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

View More View Less
  • 1 Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital;
  • 2 School of Medicine, National Yang-Ming University;
  • 3 Department of Biomedical Engineering, School of Biomedical Science and Engineering, National Yang-Ming University;
  • 4 Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University;
  • 5 Institute of Pharmacology, National Yang-Ming University;
  • 6 Taiwan International Graduate Program in Molecular Medicine, National Yang-Ming University and Academia Sinica; and
  • 7 Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $369.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

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.

ABBREVIATIONS ASD = adjacent segment disease; CDA = cervical disc arthroplasty; DDS = Dynesys dynamic stabilization; DM = diabetes mellitus; HU = Hounsfield units; JOA = Japanese Orthopaedic Association; ODI = Oswestry Disability Index; VAS = visual analog scale.

Spine - 1 year subscription bundle (Individuals Only)

USD  $369.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Correspondence Wen-Cheng Huang: Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan. wchuang518@gmail.com.

INCLUDE WHEN CITING Published online May 1, 2020; DOI: 10.3171/2020.2.SPINE191380.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Andersen T, Christensen FB, Laursen M, Smoking as a predictor of negative outcome in lumbar spinal fusion. Spine (Phila Pa 1976). 2001;26(23):26232628.

    • Search Google Scholar
    • Export Citation
  • 2

    Dickman CA, Fessler RG, MacMillan M, Haid RW. Transpedicular screw-rod fixation of the lumbar spine: operative technique and outcome in 104 cases. J Neurosurg. 1992;77(6):860870.

    • Search Google Scholar
    • Export Citation
  • 3

    Glassman SD, Anagnost SC, Parker A, The effect of cigarette smoking and smoking cessation on spinal fusion. Spine (Phila Pa 1976). 2000;25(20):26082615.

    • Search Google Scholar
    • Export Citation
  • 4

    Hermann PC, Webler M, Bornemann R, Influence of smoking on spinal fusion after spondylodesis surgery: a comparative clinical study. Technol Health Care. 2016;24(5):737744.

    • Search Google Scholar
    • Export Citation
  • 5

    Bisson EF, Bowers CA, Hohmann SF, Schmidt MH. Smoking is associated with poorer quality-based outcomes in patients hospitalized with spinal disease. Front Surg. 2015;2:20.

    • Search Google Scholar
    • Export Citation
  • 6

    De la Garza Ramos R, Goodwin CR, Qadi M, Impact of smoking on 30-day morbidity and mortality in adult spinal deformity surgery. Spine (Phila Pa 1976). 2017;42(7):465470.

    • Search Google Scholar
    • Export Citation
  • 7

    Elsamadicy AA, Adogwa O, Sergesketter A, 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. World Neurosurg. 2017;107:233238.

    • Search Google Scholar
    • Export Citation
  • 8

    Seicean A, Seicean S, Alan N, Effect of smoking on the perioperative outcomes of patients who undergo elective spine surgery. Spine (Phila Pa 1976). 2013;38(15):12941302.

    • Search Google Scholar
    • Export Citation
  • 9

    Berman D, Oren JH, Bendo J, Spivak J. The effect of smoking on spinal fusion. Int J Spine Surg. 2017;11:29.

  • 10

    Hilibrand AS, Fye MA, Emery SE, Impact of smoking on the outcome of anterior cervical arthrodesis with interbody or strut-grafting. J Bone Joint Surg Am. 2001;83(5):668673.

    • Search Google Scholar
    • Export Citation
  • 11

    Lau D, Chou D, Ziewacz JE, Mummaneni PV. The effects of smoking on perioperative outcomes and pseudarthrosis following anterior cervical corpectomy: clinical article. J Neurosurg Spine. 2014;21(4):547558.

    • Search Google Scholar
    • Export Citation
  • 12

    Tu TH, Kuo CH, Huang WC, Effects of smoking on cervical disc arthroplasty. J Neurosurg Spine. 2019;30(2):168174.

  • 13

    Fay LY, Chang CC, Chang HK, A hybrid dynamic stabilization and fusion system in multilevel lumbar spondylosis. Neurospine. 2018;15(3):231241.

    • Search Google Scholar
    • Export Citation
  • 14

    Fay LY, Huang WC, Chang CC, Unintended facet fusions after Dynesys dynamic stabilization in patients with spondylolisthesis. J Neurosurg Spine. 2018;30(3):353361.

    • Search Google Scholar
    • Export Citation
  • 15

    Fay LY, Wu JC, Tsai TY, Dynamic stabilization for degenerative spondylolisthesis: evaluation of radiographic and clinical outcomes. Clin Neurol Neurosurg. 2013;115(5):535541.

    • Search Google Scholar
    • Export Citation
  • 16

    Kuo CH, Chang PY, Wu JC, Dynamic stabilization for L4-5 spondylolisthesis: comparison with minimally invasive transforaminal lumbar interbody fusion with more than 2 years of follow-up. Neurosurg Focus. 2016;40(1):E3.

    • Search Google Scholar
    • Export Citation
  • 17

    Kuo CH, Huang WC, Wu JC, Radiological adjacent-segment degeneration in L4-5 spondylolisthesis: comparison between dynamic stabilization and minimally invasive transforaminal lumbar interbody fusion. J Neurosurg Spine. 2018;29(3):250258.

    • Search Google Scholar
    • Export Citation
  • 18

    Yeh MY, Kuo CH, Wu JC, Changes of facet joints after dynamic stabilization: continuous degeneration or slow fusion? World Neurosurg. 2018;113:e45e50.

    • Search Google Scholar
    • Export Citation
  • 19

    Ko CC, Tsai HW, Huang WC, Screw loosening in the Dynesys stabilization system: radiographic evidence and effect on outcomes. Neurosurg Focus. 2010;28(6):E10.

    • Search Google Scholar
    • Export Citation
  • 20

    Kuo CH, Chang PY, Tu TH, The effect of lumbar lordosis on screw loosening in Dynesys dynamic stabilization: four-year follow-up with computed tomography. Biomed Res Int. 2015;2015:152435.

    • Search Google Scholar
    • Export Citation
  • 21

    Wu JC, Huang WC, Tsai HW, Pedicle screw loosening in dynamic stabilization: incidence, risk, and outcome in 126 patients. Neurosurg Focus. 2011;31(4):E9.

    • Search Google Scholar
    • Export Citation
  • 22

    Pham MH, Mehta VA, Patel NN, Complications associated with the Dynesys dynamic stabilization system: a comprehensive review of the literature. Neurosurg Focus. 2016;40(1):E2.

    • Search Google Scholar
    • Export Citation
  • 23

    Schreiber JJ, Anderson PA, Hsu WK. Use of computed tomography for assessing bone mineral density. Neurosurg Focus. 2014;37(1):E4.

  • 24

    Schreiber JJ, Anderson PA, Rosas HG, Hounsfield units for assessing bone mineral density and strength: a tool for osteoporosis management. J Bone Joint Surg Am. 2011;93(11):10571063.

    • Search Google Scholar
    • Export Citation
  • 25

    Wagner SC, Formby PM, Helgeson MD, Kang DG. Diagnosing the undiagnosed: osteoporosis in patients undergoing lumbar fusion. Spine (Phila Pa 1976). 2016;41(21):E1279E1283.

    • Search Google Scholar
    • Export Citation
  • 26

    Truntzer J, Vopat B, Feldstein M, Matityahu A. Smoking cessation and bone healing: optimal cessation timing. Eur J Orthop Surg Traumatol. 2015;25(2):211215.

    • Search Google Scholar
    • Export Citation
  • 27

    Sandén B, Försth P, Michaëlsson K. Smokers show less improvement than nonsmokers two years after surgery for lumbar spinal stenosis: a study of 4555 patients from the Swedish Spine Register. Spine (Phila Pa 1976). 2011;36(13):10591064.

    • Search Google Scholar
    • Export Citation
  • 28

    Stienen MN, Joswig H, Smoll NR, Short- and long-term effects of smoking on pain and health-related quality of life after non-instrumented lumbar spine surgery. Clin Neurol Neurosurg. 2016;142:8792.

    • Search Google Scholar
    • Export Citation
  • 29

    Ditre JW, Kosiba JD, Zale EL, Chronic pain status, nicotine withdrawal, and expectancies for smoking cessation among lighter smokers. Ann Behav Med. 2016;50(3):427435.

    • Search Google Scholar
    • Export Citation
  • 30

    Mekhail N, Azer G, Saweris Y, The impact of tobacco cigarette smoking on spinal cord stimulation effectiveness in chronic spine-related pain patients. Reg Anesth Pain Med. 2018;43(7):768775.

    • Search Google Scholar
    • Export Citation
  • 31

    Richardson EJ, Ness TJ, Redden DT, Effects of nicotine on spinal cord injury pain vary among subtypes of pain and smoking status: results from a randomized, controlled experiment. J Pain. 2012;13(12):12061214.

    • Search Google Scholar
    • Export Citation
  • 32

    Fay LY, Chang PY, Wu JC, Dynesys dynamic stabilization-related facet arthrodesis. Neurosurg Focus. 2016;40(1):E4.

  • 33

    Huang W, Qian Y, Zheng K, Is smoking a risk factor for lumbar disc herniation? Eur Spine J. 2016;25(1):168176.

  • 34

    Nasto LA, Ngo K, Leme AS, Investigating the role of DNA damage in tobacco smoking-induced spine degeneration. Spine J. 2014;14(3):416423.

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 48 48 48
Full Text Views 33 33 33
PDF Downloads 24 24 24
EPUB Downloads 0 0 0