Effect of smoking on the perioperative outcomes of patients who undergo elective spine surgery

Effect of Nicotine Replacement Therapy on Perioperative Pain Management and Opioid Requirement in Abstinent Tobacco Smokers Undergoing Spinal Fusion: A Double-blind Randomized Controlled Trial

BACKGROUND

Smoking negatively impacts postoperative outcomes but acute abstinence from smoking during hospitalization can increase postoperative pain, lower pain thresholds, disrupt pain management, and trigger hyperalgesia due to abrupt nicotine withdrawal in tobacco users. Nicotine replacement therapy has been recommended to minimize these complications. We hypothesized that a high dose (21 mg/24 h) transdermal nicotine (TDN) patch would reduce postoperative pain and opioid requirements.

METHODS

One hundred abstinent tobacco smokers undergoing single-level spinal fusion were randomized into placebo (n=50) and nicotine treatment (n=50) groups. Placebo and TDN patches were applied 24 hours before surgery until 48 hours after surgery. Primary outcomes were postoperative pain scores and opioid (morphine) consumption, and serum nicotine levels. The relationship between daily tobacco use and pain and opioid requirements, and between serum nicotine levels and morphine consumption, were assessed.

RESULTS

Postoperative pain scores at rest and on movement were lower in the nicotine group than in the placebo group at 6 hours, 12 hours, and 24 hours after surgery (P<0.05). Postoperative morphine consumption was lower in the nicotine group than in the placebo group (9.92 ± 4.0 vs. 15.9 ± 5.0 mg, respectively; P=0.0002). There was a positive correlation between the number of cigarettes smoked per day and postoperative pain scores at rest (r = 0.4553; P = 0.0001) and during movement and a negative correlation between serum nicotine concentration and postoperative morphine consumption (r =-0.3664; P = 0.0089).

CONCLUSIONS

TDN patches (21 mg/24 h) reduced postoperative pain and opioid requirements in abstinent tobacco smokes undergoing spinal fusion.

Patient Comorbidities, Their Influence on Lumbar Spinal Fusion Surgery, and Recommendations to Reduce Unfavorable Outcomes

Improvements in healthcare management have led to a decrease in perioperative and postoperative complications. However, perioperative medical complications and mortality rates continue to increase in patients undergoing elective spinal surgeries. This trend is driven by the increase in the older population and the rise in the number of patients with more than two comorbidities. Managing patients with multiple comorbidities requires additional resources, augmenting the financial and societal burden. Despite the high risk of complications and mortality, patients with multiple comorbidities undergo spinal surgery for degenerative spinal conditions daily. These findings highlight the need for heightened awareness, patient education, and management of comorbidities before elective spinal surgeries. This article comprehensively reviews literature on the effects of medical comorbidities on spinal fusion surgery outcomes to increase awareness of the surgical complications associated with comorbidities. In addition, suggested preoperative and postoperative comorbidity management strategies are outlined.

Influence of smoking on patient-reported outcome measures (PROMs) in patients undergoing surgery for adult spinal deformity: a propensity score-matched analysis

PURPOSE

The purpose of this study was to determine the isolated influence of smoking in patient-reported outcome measures (PROMs) for adult spinal deformity (ASD) surgery excluding known tobacco-related complications.

METHODS

Retrospective analysis of a prospective multicenter ASD database. Patients operated on ASD with 2 year post-operative follow-up were included. Former smokers (non-active smokers) and patients developing mechanical or infectious complications were excluded. Changes of PROMs over time were analyzed using mixed models for repeated measures (MMRM). Propensity score matching (PSM) (1:1 ratio, caliper 0.10) was performed without replacement using optimum algorithm, tolerance ≤ 0.001, and estimated with 95% confidence interval (CI). PROMS in both groups were compared by paired t test or Wilcoxon signed-rank test.

RESULTS

692 out of 1246 surgical patients met our inclusion criteria. 153 smokers were matched with 153 non-smokers according to age, BMI, number of fused levels, and global tilt. After PSM both groups were homogeneous regarding baseline parameters, surgical data, and complications (mechanical complications and infection excluded). Smokers had worse baseline results for SRS-total, SRS-pain COMI-back, and ODI; smokers also showed worse 2-year outcomes for SRS-total, SRS-function, SRS-pain, SRS-self-image, and ODI. However, no differences between the two groups were found in the improvement from baseline to 2-year follow-up or in the timing of this improvement (MMRM). The proportion of patients reaching the minimal clinically important difference (MCID) after surgery was similar in the two groups, but the proportion of patients reaching patient acceptable symptom state (PASS) was significantly lower in smokers for SRS-Subtotal, SRS-function, and SRS-image.

CONCLUSION

Even in the absence of smoking-related complications, smokers had worse PROMs at baseline and 2 years after surgery with less patients achieving PASS, but similar degrees on improvement compared to non-smokers. The proportion achieving MCID was also similar between the two cohorts.

Preoperative Optimization for Adult Spinal Deformity Surgery: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

The purpose of this review is to identify modifiable risk factors in patients undergoing adult spinal deformity surgery and compile literature recommendations for the preoperative optimization of these risk factors.

SUMMARY OF BACKGROUND DATA

Optimization of modifiable risk factors not only benefits the patient but also lessens resource and cost burdens on the health care system, allowing for better quality and value-based care. There is limited but applicable literature discussing preoperative optimization in adult spinal deformity surgery patients specifically.

METHODS

We searched PubMed for studies that looked at one of the variables of interest (eg, osteoporosis, prehabilitation and functional status, multidisciplinary preoperative screening, infection, obesity, nutrition, smoking, diabetes, blood loss, chronic opioid use, and psychosocial factors) in adult patients with spinal deformity according to Preferred Reporting Items for Systematic Reviews and Meta-Analyse guidelines.

RESULTS

Seventy studies were included in the final review and synthesis of information. Guidelines and recommendations from these studies were compared and compiled into evidence-based action items for preoperative optimization of modifiable risk factors before adult spinal deformity surgery.

CONCLUSIONS

While the approach of preoperative optimization of modifiable risk factors may incur additional planning efforts and patient care time, it has the potential to significantly reduce perioperative complications and reduce morbidity and mortality during surgery, thus allowing for improved outcomes, increased quality of life, and satisfaction from this patient population.

LEVEL OF EVIDENCE

3.

Cannabis Use Disorder and Perioperative Complications

Importance

Cannabis use is growing in the US and is increasingly perceived as harmless. However, the perioperative impact of cannabis use remains uncertain.

Objective

To assess whether cannabis use disorder is associated with increased morbidity and mortality after major elective, inpatient, noncardiac surgery.

Design, Setting, and Participants

This retrospective, population-based, matched cohort study used data from the National Inpatient Sample for adult patients aged 18 to 65 years who underwent major elective inpatient surgery (including cholecystectomy, colectomy, inguinal hernia repair, femoral hernia repair, mastectomy, lumpectomy, hip arthroplasty, knee arthroplasty, hysterectomy, spinal fusion, and vertebral discectomy) from January 2016 to December 2019. Data were analyzed from February to August 2022.

Exposure

Cannabis use disorder, as defined by the presence of specific International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnostic codes.

Main Outcome and Measures

The primary composite outcome was in-hospital mortality and 7 major perioperative complications (myocardial ischemia, acute kidney injury, stroke, respiratory failure, venous thromboembolism, hospital-acquired infection, and surgical procedure-related complications) based on ICD-10 discharge diagnosis codes. Propensity score matching was performed to create a 1:1 matched cohort that was well balanced with respect to covariates, which included patient comorbidities, sociodemographic factors, and procedure type.

Results

Among 12 422 hospitalizations, a cohort of 6211 patients with cannabis use disorder (median age, 53 years [IQR, 44-59 years]; 3498 [56.32%] male) were matched with 6211 patients without cannabis use disorder for analysis. Cannabis use disorder was associated with an increased risk of perioperative morbidity and mortality compared with hospitalizations without cannabis use disorder in adjusted analysis (adjusted odds ratio, 1.19; 95% CI, 1.04-1.37; P = .01). The outcome occurred more frequently in the group with cannabis use disorder (480 [7.73%]) compared with the unexposed group (408 [6.57%]).

Conclusions and Relevance

In this cohort study, cannabis use disorder was associated with a modest increased risk of perioperative morbidity and mortality after major elective, inpatient, noncardiac surgery. In the context of increasing cannabis use rates, our findings support preoperative screening for cannabis use disorder as a component of perioperative risk stratification. However, further research is needed to quantify the perioperative impact of cannabis use by route and dosage and to inform recommendations for preoperative cannabis cessation.

The Risk of Adverse Events in Smokers Undergoing Spinal Fusion: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

Determine if tobacco use is associated with increased risk of postoperative adverse events within 90 days in patients undergoing spinal fusion surgery.

METHODS

Databases were queried to identify cohort studies that directly compared smokers with non-smokers and provided the absolute number of adverse events and the population at risk. Data quality was evaluated using the Quality in Prognosis Studies tool. Risk ratios (RR) and 95% confidence intervals were calculated and compared between studies. The grading of recommendation, assessment, development and evaluation (GRADE) criteria were used to assess the strength of the evidence.

RESULTS

Seventeen studies assessing 37 897 participants met the inclusion criteria. Of these, 10 031 (26.5%) were smokers and 27 866 (73.5%) were nonsmokers. The mean age for the study population was 58 years, and 45% were males. Smoking was not associated with increased risk of one or more major adverse events within 90 days following spine surgery (seven studies, pooled RR 1.13, 95% CI [.75-1.71], I2 = 41%). However, smoking was significantly associated with one or more major adverse events in ≤2 level fusion (three studies, pooled RR 2.46, 95% CI [1.18-5.12], I2 = 0%), but not in fusions of ≥3 levels (four studies, pooled RR .87, 95% CI [.70-1.08], I2 = 0%). Additionally, there was no statistically significant association between smoking and any adverse event, nor increased reoperation risk due to adverse events.

CONCLUSIONS

In this meta-analysis, tobacco use was not associated with a statistically significant increased risk of adverse events within 90 days in patients undergoing spinal fusion surgery. Our results are limited by the variable reporting methodology for both complication rates as well as smoking incidence between the included individual studies.

Development of Risk Stratification Predictive Models for Cervical Deformity Surgery

BACKGROUND

As corrective surgery for cervical deformity (CD) increases, so does the rate of complications and reoperations. To minimize suboptimal postoperative outcomes, it is important to develop a tool that allows for proper preoperative risk stratification.

OBJECTIVE

To develop a prognostic utility for identification of risk factors that lead to the development of major complications and unplanned reoperations.

METHODS

CD patients age 18 years or older were stratified into 2 groups based on the postoperative occurrence of a revision and/or major complication. Multivariable logistic regressions identified characteristics that were associated with revision or major complication. Decision tree analysis established cutoffs for predictive variables. Models predicting both outcomes were quantified using area under the curve (AUC) and receiver operating curve characteristics.

RESULTS

A total of 109 patients with CD were included in this study. By 1 year postoperatively, 26 patients experienced a major complication and 17 patients underwent a revision. Predictive modeling incorporating preoperative and surgical factors identified development of a revision to include upper instrumented vertebrae > C5, lowermost instrumented vertebrae > T7, number of unfused lordotic cervical vertebrae > 1, baseline T1 slope > 25.3°, and number of vertebral levels in maximal kyphosis > 12 (AUC: 0.82). For developing a major complication, a model included a current smoking history, osteoporosis, upper instrumented vertebrae inclination angle < 0° or > 40°, anterior diskectomies > 3, and a posterior Smith Peterson osteotomy (AUC: 0.81).

CONCLUSION

Revisions were predicted using a predominance of radiographic parameters while the occurrence of major complications relied on baseline bone health, radiographic, and surgical characteristics.

Tobacco Use Is Associated With Increased 90-Day Readmission Among Patients Undergoing Surgery for Degenerative Spine Disease

STUDY DESIGN

Retrospective database study.

OBJECTIVE

Tobacco use is associated with complications after surgical procedures, including poor wound healing, surgical site infections, and cardiovascular events. We used the Nationwide Readmissions Database (NRD) to determine if tobacco use is associated with increased 30- and 90-day readmission among patients undergoing surgery for degenerative spine disorders.

METHODS

Patients who underwent elective spine surgery were identified in the NRD from 2010 to 2014. The study population included patients with degenerative spine disorders treated with discectomy, fusion, or decompression. Descriptive and multivariate logistic regression analyses were performed to identify patient and hospital factors associated with 30- and 90-day readmission, with significance set at P value <.001.

RESULTS

Within 30 days, 4.8% of patients were readmitted at a median time of 9 days. The most common reasons for 30-day readmission were postoperative infection (12.5%), septicemia (3.5%), and postoperative pain (3.0%). Within 90 days, 7.3% were readmitted at a median time of 18 days. The most common reasons for 90-day readmission were postoperative infection (9.6%), septicemia (3.5%), and pneumonia (2.3%). After adjustment for patient and hospital characteristics, tobacco use was independently associated with readmission at 90 days (odds ratio 1.05, 95% confidence interval 1.03-1.07, P < .0001) but not 30 days (odds ratio 1.02, 95% confidence interval 1.00-1.05, P = .045).

CONCLUSIONS

Tobacco use is associated with readmission within 90 days after cervical and thoracolumbar spine surgery for degenerative disease. Tobacco use is a known risk factor for adverse health events and therefore should be considered when selecting patients for spine surgery.

Smoking Is Associated With Lower Satisfaction in Nondiabetic Patients Undergoing Minimally Invasive Single-level Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

This was a retrospective review of prospectively collected registry data.

OBJECTIVE

The objective of this study was to investigate the effect of smoking on 2 years postoperative functional outcomes, satisfaction, and radiologic fusion in nondiabetic patients undergoing minimally invasive transforaminal lumbar interbody fusion (TLIF) for degenerative spine conditions.

SUMMARY OF BACKGROUND DATA

There is conflicting data on the effect of smoking on long-term functional outcomes following lumbar fusion. Moreover, there remains a paucity of literature on the influence of smoking within the field of minimally invasive spine surgery.

METHODS

Prospectively collected registry data of nondiabetic patients who underwent primary single-level minimally invasive TLIF in a single institution was reviewed. Patients were stratified based on smoking history. All patients were assessed preoperatively and postoperatively using the Numerical Pain Rating Scale for back pain and leg pain, Oswestry Disability Index, Short-Form 36 Physical and Mental Component Scores. Satisfaction was assessed using the North American Spine Society questionnaire. Radiographic fusion rates were compared.

RESULTS

In total, 187 patients were included, of which 162 were nonsmokers, and 25 had a positive smoking history. In our multivariate analysis, smoking history was insignificant in predicting for minimal clinically important difference attainment rates in Physical Component Score and fusion grading outcomes. However, in terms of satisfaction score, positive smoking history remained a significant predictor (odds ratio=4.7, 95% confidence interval: 1.10-20.09, P=0.036).

CONCLUSIONS

Nondiabetic patients with a positive smoking history had lower satisfaction scores but comparable functional outcomes and radiologic fusion 2 years after single-level TLIF. Thorough preoperative counseling and smoking cessation advice may help to improve patient satisfaction following minimally invasive spine surgery.

LEVEL OF EVIDENCE

Level III-nonrandomized cohort study.

The impact of smoking on outcomes following anterior cervical fusion-nonfusion hybrid surgery: a retrospective single-center cohort study

BACKGROUND

There is mixed evidence for the impact of cigarette smoking on outcomes following anterior cervical surgery. It has been reported to have a negative impact on healing after multilevel anterior cervical discectomy and fusion, however, segmental mobility has been suggested to be superior in smokers who underwent one- or two-level cervical disc replacement. Hybrid surgery, including anterior cervical discectomy and fusion and cervical disc replacement, has emerged as an alternative procedure for multilevel cervical degenerative disc disease. This study aimed to examine the impact of smoking on intermediate-term outcomes following hybrid surgery.

METHODS

Radiographical and clinical outcomes of 153 patients who had undergone continuous two- or three-level hybrid surgery were followed-up to a minimum of 2-years post-operatively. The early fusion effect, 1-year fusion rate, the incidence of bone loss and heterotopic ossification, as well as the clinical outcomes were compared across three smoking status groups: (1) current smokers; (2) former smokers; (3) nonsmokers.

RESULTS

Clinical outcomes were comparable among the three groups. However, the current smoking group had a poorer early fusion effect and 1-year fusion rate (P < 0.001 and P < 0.035 respectively). Both gender and smoking status were considered as key factors for 1-year fusion rate. Upon multivariable analysis, male gender (OR = 6.664, 95% CI: 1.248-35.581, P = 0.026) and current smoking status (OR = 0.009, 95% CI: 0.020-0.411, P = 0.002) were significantly associated with 1-year fusion rate. A subgroup analysis demonstrated statistically significant differences in both early fusion process (P < 0.001) and the 1-year fusion rate (P = 0.006) across the three smoking status groups in female patients. Finally, non-smoking status appeared to be protective against bone loss (OR = 0.427, 95% CI: 0.192-0.947, P = 0.036), with these patients likely to have at least one grade lower bone loss than current smokers.

CONCLUSIONS

Smoking is associated with poor outcomes following hybrid surgery for multilevel cervical disc disease. Current smokers had the poorest fusion rate and most bone loss, but no statistically significant differences were seen in clinical outcomes across the three groups.

Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery.

PURPOSE

This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program.

STUDY DESIGN

This is a review article.

METHODS

Under the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature.

RESULTS

Two hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented.

CONCLUSION

Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion.

The influence of smoking in minimally invasive spinal fusion surgery

Background

The impact of smoking on spinal surgery has been studied extensively, but few investigations have focused on minimally invasive surgery (MIS) of the spine and the difference between complication rates in smokers and non-smokers. We evaluated whether a history of at least one pack-year preoperatively could be used to predict adverse peri- and postoperative outcomes in patients undergoing minimally invasive fusion procedures of the lumbar spine. In a prospective study, we assessed the clinical effectiveness of MIS in an unselected population of 187 patients.

Methods

We evaluated perioperative and postoperative complication rates in MIS fusion techniques of the lumbar spine in smoking and non-smoking patients. MIS fusion was performed using interbody fusion procedures and/or posterolateral fusion alone.

Results

Smokers were significantly younger than non-smokers. We did not encounter infection at the site of surgery or severe wound healing disorder in smokers. We registered no difference between the smoking and non-smoking groups with regard to peri- or postoperative complication rate, blood loss, or length of stay in hospital. We found a significant influence of smoking (p = 0.049) on the overall perioperative complication rate.

Conclusion

MIS fusion techniques seem to be a suitable tool for treating degenerative spinal disorders in smokers.

No Difference in Functional Outcome but Higher Revision Rate Among Smokers Undergoing Cervical Artificial Disc Replacement: Analysis of a Spine Registry

BACKGROUND

Smoking is a known predictor of negative outcomes in spinal surgery. However, its effect on the functional outcomes and revision rates after ADR is not well-documented. This study is a retrospective analysis of prospectively collected data at a major tertiary center. The objective was to elucidate the impact of smoking on functional outcomes in cervical artificial disc replacement (ADR).

METHODS

Patients who underwent cervical ADR for myelopathy or radiculopathy from 2004 to 2015 with a minimum of 2 years of follow-up were included in the study. Patient function was assessed using Short Form-36 (SF-36), American Association of Orthopaedic Surgery (AAOS) cervical spine, and Japanese Orthopaedic Association (JOA) scoring systems preoperatively and at 2 years postoperatively. Incidence of further surgery on affected and adjacent segments was analyzed as well.

RESULTS

A total of 137 patients were included in the study, consisting of 117 nonsmokers and 20 smokers. There were 60 patients who presented with myelopathy and 77 with radiculopathy. The mean age of smokers was 42.6 years, compared with 46.4 years in the nonsmoker group (P < .01). Statistical improvement was noted in postoperative range of motion, as well as AAOS, SF-36, and JOA scores in both groups, with no difference between groups at 2 years of follow-up. A total of 84.2% of nonsmokers and 87.5% of smokers reported as surgery having met their expectations. A total of 5 of 117 nonsmokers (5.1%) and 4 of 20 smokers (20%) needed revision surgery (P = .018). Three of the 4 smokers who required surgery for adjacent or multisegment disease, whereas only 2 of the nonsmokers needed an operation for adjacent segment disease.

CONCLUSIONS

Our analysis indicates that there is no difference in functional outcome or patient satisfaction between smokers and nonsmokers. Smokers have a higher chance of revision surgery after an artificial disc replacement compared with nonsmokers at 2 years.

LEVEL OF EVIDENCE

3.

Effects of smoking on pedicle screw-based dynamic stabilization: radiological and clinical evaluations of screw loosening in 306 patients

OBJECTIVE

Cigarette smoking has been known to increase the risk of pseudarthrosis in spinal fusion. However, there is a paucity of data on the effects of smoking in dynamic stabilization following lumbar spine surgery. This study aimed to investigate the clinical outcomes and the incidence of screw loosening among patients who smoked.

METHODS

Consecutive patients who had lumbar spondylosis, recurrent disc herniations, or low-grade spondylolisthesis that was treated with 1- or 2-level surgical decompression and pedicle screw-based Dynesys dynamic stabilization (DDS) were retrospectively reviewed. Patients who did not complete the minimum 2 years of radiological and clinical evaluations were excluded. All screw loosening was determined by both radiographs and CT scans. Patient-reported outcomes, including visual analog scale (VAS) scores of back and leg pain, Japanese Orthopaedic Association (JOA) scores, and Oswestry Disability Index (ODI), were analyzed. Patients were grouped by smoking versus nonsmoking, and loosening versus intact screws, respectively. All radiological and clinical outcomes were compared between the groups.

RESULTS

A total of 306 patients (140 women), with a mean age of 60.2 ± 12.5 years, were analyzed during an average follow-up of 44 months. There were 34 smokers (9 women) and 272 nonsmokers (131 women, 48.2% more than the 26.5% of smokers, p = 0.017). Postoperatively, all the clinical outcomes improved (e.g., VAS back and leg pain, JOA scores, and ODI, all p < 0.001). The overall rate of screw loosening was 23.2% (71 patients), and patients who had loosened screws were older (61.7 ± 9.6 years vs 59.8 ± 13.2 years, p = 0.003) and had higher rates of diabetes mellitus (33.8% vs 21.7%, p = 0.038) than those who had intact DDS screws. Although the patients who smoked had similar clinical improvement (even better VAS scores in their legs, p = 0.038) and a nonsignificantly lower rate of screw loosening (17.7% and 23.9%, p = 0.416), the chances of secondary surgery for adjacent segment disease (ASD) were higher than for the nonsmokers (11.8% vs 1.5%, p < 0.001).

CONCLUSIONS

Smoking had no adverse effects on the improvements of clinical outcomes in the pedicle screw-based DDS surgery. For smokers, the rate of screw loosening trended lower (without significance), but the chances of secondary surgery for ASD were higher than for the nonsmoking patients. However, the optimal surgical strategy to stabilize the lumbar spine of smoking patients requires future investigation.

Risk Factors for Wound-Related Complications After Surgery for Primary and Metastatic Spine Tumors: A Systematic Review and Meta-Analysis

OBJECTIVE

We systematically reviewed the literature to compare risk factors for postoperative complications at the surgical wound site in primary and metastatic tumor operations.

METHODS

We screened English-language publications on the outcomes of primary and metastatic spinal tumor operations. Pooled analyses and meta-analyses with random-effects modeling were performed comparing patients with and without wound complications, which were defined as surgical site infection or sterile wound dehiscence.

RESULTS

Our search identified 5471 unique citations, from which we included 23 studies describing 5104 patients. A total of 1936 patients underwent surgery for primary tumors, with a wound complication rate of 8.1%. Subgroup analysis of benign and malignant primary tumors yielded significantly different wound complication rates of 7.8% and 26.9%, respectively. The metastatic tumor cohort included 168 patients and a complication rate of 6.6%. In a pooled analysis of primary tumors, higher wound complication rates were associated with sacral operations and the use of instrumentation. In the metastatic tumor cohort, higher complication rates were associated with female sex, smoking history, preoperative chemotherapy, preoperative radiotherapy, corticosteroid use, and previous spine surgery. Instrumentation remained a statistically significant risk factor for primary tumors with the addition of random-effects meta-analysis.

CONCLUSIONS

Risk factors for wound complications after primary tumor operations were related to tumor histology and the spinal location of the operation. Risk factors for metastatic tumors may be related to several systemic preoperative treatments and baseline comorbidities. Random-effects meta-analysis showed the limited generalizability of these findings because of the small heterogenous primary literature.

The Effect of Tobacco Smoking on Adverse Events Following Adult Complex Deformity Surgery: Analysis of 270 Patients From the Prospective, Multicenter Scoli-RISK-1 Study

STUDY DESIGN

Post-hoc analysis of a prospective, multicenter cohort study.

OBJECTIVE

To analyze the impact of smoking on rates of postoperative adverse events (AEs) in patients undergoing high-risk adult spine deformity surgery.

SUMMARY OF BACKGROUND DATA

Smoking is a known predictor of medical complications after adult deformity surgery, but the effect on complications, implant failure and other AEs has not been adequately described in prospective studies.

METHODS

Twenty-six patients with a history of current smoking were identified out of the 272 patients enrolled in the SCOLI-RISK-1 study who underwent complex adult spinal deformity surgery at 15 centers, with 2-year follow-up. The outcomes and incidence of AEs in these patients were compared to the nonsmoking cohort (n = 244) using univariate analysis, with additional multivariate regression to adjust for the effect of patient demographics, complexity of surgery, and other confounders.

RESULTS

The number of levels and complexity of surgery in both cohorts were comparable. In the univariate analysis, the rates of implant failure were almost double (odds ratio 2.28 [0.75-6.18]) in smoking group (n = 7; 26.9%)) that observed in the nonsmoking group (n = 34; 13.9%), but this was not statistically significant (P = 0.088). Surgery-related excessive bleeding (>4 L) was significantly higher in the smoking group (n = 5 vs. n = 9; 19.2% vs. 3.7%; OR 6.22[1.48 - 22.75]; P = 0.006). Wound infection rates and respiratory complications were similar in both groups. In the multivariate analysis, the smoking group demonstrated a higher incidence of any surgery-related AEs over 2 years (n = 13 vs. n = 95; 50.0% vs. 38.9%; OR 2.12 [0.88-5.09]) (P = 0.094).

CONCLUSION

In this secondary analysis of patients from the SCOLI-RISK-1 study, a history of smoking significantly increased the risk of excessive intraoperative bleeding and nonsignificantly increased the rate of implant failure or surgery-related AEs over 2 years. The authors therefore advocate a smoking cessation program in patients undergoing complex adult spine deformity surgery.

LEVEL OF EVIDENCE

2.

The Effect of Tobacco Use on Postoperative Pain Following Anterior Cervical Discectomy and Fusion

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

To identify the differences in inpatient pain scores, narcotic consumption, and patient-reported outcomes (PROs) between tobacco users and nonusers following an anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Previous studies have investigated tobacco use as a risk factor for negative postsurgical outcomes following spine surgery; however, few studies have analyzed the effects of tobacco on pain following ACDF.

METHODS

Patients undergoing primary, 1-level, or 2-level ACDF were retrospectively reviewed and stratified by tobacco use at the time of surgery. Inpatient pain scores and narcotic consumption were collected. Neck Disability Index and Visual Analogue Scale (VAS) neck and arm pain scores were collected preoperatively and at 6-week, 3-month, and 6-month follow-up visits. Differences in demographics and perioperative characteristics were assessed using χ analysis and multivariate linear regression. An association between immediate postoperative pain, narcotics consumption, and long-term PROs was tested for using multivariate linear regression.

RESULTS

A total of 192 patients were included and stratified by tobacco use: tobacco (n=25) and nontobacco (n=167). There were no significant differences in demographic and perioperative characteristics. No statistical differences were observed in inpatient VAS pain scores and narcotic consumption on postoperative day 0 and postoperative day 1. Preoperative VAS neck pain and arm pain was greater in tobacco users, however, improvements in neck and arm pain were similar in the postoperative period through 6-month follow-up. In addition, no statistical differences in Neck Disability Index were observed preoperatively or at any postoperative time points.

CONCLUSIONS

Our study suggests that tobacco use does not influence inpatient pain scores, narcotic consumption, and improvements in PROs following ACDF. As such, tobacco users and nonusers should receive similar postoperative pain management protocols following surgery.

LEVEL OF EVIDENCE

Level III.

Non-medical factors significantly influence the length of hospital stay after surgery for degenerative spine disorders

BACKGROUND

Unnecessarily long hospital stays are costly and inefficient. Studies have shown that the length of hospital stay (LOS) for spine surgical procedures is influenced by various disease-related or medical factors, but few have examined the role of socio-demographic/socio-economic (SDE) factors.

METHODS

This was a retrospective analysis of data from 10,770 patients (5056 men, 5714 women; 62 ± 15 years) with degenerative spinal disorders, collected prospectively in an in-house database within the framework of EUROSPINE's Spine Tango Registry. Surgeons completed the Tango surgery form (clinical history, demographics, surgical measures, complications), and patients, a baseline Core Outcome Measures Index. Stepwise linear regression analyses examined SDE predictors of LOS, controlling for potential medical/biological factors.

RESULTS

The mean LOS was 7.9 ± 5.2 days. The final model accounted for 42% of variance in LOS, with SDE variables explaining 13% variance and medical/surgical predictors, 29%. In the final model, the SDE factors age and being female were significant independent predictors of LOS, whereas others were either non-significant (insurance status, being of Swiss nationality, being a smoker) or reached only borderline significance (p < 0.1) (BMI). Controlling for all other SDE and medical/surgical confounders, being female was associated with 1.11-day longer LOS (95% CI 0.96-1.27; p < 0.0001).

CONCLUSIONS

Patients of advanced age and female gender are at increased risk of longer hospital stay after surgery for degenerative spinal disorders. Further studies should seek to understand the reasoning behind the gender disparity, in order to minimise potentially unnecessary costs of prolonged LOS. Targeted preoperative discharge planning may improve the utilisation of hospital resources. These slides can be retrieved under Electronic Supplementary Material.

Effects of active smoking on postoperative outcomes in hospitalised patients undergoing elective surgery: a retrospective analysis of an administrative claims database in Japan

OBJECTIVES

The purpose of this study was to investigate the effects of smoking on prognosis after elective surgeries. Incidence of 30-day postoperative complications was compared between propensity score-matched 'ever-smoker' and 'never-smoker' cohorts. Thirty-day mortality and medical costs during the hospital stay were also compared.

DESIGN AND SETTING

A large-scale retrospective study using deidentified administrative claims data obtained from 372 acute care hospitals across Japan using the Diagnosis Procedure Combination system (ie, a flat-fee payment system).

PARTICIPANTS

Inpatients who were hospitalised to undergo elective surgery.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint of this study was incidence of 30-day postoperative complications. Secondary endpoints were 30-day mortality and total medical costs during hospitalisation. Comparison between ever-smokers and never-smokers was conducted using matched cohorts created by 1:1 propensity score matching.

RESULTS

Using 561 598 eligible patients, matched ever-smoker and never-smoker cohorts (n=1 55 593 each) were created. Ever-smokers were defined as patients with Brinkman Index ≥1. The percentage of patients who were male was 76.7%, and mean ages for ever-smokers and never-smokers were 65.1±13.8 years old and 66.4±15.3 years old, respectively. The Brinkman Index of the ever-smoker cohort was 677.6±553.4. Smoking was significantly associated with higher risk of 30-day postoperative complications compared with not smoking (OR 1.15, 95% CI 1.13 to 1.17, p<0.001). Similarly, smoking was significantly associated with postoperative 30-day mortality, with OR of 1.22 (95% CI 1.08 to 1.39, p=0.002).

CONCLUSIONS

Our results suggest that smoking could be associated with risk of poor postoperative outcomes. In particular, a history of smoking may increase the risk of 30-day postoperative complications as well as that of 30-day mortality. The results suggest that smoking might have a harmful effect on postoperative outcomes irrespective of types of surgery.

The Role of Potentially Modifiable Factors in a Standard Work Protocol to Decrease Complications in Adult Spinal Deformity Surgery: A Systematic Review, Part 1

STUDY DESIGN

Structured Literature Review.

OBJECTIVES

We sought to evaluate the peer-reviewed literature for potentially modifiable patient and surgical factors that could be incorporated into a Standard Work protocol to decrease complications in adult spinal deformity (ASD) surgery.

SUMMARY OF BACKGROUND DATA

Lean Methodology uses Standard Work to improve efficiency and decrease waste and error. ASD is known to have a high surgical complication rate. Several patient and surgical potentially modifiable factors have been suggested to affect complications, including preoperative hemoglobin, bone density, body mass index (BMI), age-appropriate realignment, preoperative albumin/prealbumin, and smoking status. We sought to evaluate the literature for evidence supporting these factors to include in a Standard Work protocol to decrease complications.

METHODS

Each of these six factors was developed into an appropriate clinical question that included the patient population, surgical intervention, a comparison group, and outcomes measure (PICO question). A comprehensive literature search was then performed. The authors reviewed abstracts and analyzed data from included studies. From 456 initial citations with abstract, 173 articles underwent full-text review. The best available evidence for clinical questions regarding the influence of these factors was provided by 93 included studies.

RESULTS

We found fair evidence supporting a low preoperative hemoglobin level associated with increased transfusion rates and decreased BMD and increased BMI associated with increased complication rates. Fair evidence supported low albumin/prealbumin associated with increased complications. There was fair evidence associating smoking exposure to increased reoperations, but conflicting evidence associating it with increased complications. There was no evidence in the literature evaluating age-appropriate realignment and complications.

CONCLUSION

Preoperative hemoglobin, bone density, body mass index, preoperative albumin/prealbumin, and smoking status all are potentially modifiable risk factors that are associated with increased complications in the adult spine surgery population. Developing a Standard Work Protocol for patient evaluation and optimization should include these factors.

LEVEL OF EVIDENCE

Level II.

Associations between smoking and postoperative complications following elective craniotomy

BACKGROUND

Evidence of postoperative complications associated with smoking has varied. We conducted this study to clarify the relationships between tobacco smoking and postoperative complications following craniotomy.

METHODS

A retrospective cohort analysis identified 800 patients who underwent cranial surgery with general anesthesia at a medical center with 2,700 beds in Seoul, Korea between January and December 2011.

RESULTS

Prior smokers (34.8%) and current smokers (35.1%) were hospitalized for at least 11 days longer than never smokers (25.5%) (x2 = 6.74, p = 0.036). There were no statistically significant differences in the incidence of postoperative complications among never smokers (5.2%), prior smokers (9.6%), and current smokers (9.6%). The incidences of postoperative complications among prior smokers (9.6%) and current smokers (9.6%) were similar. Comparisons between never smokers (25.5%) and current smokers (34.9%) showed smokers had longer hospital stays and a higher incidence of complications (x2 = 6.74, p = 0.012). The incidence of major complications (x2 = 5.27, p = 0.024) and overall complications (x2 = 4.84, p = 0.033) were also significantly higher among smokers than never smokers. The impact of smoking status on postoperative complications was not identified.

CONCLUSIONS

We found significant associations between smoking status and postoperative complications. The incidence of major complications was twice as high among smokers as among never smokers. Therefore, it is recommended to continuously monitor current smokers to prevent postoperative complications after craniotomy.

Effect of various durations of smoking cessation on postoperative outcomes: A retrospective cohort analysis

BACKGROUND

Preoperative smoking cessation is commonly advised in an effort to improve postoperative outcomes. However, it remains unclear for how long smoking cessation is necessary, and even whether a brief preoperative period of abstinence is helpful and well tolerated.

OBJECTIVE

We evaluated associations between various periods of preoperative smoking cessation and major morbidity and death.

DESIGN

Retrospective cohort analysis.

SETTING

Adults who had noncardiac surgery at the Cleveland Clinic Main Campus between May 2007 and December 2013.

PATIENTS

A total of 37 511 patients whose smoking history was identified from a preoperative Health Quest questionnaire. Of these patients, 26 269 (70%) were former smokers and 11 242 (30%) were current smokers. Of the current smokers, 9482 (84%) were propensity matched with 9482 former smokers (36%). We excluded patients with American Society of Anesthesiologists' physical status exceeding four, patients who did not have general anaesthesia, and patients with missing outcomes and/or covariables. When multiple procedures were performed within the study period, only the first operation for each patient was included in the analysis.

MAIN OUTCOME MEASURES

The relationship between smoking cessation and in-hospital morbidity/mortality.

RESULTS

The incidence of the primary composite of in-hospital morbidity/mortality was 6.9% (656/9482) for all former smokers; the incidence was 7.8% (152/1951) for patients who stopped smoking less than 1 year before surgery, 6.3% (118/1977) for 1 to 5 years, 7.2% (115/1596) for 5 to 10 years and 6.9% (271/3457) for more than 10 years.

CONCLUSION

Smoking cessation was associated with reduced in-hospital morbidity and mortality which was independent of cessation interval.

Platelet count abnormalities and peri-operative outcomes in adults undergoing elective, non-cardiac surgery

BACKGROUND

Anemia and transfusion of blood in the peri-operative period have been shown to be associated with increased morbidity and mortality across a wide variety of non-cardiac surgeries. While tests of coagulation, including the platelet count, have frequently been used to identify patients with an increased risk of peri-operative bleeding, results have been equivocal. The aim of this study was to assess the effect of platelet level on outcomes in patients undergoing elective surgery.

MATERIALS AND METHODS

Retrospective cohort analysis of prospectively-collected clinical data from American College of Surgeons National Surgical Quality Improvement Program (NSQIP) between 2006-2016.

RESULTS

We identified 3,884,400 adult patients who underwent elective, non-cardiac surgery from 2006-2016 at hospitals participating in NSQIP, a prospectively-collected, national clinical database with established reproducibility and validity. After controlling for all peri- and intraoperative factors by matching on propensity scores, patients with all levels of thrombocytopenia or thrombocytosis had higher odds for perioperative transfusion. All levels of thrombocytopenia were associated with higher mortality, but there was no association with complications or other morbidity after matching. On the other hand, thrombocytosis was not associated with mortality; but odds for postoperative complications and 30-day return to the operating room remained slightly increased after matching.

CONCLUSIONS

These findings may guide surgeons in the appropriate use and appreciation of the utility of pre-operative screening of the platelet count prior to an elective, non-cardiac surgery.

Effects of smoking on cervical disc arthroplasty

Objective

Cigarette smoking can adversely affect bone fusion in patients who undergo anterior cervical discectomy and fusion. However, there is a paucity of data on smoking among patients who have undergone cervical disc arthroplasty (CDA). The present study aimed to compare the clinical and radiological outcomes of smokers to those of nonsmokers following CDA.

Methods

The authors retrospectively reviewed the records of consecutive patients who had undergone 1- or 2-level CDA for cervical disc herniation or spondylosis and had a minimum 2-year follow-up. All patients were grouped into a smoking group, which consisted of those who had consumed cigarettes within 6 months prior to the CDA surgery, or a nonsmoking group, which consisted of those who had not consumed cigarettes at all or within 6 months of the CDA. Clinical outcomes were evaluated according to the visual analog scale for neck and arm pain, Neck Disability Index, Japanese Orthopaedic Association Scale, and Nurick Scale at each time point of evaluation. Radiological outcomes were assessed using radiographs and CT for multiple parameters, including segmental range of motion (ROM), neutral lordotic curve, and presence of heterotopic ossification (HO).

Results

A total of 109 patients completed at least 2 years of follow-up and were analyzed (mean follow-up 42.3 months). There were 89 patients in the nonsmoking group and 20 in the smoking group. The latter group was younger and predominantly male (both p < 0.05) compared to the nonsmoking group. The two groups had similar improvements in all clinical outcomes after CDA compared to preoperatively. Radiological evaluations were also very similar between the two groups, except for two factors. The smoking group had well-preserved segmental ROM after CDA at an average of 8.1° (both pre- and postoperation). However, while the nonsmoking group remained mobile, segmental ROM decreased significantly (8.2° to 6.9°, p < 0.05) after CDA. There was a trend toward more HO development in the nonsmoking group than in the smoking group, but the difference was without significance (59.6% vs 50.0%, p = 0.43).

Conclusions

During an average 3.5 years of follow-up after 1- and 2-level CDA, cigarette smokers and nonsmokers had similar improvements in clinical outcomes. Moreover, segmental mobility was slightly better preserved in smokers. Since smoking status did not negatively impact outcomes, CDA may be a reasonable option for selected patients who have smoked.

Abbreviations

ACDF = anterior cervical discectomy and fusion; ASD = adjacent-segment degeneration; CDA = cervical disc arthroplasty; FDA = Food and Drug Administration; HO = heterotopic ossification; JOA = Japanese Orthopaedic Association; NDI = Neck Disability Index; ROM = range of motion; VAS = visual analog scale.

The Effect of Cigarette Smoking on Wound Complications After Single-Level Posterolateral and Interbody Fusion for Spondylolisthesis

OBJECTIVE

To evaluate the impact of cigarette smoking on the development of wound complications, including wound dehiscence, superficial infection, deep infection, or organ space infection, within the first 30 postoperative days in patients undergoing surgery for spondylolisthesis.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for the years 2012-2014 was used to identify adult patients who underwent single-level posterolateral fusion (PLF) or interbody fusion for spondylolisthesis. Wound complications occurring within 30 days were compared between current smokers and nonsmokers.

RESULTS

A total of 1688 patients who underwent single-level PLF or interbody fusion for spondylolisthesis were identified, among whom 271 were current smokers (16.1%). The overall wound complication rate was 3.3% for smokers versus 1.8% for nonsmokers (P = 0.095). When stratified by operative technique, the rate of wound complications was not significantly different between smokers and nonsmokers undergoing PLF (2.4% vs. 2.6%; P = 1.00); however, smokers who underwent interbody fusion were more likely to experience a wound complication compared with nonsmokers undergoing interbody fusion (3.7% vs. 1.3%; P = 0.028). On multivariate analysis, smoking was an independent predictor of organ/space infection irrespective of fusion technique used (odds ratio, 15.4; 95% confidence interval, 1.34-175.4; P = 0.028).

CONCLUSIONS

The rate of wound complications was not higher in smokers undergoing PLF alone, but was significantly higher in smokers who underwent interbody fusion. However, multivariate analysis identified smoking as an independent predictor of organ/space infection irrespective of fusion technique used.

Patient characteristics of smokers undergoing lumbar spine surgery: an analysis from the Quality Outcomes Database

OBJECTIVE

In this analysis the authors compare the characteristics of smokers to nonsmokers using demographic, socioeconomic, and comorbidity variables. They also investigate which of these characteristics are most strongly associated with smoking status. Finally, the authors investigate whether the association between known patient risk factors and disability outcome is differentially modified by patient smoking status for those who have undergone surgery for lumbar degeneration.

METHODS

A total of 7547 patients undergoing degenerative lumbar surgery were entered into a prospective multicenter registry (Quality Outcomes Database [QOD]). A retrospective analysis of the prospectively collected data was conducted. Patients were dichotomized as smokers (current smokers) and nonsmokers. Multivariable logistic regression analysis fitted for patient smoking status and subsequent measurement of variable importance was performed to identify the strongest patient characteristics associated with smoking status. Multivariable linear regression models fitted for 12-month Oswestry Disability Index (ODI) scores in subsets of smokers and nonsmokers was performed to investigate whether differential effects of risk factors by smoking status might be present.

RESULTS

In total, 18% (n = 1365) of patients were smokers and 82% (n = 6182) were nonsmokers. In a multivariable logistic regression analysis, the factors significantly associated with patients’ smoking status were sex (p < 0.0001), age (p < 0.0001), body mass index (p < 0.0001), educational status (p < 0.0001), insurance status (p < 0.001), and employment/occupation (p = 0.0024). Patients with diabetes had lowers odds of being a smoker (p = 0.0008), while patients with coronary artery disease had greater odds of being a smoker (p = 0.044). Patients’ propensity for smoking was also significantly associated with higher American Society of Anesthesiologists (ASA) class (p < 0.0001), anterior-alone surgical approach (p = 0.018), greater number of levels (p = 0.0246), decompression only (p = 0.0001), and higher baseline ODI score (p < 0.0001). In a multivariable proportional odds logistic regression model, the adjusted odds ratio of risk factors and direction of improvement in 12-month ODI scores remained similar between the subsets of smokers and nonsmokers.

CONCLUSIONS

Using a large, national, multiinstitutional registry, the authors described the profile of patients who undergo lumbar spine surgery and its association with their smoking status. Compared with nonsmokers, smokers were younger, male, nondiabetic, nonobese patients presenting with leg pain more so than back pain, with higher ASA classes, higher disability, less education, more likely to be unemployed, and with Medicaid/uninsured insurance status. Smoking status did not affect the association between these risk factors and 12-month ODI outcome, suggesting that interventions for modifiable risk factors are equally efficacious between smokers and nonsmokers.

The Effect of Smoking on Spinal Fusion

BACKGROUND

Spinal fusion surgery is performed about half a million times per year in the United States and millions more worldwide. It is an effective method for reducing pain, increasing stability, and correcting deformity in patients with various spinal conditions. In addition to being a well-established risk factor for a variety of medical conditions, smoking has deleterious effects on the bone healing of spinal fusions. This review aims to specifically analyze the ways in which smoking affects the outcomes of spinal fusion and to explore ways in which these negative consequences can be avoided.

PURPOSE

This article provides a complete understanding of the ways smoking affects spinal fusion from a biochemical and clinical perspective. Recommendations are also provided for ways in which surgeons can limit patient exposure to the most serious negative outcomes associated with cigarette smoking.

STUDY DESIGN/SETTING

This study was a retrospective literature review done using the NCBI database. The research was compiled at NYU Hospital for Joint Diseases and the NYU Center for Musculoskeletal Care.

METHODS

A comprehensive literature review was done spanning research on a variety of subjects related to smoking and spinal fusion surgery. The biochemistry of smoking and fusion healing were examined in great detail. In addition, both in vivo animal studies and human clinical studies were evaluated to explore fusion success related to the effects of smoking and its biochemical factors on spinal fusion surgery.

RESULTS

Smoking significantly increases the risk of pseudoarthrosis for patients undergoing both lumbar and cervical fusions. In addition to nonunion, smoking also increases the risk of other perioperative complications such as infection, adjacent-segment pathology, and dysphagia. Treatment options are available that can be explored to reduce the risk of smoking-related morbidity, such as nicotine replacement therapy and use of bone morphogenetic proteins (BMPs).

CONCLUSIONS

It has been clearly demonstrated from both a biochemical and clinical perspective that smoking increases the rate of perioperative complications for patients undergoing spinal fusion surgery, particularly pseudoarthosis. It has also been shown that there are certain approaches that can reduce the risk of morbidity. The most important recommendation is smoking cessation for four weeks after surgery. In addition, patients may be treated with certain surgical techniques, including the use of BMPs, to reduce the risk of pseudoarthrosis. Lastly, nicotine replacement therapy is an area of continued interest in relation to spinal fusion outcomes and more research needs to be done to determine its efficacy moving forward.

Reduced Impact of Smoking Status on 30-Day Complication and Readmission Rates After Elective Spinal Fusion (≥3 Levels) for Adult Spine Deformity: A Single Institutional Study of 839 Patients

BACKGROUND

Smoking status has been shown to affect postoperative outcomes after surgery. The aim of this study was to determine whether patients' smoking status impacts 30-day complication and readmission rates after elective complex spinal fusion (≥3 levels).

METHODS

The medical records of 839 adult spinal deformity patients undergoing elective complex spinal fusion (≥3 levels) at a major academic institution from 2005 to 2015 were reviewed. We identified 124 (14.8%) smokers and 715 (85.2%) nonsmokers. Patient demographics, comorbidities, intraoperative and postoperative complications, and 30-day readmission rates were collected for each patient. The primary outcome investigated in this study was the rate of 30-day postoperative complication and readmission rates.

RESULTS

Patient demographics and comorbidities were similar between both groups, including age, sex, and body mass index. Median [interquartile] number of fusion levels and operative time were similar between the cohorts (smoker: 5 [4-7] vs. nonsmoker: 5 [4-8], P = 0.58) and (smoker: 309.6 ± 157.9 minutes vs. nonsmoker: 287.5 ± 131.7 minutes, P = 0.16), respectively. Both cohorts had similar postoperative complication rates and lengths of hospital stay. There was no significant difference in 30-day readmission between the cohorts (smoker: 12.9% vs. nonsmoker: 10.8%, P = 0.48). There were no observed differences in 30-day complication rates, including pain (P = 0.46), UTI (P = 0.54), hardware failure (P = 0.36), wound dehiscence (P = 0.29), and wound drainage (P = 0.86). Smokers had greater rates of 30-day cellulitis (smoker: 1.6% vs. nonsmoker: 0.3%, P = 0.05) and DVT (smoker: 0.8% vs. nonsmoker: 0.0%, P = 0.02).

CONCLUSIONS

Our study suggests that smoking does not significantly affect 30-day readmission rates after complex spinal surgery requiring ≥3 levels of fusion. Further studies are necessary to corroborate our findings.

Impact of Smoking on 30-day Morbidity and Mortality in Adult Spinal Deformity Surgery

STUDY DESIGN

A retrospective cohort study of a prospectively collected surgical database.

OBJECTIVE

The aim of this study was to investigate the effect of smoking on 30-day morbidity and mortality in patients undergoing surgery for adult spinal deformity (ASD).

SUMMARY OF BACKGROUND DATA

There is conflicting evidence regarding the impact of smoking on short-term outcomes after spinal fusion.

METHODS

A retrospective review of the prospectively collected American College of Surgeons National Surgical Quality Improvement database was performed for the years 2007 to 2013. Patients who underwent spinal fusion for ASD were identified. Thirty-day morbidity and mortality were compared between current smokers and nonsmokers. The independent effect of smoking was investigated via multivariate logistic regression analysis.

RESULTS

A total of 1368 patients met inclusion criteria and were included in this study. Of the 1368 patients, 15.9% were smokers and 84.1% nonsmokers. The proportion of smokers who developed at least one complication was 9.7% versus 13.6% for nonsmokers (P = 0.119). Major complication rates (including 30-day mortality) were 6.5% for smokers and 8.4% for nonsmokers (P = 0.328). Current smoking status was not associated with increased odds of developing any complication [odds ratio (OR) 0.90; 95% confidence interval (95% CI), 0.47-1.71; P = 0.752] or major complications (OR 1.32; 95% CI 0.64-2.70; P = 0.447) after multivariate analysis.

CONCLUSION

Smoking was not associated with higher 30-day complications or mortality after corrective surgery for ASD in this study. However, given the negative effects of smoking on overall health and spine surgery outcomes in the long term, smoking cessation before spinal fusion is still recommended.

LEVEL OF EVIDENCE

3.

The Influence of Race on Short-term Outcomes After Laminectomy and/or Fusion Spine Surgery

STUDY DESIGN

A retrospective cohort analysis of prospectively collected clinical data.

OBJECTIVE

The aim of this study was to assess the effect of race on outcomes in patients undergoing elective laminectomy and/or fusion spine surgery.

SUMMARY OF BACKGROUND DATA

Studies that have looked at the effect of race on spine surgery outcomes have failed to take into account baseline risk factors that may influence peri-operative outcomes.

METHODS

We identified 48,493 adult patients who underwent elective spine surgery consisting of elective laminectomy and/or fusion, from 2006 to 2012, at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), a prospectively collected, national clinical database with established reproducibility and validity. Pre- and intraoperative characteristics and 30-day outcomes were stratified by race. We used propensity scores to match African-American and Caucasian patients on all pre- and intraoperative factors, including by principal diagnosis leading to surgery as well as surgery performed. We used regular and conditional logistic regression to predict the effect of race on adverse postoperative outcomes in the full sample and matched sample.

RESULTS

Caucasians comprised 82% of our sample. We found no differences in the incidence of pre- and intraoperative factors when comparing Caucasian patients with all minority patients, and only minimal increased odds for prolonged length of length of hospitalization (LOS) and discharge with continued care. However, African-American patients, who comprised 39% of our minority sample, had more preoperative comorbidities than Caucasian patients. Even after eliminating all differences between pre- and intraoperative factors between Caucasian and African-American patients, African-American patients continued to have LOS that was, on average, one day longer than Caucasian patients. African-American patients also had higher odds for major complications [odds ratio (OR) = 1.3; 95% confidence interval (95% CI) 1.1-1.6], and to be discharged requiring continued care (OR = 2.3; 95% CI 1.8-2.8).

CONCLUSION

African-American race is independently associated with prolonged LOS, major complications, and a need to be discharged with continued care in patients undergoing elective spine surgery.

LEVEL OF EVIDENCE

3.

Predictors of Discharge Destination After Lumbar Spine Fusion Surgery

STUDY DESIGN

Retrospective cohort study of the prospective collected American College of Surgeons National Surgical Quality Improvement Program database.

OBJECTIVE

The aim of the study was to identify predictive factors for the need of discharging patients to a facility other than home after lumbar spine fusion surgery.

SUMMARY OF BACKGROUND DATA

Lumbar spine fusion surgery is a common surgical procedure used to treat a variety of lumbar spine conditions. A great number of patients fail to go home after surgery and require admission to a rehabilitation center. Predictive factors for discharging patients to a facility other than home after lumbar fusion surgery do not exist in the literature.

METHODS

A total of 15,092 patients undergoing lumbar spine fusion were dichotomized based on discharge destination to patients who were discharged home (N = 12,339) and others who were discharged to a facility other than home (N = 2753). Outcomes included patient demographics, comorbidities, and clinical characteristics. A multivariate logistic regression was used to identify whether outcomes studied were predictive factors for discharging patients to a facility other than home after lumbar fusion surgery.

RESULTS

Majority of patients were discharged home after lumbar fusion surgery (81.76%), with only some discharged to a facility other than home (18.24%). Multivariate analysis identified age, female sex, comorbidities (diabetes, chronic obstructive pulmonary disease, congestive heart failure, hypertension, and obesity), minor and major complications, hospital length of stay, operative time at least 259 minutes, and multilevel surgery as significant predictive factors of discharging patients to a facility other than home after lumbar fusion surgery.

CONCLUSION

The identified predictive factors can help the health system in developing an algorithm for early recognition of patients requiring postoperative admission to a facility other than home and possibly decreasing their hospital length of stay. This can significantly decrease the hospital costs for such patients.

LEVEL OF EVIDENCE

3.

Impact of Gender on 30-Day Complications After Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective study of prospectively collected data.

OBJECTIVE

To determine if postoperative morbidity for patients undergoing spinal deformity surgery varies by sex.

SUMMARY OF BACKGROUND DATA

Influence of sex has been investigated in other surgical procedures but has not yet been studied in adult spinal deformity surgery.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent fusion for spinal deformity. Patients were separated into groups of male and female sex. Univariate analysis and multivariate logistic regression were used to analyze the effect of sex on the incidence of postoperative morbidity and mortality.

RESULTS

Female sex was found to be a predictor of any complication[odds ratio (OR): 1.4, 95% confidence interval (CI) 1.2-1.7, P < 0.0001], intra- or postoperative RBC transfusion (OR: 1.6, 95% CI 1.4-1.9, P < .0001), urinary tract infection (OR: 2.0, 95% CI 1.2-3.3, P = 0.0046), and length of stay >5 days (OR: 1.3, 95% CI 1.1-1.5, P = 0.0015). Male sex was associated with higher rate of pulmonary (2.9% vs. 2.0%, P = 0.0344) and cardiac complications (0.9% vs. 0.5%, P = 0.0497). However, male sex as an independent risk factor for pulmonary (OR: 1.4, 95% CI 1.0-2.1, P = 0.0715) and cardiac complications (OR: 1.9, 95% CI 0.9-4.0, P = 0.1076) did not reach significance.

CONCLUSION

Female sex was found to increase overall morbidity, particularly for urinary tract infection, transfusion, and length of stay >5 days. Male sex was associated with greater incidence of pulmonary and cardiac complications. Thus, sex and other patient characteristics highlighted must be considered as part of surgical risk planning and patient counseling.

LEVEL OF EVIDENCE

3.

The Impact of Current Smoking and Smoking Cessation on Short-Term Morbidity Risk After Lumbar Spine Surgery

STUDY DESIGN

A retrospective review of prospectively collected data.

OBJECTIVE

The aim of this study was to determine the impact of current smoking or prior smoking cessation on 30-day morbidity risk following lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Prior studies have reported conflicting data regarding the impact of smoking on morbidity risk, and few studies have investigated smoking cessation.

METHODS

A large, multicenter, prospectively collected clinical registry was queried for all adult patients undergoing lumbar spine surgery in 2012 and 2013, and 35,477 cases were identified. Morbidity data are collected by on-site clinical personnel for 30 days postoperatively. Patients were divided into categories of "never-smoker," for patients with no reported cigarette use (n = 27,246), "former smoker," for patients who quit smoking more than 12 months before surgery (n = 562), and "current smoker," for patients still using cigarettes (n = 7669). A univariate analysis was conducted to identify un-adjusted differences in morbidity risk, and a multivariate analysis was conducted in an attempt to control for confounders.

RESULTS

In the multivariate analysis, current smokers had a significantly higher risk of both superficial surgical site infection and overall wound complications, than never-smokers (P < 0.05 for each). Current smokers also had a significantly higher risk of total 30-day morbidity (P = 0.04). There was a trend toward former smokers also having an increased risk, but this did not reach significance in any category. Patients with a pack-year smoking history of 1 to 20 pack-years and more than 40 pack-years both had a significantly higher risk of superficial surgical site infections (P < 0.05 for each).

CONCLUSION

Current smoking is associated with a small but significant increase in systemic morbidity and wound complications following elective lumbar spine procedures. Increasing pack year history was also associated with wound complication risk, suggesting a dose-related effect. The data provide preliminary support for future studies on smoking cessation.

LEVEL OF EVIDENCE

3.

Increased Preoperative Narcotic Use and Its Association With Postoperative Complications and Length of Hospital Stay in Patients Undergoing Spine Surgery

STUDY DESIGN

Prospective cohort analysis.

OBJECTIVE

To assess the effect of preoperative narcotic use on the incidence of 30- and 90-day postoperative complications, as well as length of hospital stay (LOS) in patients undergoing spine surgery.

SUMMARY OF BACKGROUND DATA

Previous work has associated an increased incidence of complications and length of stay following surgery in patients with increased preoperative narcotic use. Despite this and recent national attention highlighting the negative effects of narcotics, they remain commonly used for the management of pain in patients undergoing spine surgery.

MATERIALS AND METHODS

A total of 583 patients undergoing spine surgery for a structural lesion were evaluated. Self-reported preoperative narcotic consumption was obtained and converted to morphine equivalents at the initial preoperative visit. LOS was recorded upon discharge and presence/type of a postoperative complication within 30/90 days was obtained. A multivariable logistic and linear regression analysis was performed for the incidence of complications and length of stay controlling for clinically important covariates.

RESULTS

Narcotic use was not associated with 30- or 90-day complications; however, smoking status was significantly associated with 30-day complications. Increased preoperative narcotic use was significantly associated with increased LOS, as was age, type of surgery, and depression.

CONCLUSIONS

Increased preoperative narcotic use and depression are associated with increased LOS in patients undergoing spine surgery. We calculated that for every 100 morphine equivalents a patient is taking preoperatively; their stay is extended 1.1 days. Narcotic use was not associated with 30- or 90-day postoperative complications. As reimbursement is bundled before surgery, providing interventions for patients with treatable causes for increased length of stay can save cost overall.

The National Neurosurgery Quality and Outcomes Database Qualified Clinical Data Registry: 2015 measure specifications and rationale

Meaningful quality measurement and public reporting have the potential to facilitate targeted outcome improvement, practice-based learning, shared decision making, and effective resource utilization. Recent developments in national quality reporting programs, such as the Centers for Medicare & Medicaid Services Qualified Clinical Data Registry (QCDR) reporting option, have enhanced the ability of specialty groups to develop relevant quality measures of the care they deliver. QCDRs will complete the collection and submission of Physician Quality Reporting System (PQRS) quality measures data on behalf of individual eligible professionals. The National Neurosurgery Quality and Outcomes Database (N2QOD) offers 21 non-PQRS measures, initially focused on spine procedures, which are the first specialty-specific measures for neurosurgery. Securing QCDR status for N2QOD is a tremendously important accomplishment for our specialty. This program will ensure that data collected through our registries and used for PQRS is meaningful for neurosurgeons, related spine care practitioners, their patients, and other stakeholders. The 2015 N2QOD QCDR is further evidence of neurosurgery’s commitment to substantively advancing the health care quality paradigm. The following manuscript outlines the measures now approved for use in the 2015 N2QOD QCDR. Measure specifications (measure type and descriptions, related measures, if any, as well as relevant National Quality Strategy domain[s]) along with rationale are provided for each measure.

Preoperative steroid use and the incidence of perioperative complications in patients undergoing craniotomy for definitive resection of a malignant brain tumor

We studied the impact of preoperative steroids on 30 day morbidity and mortality of craniotomy for definitive resection of malignant brain tumors. Glucocorticoids are used to treat peritumoral edema in patients with malignant brain tumors, however, prolonged (⩾ 10 days) use of preoperative steroids as a risk factor for perioperative complications following resection of brain tumors has not been studied comprehensively. Therefore, we identified 4407 patients who underwent craniotomy to resect a malignant brain tumor between 2007 and 2012, who were reported in the National Surgical Quality Improvement Program, a prospectively collected clinical database. Metastatic brain tumors constituted 37.5% (n=1611) and primary malignant gliomas 62.5% (n=2796) of the study population. We used logistic regression to assess the association between preoperative steroid use and perioperative complications before and after 1:1 propensity score matching. Patients who received steroids constituted 22.8% of the population (n=1009). In the unmatched cohort, steroid use was associated with decreased length of hospitalization (odds ratio [OR] 0.7; 95% confidence interval [CI] 0.6-0.8), however, the risk for readmission (OR 1.5; 95% CI 1.2-1.8) was increased. In the propensity score matched cohort (n=465), steroid use was not statistically associated with any adverse outcomes. Patients who received steroids were less likely to stay hospitalized for a protracted period of time, but were more likely to be readmitted after discharge following craniotomy. As an independent risk factor, preoperative steroid use was not associated with any observed perioperative complications. The findings of this study suggest that preoperative steroids do not independently compromise the short term outcome of craniotomy for resection of malignant brain tumors.

Impact of smoking on complication and pseudarthrosis rates after single- and 2-level posterolateral fusion of the lumbar spine

STUDY DESIGN

Retrospective study.

OBJECTIVE

To study the impact of smoking status on postoperative complications and pseudarthrosis in adult patients undergoing posterolateral fusion (PLF) of the lumbar spine.

SUMMARY OF BACKGROUND DATA

Results of studies analyzing the impact of smoking on complication and pseudarthrosis rates after spine surgery are conflicting.

METHODS

A retrospective medical record review was performed to identify all adult patients who underwent single- and 2-level instrumented PLF without interbody devices for degenerative spine disease in a 21-year period at a single institution. Patients were divided into smokers and nonsmokers. The main outcome variables were development of at least one postoperative complication and development of pseudarthrosis.

RESULTS

A total of 281 patients underwent single- or 2-level PLF in the 21-year period. Of these, 231 (82.21%) patients were nonsmokers and 50 (17.9%) were smokers. For patients undergoing single-level PLF, complication rates in nonsmokers (3.57%) versus smokers (7.69%) were not significantly different (P = 0.353); pseudarthrosis in nonsmokers occurred in 9.82% of cases compared with 7.69% in the smokers group (P = 0.738). Nonsmokers undergoing 2-level PLF had complication rates of 6.72%, compared with 4.17% in smokers (P = 0.638), but pseudarthrosis rates were significantly higher in the smokers group than in the nonsmokers group (29.17% vs. 10.92%; P = 0.019). Patients were followed up for an average of 53.5 months.

CONCLUSION

The findings in this study suggest that smoking has a significant impact on pseudarthrosis rates after 2-level PLF of the lumbar spine, but not necessarily on single-level PLF.

LEVEL OF EVIDENCE

4.

Surgeon specialty differences in single-level anterior cervical discectomy and fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine the impact of spine surgeon specialty on 30-day postoperative complication rates of single-level anterior cervical discectomy and fusions (ACDFs).

SUMMARY OF BACKGROUND DATA

ACDFs are performed by both neurological and orthopedic surgeons. Although previous studies have examined preoperative risk factors for postoperative complications in ACDFs, no studies have shown the impact of surgical specialty on these variables.

METHODS

All patients who underwent any single-level ACDF between 2006 and 2012 were selected from the American College of Surgeons National Surgical Quality Improvement Program database. Propensity-score matching was used to reduce confounding preoperative differences. Baseline demographics, comorbidities, and complications were compared between the 2 surgical specialties using univariate analyses. Multivariate logistic regression models were created to isolate independent effects of surgeon specialty on complications.

RESULTS

A total of 1944 patients undergoing single-level ACDFs were included in our analysis. Orthopedic surgeons and neurosurgeons performed 19.9% and 80.1% of ACDFs, respectively. Patients who underwent surgery by neurosurgeons had a higher number of comorbidities. After propensity matching, however, not all preoperative variables vary significantly between the specialty cohorts. Multivariate analysis of the propensity-matched groups revealed that for single-level ACDFs, treating physician cohort (orthopedic surgeons vs. neurosurgeons) was not associated with higher odds for overall complications (OR, 1.708; 95% CI, 0.849-3.436; P = 0.133), surgical site complications (OR, 0.869; 95% CI, 0.233-3.247; P = 0.835), or medical complications (OR, 1.863; 95% CI, 0.805-4.311; P = 0.146).

CONCLUSION

Spine surgeon specialty is not a risk factor for any reported postoperative complication in patients undergoing single-level ACDFs.

LEVEL OF EVIDENCE

4.

Impact of increased body mass index on outcomes of elective spinal surgery

STUDY DESIGN

Observational retrospective cohort study of prospectively collected database.

OBJECTIVE

To determine whether overweight body mass index (BMI) influences 30-day outcomes of elective spine surgery.

SUMMARY OF BACKGROUND DATA

Obesity is prevalent in the United States, but its impact on the outcome of elective spine surgery remains controversial.

METHODS

We used National Surgical Quality Improvement Program, a prospective clinical database with proven validity and reproducibility consisting of 256 perioperative standardized variables from surgical patients at nearly 400 academic and nonacademic hospitals nationwide. We identified 49,314 patients who underwent elective fusion, laminectomy or both between 2006 and 2012. We divided patients according to BMI (kg/m2) as normal (18.5-24.9), preobese (25.0-29.9), obese I (30.0-34.9), obese II (35.0-39.9), and obese III (≥40). Relationship between increased BMI and outcome of surgery measured as prolonged hospitalization, complications, return to the operating room, discharged with continued care requirement, readmission, and death was determined using logistic regression before and after propensity score matching.

RESULTS

All overweight patients (BMI ≥25 kg/m2) showed increased odds of an adverse outcome compared with normal patients in unmatched analyses, with maximal effect seen in obese III group. In the propensity-matched sample, obese III patients continued to show increased odds for complications (odds ratio, 1.6; 95% confidence interval, 1.1-2.3), readmission (odds ratio, 2.3; 95% confidence interval, 1.1-4.9), and return to the operating room (odds ratio, 1.8; 95% confidence interval, 1.1-3.1).

CONCLUSION

Impact of obesity on elective spine surgery outcome is mediated, at least in part, by comorbidities in patients with BMI between 25.0 and 39.9 kg/m2. However, BMI itself is an independent risk factor for adverse outcomes in morbidly obese patients.

LEVEL OF EVIDENCE

3.

The effects of smoking on perioperative outcomes and pseudarthrosis following anterior cervical corpectomy: Clinical article

OBJECT

Smoking is one of the leading causes of preventable morbidity and death in the U.S. and has been associated with perioperative complications. In this study, the authors examined the effects of smoking on perioperative outcomes and pseudarthrosis rates following anterior cervical corpectomy.

METHODS

All adult patients from 2006 to 2011 who underwent anterior cervical corpectomy were identified. Patients were categorized into 3 groups: patients who never smoked (nonsmokers), patients who quit for at least 1 year (quitters), and patients who continue to smoke (current smokers). Demographic, medical, and surgical covariates were collected. Multivariate analysis was used to define the relationship between smoking and blood loss, 30-day complications, length of hospital stay, and pseudarthrosis.

RESULTS

A total of 160 patients were included in the study. Of the 160 patients, 49.4% were nonsmokers, 25.6% were quitters, and 25.0% were current smokers. The overall 30-day complication rate was 20.0%, and pseudarthrosis occurred in 7.6% of patients. Mean blood loss was 368.3 ml and mean length of stay was 6.5 days. Current smoking status was significantly associated with higher complication rates (p < 0.001) and longer lengths of stay (p < 0.001); current smoking status remained an independent risk factor for both outcomes after multivariate logistic regression analysis. The complications that were experienced in current smokers were mostly infections (76.5%), and this proportion was significantly greater than in nonsmokers and quitters (p = 0.013). Current smoking status was also an independent risk factor for pseudarthrosis at 1-year follow-up (p = 0.012).

CONCLUSIONS

Smoking is independently associated with higher perioperative complications (especially infectious complications), longer lengths of stay, and higher rates of pseudarthrosis in patients undergoing anterior cervical corpectomy.

Impact of age on 30-day postoperative outcome of surgery for ruptured and unruptured intracranial aneurysms

OBJECTIVE

To assess in a retrospective analysis of a prospectively collected database, the impact of increased age on 30-day postoperative outcomes of surgery for intracranial aneurysms (ICAs).

METHODS

721 adult patients who underwent surgery for ICA were identified in the 2006-2012 American College of Surgeons' National Surgical Quality Improvement Program. Baseline characteristics and 30-day outcomes were stratified by age: <50 years (n=221), 50-60 years (n=221), and >60 years (n=266). Patients <50 and 50-60 years old were propensity score-matched to those aged >60 years. Logistic regression was used to examine the relationship between increased age and surgical outcome.

RESULTS

In unadjusted analyses, age <50 years was associated with fewer postoperative complications (OR=0.5, 95% CI 0.3 to 0.7) and lower mortality (OR=0.4, 95% CI 0.2 to 0.9) compared with those aged >60 years. Patients aged between 50 and 60 years were less likely to have complications (OR=0.6, 95% CI 0.4 to 0.8) in unadjusted analyses. Upon propensity score matching, covariate balance was achieved for all age strata. In adjusted analyses, patients <50 years (OR=0.4, 95% CI 0.2 to 0.7) and 50-60 years (OR=0.5, 95% CI 0.3 to 0.8) of age continued to have fewer complications than those aged >60.

CONCLUSIONS

Age >60 is independently associated with 30-day postoperative morbidity in patients undergoing surgery for ICA. The results of this study suggest age >60 should be considered an a priori risk factor in surgical management of ICA, regardless of associated comorbidities often associated with increased age.

Smoking and postoperative outcomes in elective cranial surgery

Object

The goal in this study was to assess whether a current or prior history of smoking and the number of smoking pack years affect the risk for adverse outcomes in the 30-day postoperative period in patients who undergo elective cranial surgery.

Methods

Data from the 2006–2011 American College of Surgeons' National Surgical Quality Improvement Project were used in this study. The authors identified 8296 patients who underwent elective cranial surgery, of whom 1718 were current smokers, 854 were prior smokers, and 5724 were never smokers. Using propensity scores and age, the authors matched current and prior smokers to never smokers. Odds ratios for adverse postoperative outcomes were predicted with logistic regression. The relationship between number of pack years and poor outcomes was also examined.

Results

In unadjusted analyses, prior and current smokers did not differ from never smokers for having poor outcomes postoperatively. Similarly, in matched analyses, no association was found between smoking and adverse outcomes. Number of pack years in propensity-matched analyses did not predict worse outcomes in prior or current smokers versus never smokers.

Conclusions

The authors did not find smoking to be associated with 30-day postoperative morbidity or mortality. Although smoking cessation is beneficial for overall health, it may not improve the short-term (≤ 30 days) outcome of elective cranial surgery. Thus postponement of elective cranial cases only for smoking cessation may not be necessary.