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The effect of smoking on patients having spinal surgery

Schroeder, Gregory D. MD; Kepler, Christopher K. MD, MBA; Hilibrand, Alan S. MD

doi: 10.1097/BCO.0000000000000331
SPECIAL FOCUS: Orthopaedics and Comorbidities

Almost 18% of American adults smoke cigarettes, and although the harmful effects of tobacco smoke on cardiac and pulmonary systems are common knowledge, the negative effects of cigarette smoking on the spine are also substantial, yet not widely recognized. Cigarette smoking leads to a significant alteration in the local environment of intervertebral discs by changing the total blood flow through the capillaries and decreasing the ability of red blood cells to deliver oxygen. In combination with the direct toxic effect of smoking byproducts, the decrease in oxygen delivery leads to an increase in expression of degradative enzymes, such as aggrecan, disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS), and matrix-metalloproteinases (MMP), resulting in accelerated disc degeneration. Unfortunately, tobacco smoke not only increases the risk of symptomatic spinal pathology, but it also decreases the efficacy of both conservative and surgical treatment. Smoking is associated with a worse health-related quality of life after nonoperative care, and patients undergoing both cervical and lumbar fusions are at an increased risk of developing nonunion. Furthermore, even in patients who only require decompression, smoking leads to inferior clinical outcomes and possibly an increase risk of perioperative complications.

The Rothman Institute at Thomas Jefferson University, Philadelphia PA

Financial Disclosure: Dr. Shroeder has received travel reimbursement from Medtronic. Dr. Kepler is a consultant for Healthgrades. Dr. Hilibrand receives royalties from Aesculap/B.Braum, Amedica, Bimet, Stryker and owns stock in Amedica, Benvenue Med, Lifespine, Nexgen, Paradigm Spine, PSD, Spinal Venutres, and Vertiflex. The authors report no conflicts of interest in regard to this work.

Correspondence to Alan S. Hilibrand, MD, Rothman Institute at Thomas Jefferson University, 925 Chestnut Street, Philadelphia, PA 19107 Tel: +609-677-6060; fax: +609-677-6061; e-mail:

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