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Impact of Smoking on the Outcome of Anterior Cervical Arthrodesis with Interbody or Strut-Grafting
Alan S. Hilibrand, MD; Mark A. Fye, MD; Sanford E. Emery, MD; Mark A. Palumbo, MD; Henry H. Bohlman, MD
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Investigation performed at the University Hospitals Spine Institute and the Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio
Alan S. Hilibrand, MD The Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107. E-mail address: alan.hilibrand@mail.tju.edu
Mark A. Fye, MD Sanford E. Emery, MD Henry H. Bohlman, MD University Hospitals Spine Institute, 11100 Euclid Avenue, Cleveland, OH 44106
Mark A. Palumbo, MD University Orthopaedics, Incorporated, 2 Dudley Street, Suite 200, Providence, RI 02905
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
A video supplement to this article is available from the Video Journal of Orthopaedics. A video clip is available at the JBJS web site, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.

J Bone Joint Surg Am, 2001 May 01;83(5):668-673
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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, or both.

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.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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