorder was excluded, 77% of patients met lifetime diagnostic criteria and 59% demonstrated current symptoms for at least one psychiatric diagnosis. The most common of these were major depression, substance abuse, and anxiety disorders. In addition, 51% met criteria for at least one personality disorder. All of the prevalence rates were significantly greater than the base rate for the general population. Finally, and most importantly, of these patients with a positive lifetime history for psychiatric syndromes, 54% of those with depression, 94% of those with substance abuse, and 95% of those with anxiety disorders had experienced these syndromes before the onset of their back pain. These are the first results to indicate that certain psychiatric syndromes appear to precede chronic low-back pain (substance abuse and anxiety disorders), whereas others (specifically, major depression) develop either before or after the onset of chronic low-back pain. Such findings substantially add to our understanding of causality and predisposition in the relationship between psychiatric disorders and chronic low-back pain. They also clearly reveal that clinicians should be aware of potentially high rates of emotional distress syndromes in chronic low-back pain and enlist mental health professionals to help maximize treatment outcomes.
Psychiatry has been essentially uninterested in cigarette smoking and nicotine. However, it is the view of this author that both cigarette smoking and smoking cessation are highly relevant to the clinical psychiatrist in the care of patients and that they are potentially a source of important insights into psychopathology. To support that view, the author reviews the evidence that both major depression and depressive symptoms are associated with a high rate of cigarette smoking and that lifetime history of major depression has an adverse impact on smoking cessation. He also reviews the data available on the influence of cigarette smoking cessation on the course of major depression, the relationship between cigarette smoking and other psychiatric diagnoses, particularly schizophrenia, and the neuropharmacology that might underlie these associations. Finally, the implications of these relationships for psychiatry are discussed.
Eighty-six patients had a total of eighty-eight primary attempts at repair of a pseudarthrosis that had developed after a localized arthrodesis in the lumbar spine. A follow-up questionnaire was sent to all patients at a mean of fifty-one months (range, twenty-five to seventy-eight months) after the operation; seventy-two patients (84 percent) completed to questionnaire. A solid fusion was ultimately achieved after the treatment of eighty-one (94 percent) of the eighty-six pseudarthroses for which radiographic data were available. With the numbers available, we could find no significant association between a solid fusion and the patient's age, gender, body-mass index, return to work, or outcome score. Despite the high rate of fusion after the index repair and subsequent procedures, only nineteen (26 percent) of the seventy-two patients who completed the questionnaire eventually had a good or excellent outcome. Seven (10 percent) had an excellent result (90 to 100 points), twelve (17 percent) had a good result (70 to 89 points), fourteen (19 percent) had a fair result (50 to 69 points), and thirty-nine (54 percent) had a poor result (less than 50 points). Nevertheless, fifty-one patients (71 percent) reported that the operation led to some improvement, and fifty-five (76 percent) said that they would have the operation again if the circumstances were similar to those before the repair of the pseudarthrosis. Thirty-four of the seventy-two patients were smokers and thirty-eight were non-smokers at the time of the operation. There was a negative linear association between the outcome scores and the number of pack-years (p = 0.02). Cessation of smoking before the operation positively affected the outcome; the patients who had stopped smoking had a mean outcome score of 65 points, compared with 45 points for those who had not stopped (p = 0.03). Patients who had stopped smoking were also more likely to return to work full time (p < 0.001). At the latest follow-up evaluation, twenty of the seventy-two patients had returned to full-time employment. Patients who had been receiving Workers' Compensation at the time of the operation generally did poorly on the outcome questionnaire, but, with the numbers available, they did not have a significantly different rate of solid fusion than patients who had not been receiving Workers' Compensation. Also, the outcome score and the rate of fusion were nor significantly affected by age or by obesity.
Ninety-four patients were assigned to groups either with or without implanted bone growth stimulation as an adjunct to instrumented animal fusion between May 1990 and December 1992. Consecutive groups with or without stimulation were compared prospectively; a small group was compared with random assignment of surgery with or without stimulation.
To test the efficacy of implanted bone growth stimulation in instrumented fusion, especially regarding high-rist patient groups including smokers, those with previous back surgery, and those with multiple fusion levels.
No reports have specifically addressed implanted bone growth stimulation with instrumented spinal fusion, although the effects of stimulation on long-bone and in situ spinal fusion have been reported.
Fusion surgery was performed by the same two surgeons for all patients, using autologous graft and instrumentation (pedicle screw and rod). Surgical indications and pre- and postoperative regimens were similar for all patients. Average follow-up period was 20.5 months.
Ninety-six percent of patients with stimulation had solid fusion versus 85% fusion in patients who did not have stimulation.
Implanted bone growth stimulation can improve fusion results in patients with instrumented lumbosacral fusion as has been demonstrated in in situ fusions. Patients in high-risk categories (smokers, those with multiple back surgeries, and multilevel fusions) also are demonstrated to have higher fusion rates with implanted bone growth stimulation than those without benefit of stimulation.
Attainment of successful lumbar fusion in adults with spondylolisthesis has historically been unpredictable. Recent results and conclusions have been conflicting regarding the role of instrumentation in improving the fusion rate and clinical outcome in this patient population. In a retrospective multicenter clinical study, we assessed the outcome of 42 adults with spondylolisthesis who underwent posterolateral lumbar fusion by using pedicular instrumentation with AO DC plates. No attempt was made to reduce slippage. Follow-up clinical outcome was obtained from a patient questionnaire administered and assessed by an independent reviewer. Fusion status was assessed by anteroposterior, lateral, and oblique radiographs at the most recent follow-up examination. Spondylolisthesis was classified as degenerative in 21 patients and isthmic in 21 patients. Solid fusion was achieved in 32 (76%) patients; pseudoarthrosis occurred in two (5%) patients; the fusion mass was indeterminate in eight (19%) patients. Clinical outcome parameters rated 73% excellent to good and 27% fair to poor. Complications included four infections and two screw breakages. Poor results correlated strongly with cigarette smoking and multiple previous surgeries. In this study, fusion rate and clinical outcome were consistent with previous reports of adult spondylolisthesis. Rates of successful fusion varied according to the type of spondylolisthesis.
Chronic cigarette consumption has significant adverse effects on the human spinal column. Multiple mechanisms induced by tobacco use lead to less strong, less healthy, mineral-deficient vertebrae with reduced bone blood supply and fewer and less functional bone-forming cells among chronic smokers. Compared to nonsmokers, chronic smokers develop advanced bony degradation, are more likely to suffer from spinal column degenerative disease, and seem more susceptible to traumatic vertebral injury. Spinal fusion procedures in chronic smokers are less often clinically and radiographically successful, compared to similar procedures performed among nonsmokers for definitive biological, physiological, and mechanical reasons.
Forty-two neurologically intact adults in whom non-operative treatment of grade-I or grade-II isthmic spondylolisthesis of the most caudad lumbar segment had failed were entered into a prospective study of the results of operative treatment. Twenty patients who smoked were managed with a posterolateral arthrodesis with instrumentation (transpedicular fixation), and twenty-two patients who did not smoke were managed with a posterolateral arthrodesis without instrumentation. Of the patients who were managed with instrumentation, eight were randomized to treatment with a decompressive laminectomy and twelve, to treatment without it; in the group that was managed without instrumentation, the distribution was ten and twelve patients, respectively. The patients were followed clinically for a mean of 4.5 years (range, 3.5 to six years). Of the eighteen patients who had been managed with decompression, four had a pseudarthrosis and six had an unsatisfactory result compared with none and one of the twenty-four who had been managed without decompression (p = 0.02 and p = 0.01, respectively). In the group of twenty patients (smokers) who had been managed with instrumentation, none of the twelve managed without decompression had a pseudarthrosis compared with one of the eight managed with decompression (p = 0.2). In the group of twenty-two patients (non-smokers) who had been managed without instrumentation, none of the twelve managed without decompression had a pseudarthrosis compared with three of the ten managed with decompression (p = 0.04). In the group managed with instrumentation, two of the eight who had had decompression had an unsatisfactory result compared with none of the twelve who had not had decompression. In the group managed without instrumentation, four of the ten who had had decompression had an unsatisfactory result compared with one of the twelve who had not had decompression. The addition of decompression to arthrodesis, performed with or without instrumentation, for the treatment of low-grade isthmic spondylolisthesis in patients who do not have a serious neurological deficit does not appear to improve the result and may significantly increase the rates of pseudarthrosis and unsatisfactory results.
Smoking during pregnancy is a serious threat to the health of mother and baby. Smoking during a pregnancy increases the risk of placental and other pregnancy complications. 1 Smoking during and after pregnancy increases the risk of acute and chronic lung and cardiovascular disease in the mother. 2 In addition, many studies link maternal smoking to infant mortality, low birthweight, and other adverse birth outcomes, such as birth defects. 3 One study estimated that elimination of maternal smoking would reduce infant mortality by 10%. 4 Another study of a low-income population found that 31 % of low-weight births among non-Hispanic whites and 14 % of low-weight births among blacks were attributable to smoking. 5 Because the negative health effects of smoking during pregnancy are so well documented, most people would agree on the need for effective smoking cessation strategies. We undertook the present study to describe the prevalence of smoking among demographic subgroups of pregnant women in North Carolina and to show how these patterns have changed over time. This information should help in developing and targeting smoking cessation programs. Methods We gathered data about smoking from NC birth certificates from 1988 through 1994. In some cases, the person filling out the birth certificate may consult the maternal medical record to determine whether the mother smoked during pregnancy, but usually this information is obtained directly from the mother while she is in the hospital. Even when the information comes from the medical record, it is usually based on self-report by the mother. The validity of the smoking information on the birth certificate is very important to this study. In 1988, two questions about smoking during pregnancy
The influence of ketorolac on spinal fusion was studied in a retrospective review of 288 patients who underwent an instrumented spinal fusion.
To assess the effect of postoperative ketorolac administration on subsequent fusion rates.
Nonsteroidal anti-inflammatory drugs are widely used compounds, which are known to inhibit osteogenic activity and have been shown to decrease spinal fusion in an animal model. No previous studies have examined the influence of nonsteroidal anti-inflammatory drugs on spinal fusion in clinical practice.
The medical records of 288 patients who underwent instrumented spinal fusion from L4 to the sacrum between 1991 and 1993 were reviewed retrospectively. The 121 patients who received no nonsteroidal anti-inflammatory drugs were compared with the 167 patients who received ketorolac after surgery. The groups were demographically equivalent.
Ketorolac had a significant adverse effect on fusion, with five nonunions in the nondrug group and 29 nonunions in the ketorolac group (P > 0.001). Ketorolac administration also significantly decreased the fusion rate for subgroups including men, women, smokers, and nonsmokers. The odds ratio demonstrated that nonunion was approximately five times more likely after ketorolac administration. Cigarette smoking also decreased the fusion rate (P > 0.01); smokers were 2.8 times more likely to develop nonunion.
These data suggest that nonsteroidal anti-inflammatory drugs significantly inhibit spinal fusion at doses typically used for postoperative pain control. The authors recommend that these drugs be avoided in the early postoperative period.
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Controversies: Smoking abstinence: is it necessary before spinal fusion? Address reprint requests to Steven D. Glassman, MD Spine Institute for Special Surgery, PSC 210 E. Gray St, Suite 900 Louisville, KY 40202 E-mail: SISS001@aol
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Volvo Award in Clinical Sciences. Smoking and lumbar intervertebral disc degeneration: an MRI study of identical twins
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