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Smoking is Associated With 1-year Suboptimal Patient-reported Outcomes After 2-level Anterior Cervical Fusion

Cerier, Emily, BS*; Jain, Nikhil, MD; Lenobel, Scott, MD; Niedermeier, Steven R., MD; Stammen, Kari, AT; Yu, Elizabeth, MD

doi: 10.1097/BSD.0000000000000765

Study Design: Retrospective cohort study.

Objective: To study the impact of smoking on patient-reported outcomes after primary 2-level anterior cervical discectomy and fusion (ACDF).

Summary of Background Data: Previous studies have found suboptimal outcomes after multilevel ACDF in smoking patients. There is contrasting evidence on the negative effects of smoking in single-level ACDF, while there are no specific reports in 2-level ACDF. Adding knowledge of smoking’s impact on patient-reported outcomes (PRO) will help in tailored patient counseling and preoperative education.

Methods: Patients 18 years of age or older at a single academic institution who underwent 2-level ACDF to treat cervical radiculopathy and/or myelopathy between September 2013 and September 2015 were included. PRO was studied using the neck disability index (NDI) preoperatively, and at 3, 6, 12 months. χ2 test for qualitative variables, and one-way analysis of variance (ANOVA) and unpaired t test for quantitative variables were used for statistical analysis.

Results: A total of 61 patients, of which 23 (37.7%) were classified as smokers were included. Demographic and clinical profile of patients was similar both groups. Preoperatively, smokers had a mean NDI of 62.8±12.7 with a 17.5%, 18.7%, and 27.7% decrease at 3, 6, and 12-months, respectively. Nonsmokers had a mean preoperative NDI of 45.9±15.3, with a 36.4%, 61.2% and 65.4% decrease at 3, 6, and 12-months, respectively. Despite higher baseline NDI in smokers, improvement in NDI reached significance at 3-months in nonsmokers. In smokers, the improvement in NDI was slower and reached significance at 12-months. The radiographic fusion status at latest follow-up was similar in smokers and nonsmokers (P=0.67).

Conclusions: Smokers had lower improvements in NDI scores compared to nonsmokers after a 2-level ACDF. Preoperative counseling before 2-level ACDF should include education about risks of inferior clinical outcomes in smokers independent of fusion status.

*Department of Orthopaedics, College of Medicine, The Ohio State University

Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH

The authors declare no conflict of interest.

Reprints: Elizabeth Yu, MD, Department of Orthopaedics, The Ohio State University, 725 Prior Hall, Columbus, OH 43210 (e-mail:

Received March 16, 2018

Accepted October 1, 2018

© 2019 by Lippincott Williams & Wilkins, Inc.