Tobacco and Fusions: Quitting Before Surgery

By Chelsea Commander, APRN, FNP-C

When considering the consequences of smoking cigarettes prior to having back surgery, there really is no grey area. There has been more than enough research on this topic to determine that patients who smoke prior to undergoing a spinal fusion subject themselves to significant hazards.

First of all, the nicotine can greatly decrease the rate of successful fusions called a non-union or pseudoarthroses. Patients who use nicotine prior to surgery also experience less pain reduction even if a successful fusion was achieved. They also have poorer functional rehabilitation after surgery and generally a lower overall satisfaction with the procedure. It is important to note that this research clarifies that the hazards are not limited to just smoking cigarettes, but apply to all forms of nicotine use such as: chewing tobacco, cigars, pipes, nicotine patches, and nicotine gum.

It should come as no surprise that a surgeon could reasonably deny a patient’s decision to undergo this type of surgery because of their nicotine habit. In fact, some insurance companies will not approve a spinal fusion if the patient is a known tobacco user. Anyone considering this option must have a clear understanding of the extensive healing and rehabilitation involved post-op. Nicotine use interferes so greatly with the recovery phase that it can reduce a patient’s candidacy and lead to a poorer prognosis post operatively.

Studies have shown that the rate of non-fusion in smokers is as much as twice that found in non-smokers. Although those studies can vary depending on the procedures used, non-fusion rate for nonsmokers is about 5%-15% whereas in smokers it is about 20%-30%. The difference lies in the negative effect that nicotine has on bone growth, which is obviously essential for achieving the goal of a spinal fusion. This is caused by a decreased revascularization of the bone graft. The graft does not get enough nutrients due to a lack of blood supply and, therefore, does not grow and cannot form a fusion mass.

There have been methods recently developed to increase the success rate for smokers. One of those in particular is bone morphogenic proteins (BMP).  BMP’s are a group of growth factors known for their ability to induce formation of bone and cartilage. The BMP is placed at time of surgery and can enhance the growth beyond what would normally occur under normal circumstances. However a recent study by Glassman, Dimar et al. (2007), concluded that “While BMP is a valuable tool for lumbar fusion in smokers, smoking abatement is still the optimal management technique for patients undergoing lumbar fusion surgery”.

Bottom line is quit smoking. Not only does it improve your surgical outcome, but it will improve your overall health.