Background: An increased rate of pseudarthrosis
has been documented following posterolateral lumbar spine grafting
in patients who smoke. This same relationship has been assumed for
anterior cervical interbody grafting, but to our knowledge it has
never been proven. This study compared the long-term radiographic
and clinical results of smokers and nonsmokers who had undergone
arthrodesis with autogenous bone graft following multilevel anterior cervical
decompression for the treatment of cervical radiculopathy or myelopathy,
Methods: One hundred and ninety patients were followed clinically
and radiographically for at least two years (range, two to fifteen
years). Fifty-nine of the patients had corpectomy with strut-grafting,
and 131 patients had multiple discectomies and interbody grafting.
Fifty-five of the 190 patients had a history of active cigarette-smoking;
fifteen of the fifty-five had corpectomy with strut-grafting, and forty
had multilevel discectomies and interbody grafting. Internal fixation
was not used in any patient. The reconstruction techniques and postoperative
bracing regimen were similar between smokers and nonsmokers. Osseous
union was judged on dynamic lateral radiographs made at least two
years following surgery, and clinical outcomes were judged on the
basis of pain level, medication usage, and daily activity level.
Results: Of the forty smokers who had undergone
multilevel interbody grafting, twenty had a solid fusion at all
levels, whereas sixty-nine of the ninety-one nonsmokers had solid
fusion at all levels (p < 0.02; chi-square test). This
difference was especially pronounced among patients who had had
a two-level interbody grafting procedure (p < 0.002; chi-square test).
With the numbers available, there was no difference in the rate
of fusion between smokers (fourteen of fifteen) and nonsmokers (forty-one
of forty-four) who had undergone corpectomy and strut-grafting,
as 93% of both groups had a solid union. In addition, clinical
outcomes were significantly worse among smokers when compared with
nonsmokers (p < 0.03; rank-sum analysis).
Conclusions: Smoking had a significant negative
impact on healing and clinical recovery after multilevel anterior cervical
decompression and fusion with autogenous interbody graft for radiculopathy
or myelopathy. Since smoking had no apparent effect upon the healing
of autogenous iliac-crest or fibular strut grafts, subtotal corpectomy
and autogenous strut-grafting should be considered when a multilevel anterior
cervical decompression and fusion is performed in patients who are
unable or unwilling to stop smoking prior to surgical treatment.