title: Impact of smoking on the outcome of anterior cervical arthrodesis with interbody or strut-grafting.
abstract: 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 multi-level 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.
authors.affiliation: University Hospitals Spine Institute and the Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA. alan.hilibrand@mail.tju.edu
authors.forename: A S
authors.initials: AS
authors.lastname: Hilibrand
authors.forename: M A
authors.initials: MA
authors.lastname: Fye
authors.forename: S E
authors.initials: SE
authors.lastname: Emery
authors.forename: M A
authors.initials: MA
authors.lastname: Palumbo
authors.forename: H H
authors.initials: HH
authors.lastname: Bohlman
mesh_terms: D016025:Bone Transplantation; D001842:Bone and Bones; D002574:Cervical Vertebrae / Q000601:surgery*; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011843:Radiculopathy / Q000601:surgery; D012907:Smoking / Q000009:adverse effects*; D013118:Spinal Cord Diseases / Q000601:surgery; D013123:Spinal Fusion / Q000379:methods*; D013128:Spinal Osteophytosis / Q000601:surgery; D016896:Treatment Outcome