Effects of smoking on cervical disc arthroplasty

Restricted access


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.


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).


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).


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.

Article Information

Correspondence Jau-Ching Wu: Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan. jauching@gmail.com.

INCLUDE WHEN CITING Published online November 16, 2018; DOI: 10.3171/2018.7.SPINE18634.

T.H.T. and C.H.K. contributed equally to this study.

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

© AANS, except where prohibited by US copyright law.



  • View in gallery

    A patient underwent CDA that addressed a herniated disc at C3–4. Preoperative sagittal T2-weighted MR image demonstrating marked spinal cord compression at the C3–4 level (arrowhead, A). After surgery, the Prestige LP artificial disc was positioned with good alignment and reasonable size (B). At the 43-month postoperative follow-up, lateral dynamic radiographs demonstrated good preservation of the segmental mobility (C). A small HO was demonstrated on the lateral radiographs (arrowhead, C). Interestingly, when scrutinized using CT, there were small HOs both anterior and posterior to the artificial disc (arrowheads, D). Despite HO formation, the indexed level remained mobile throughout the follow-up.

  • View in gallery

    Comparison of pre- and postoperative segmental ROM at the index level (plotted as mean ± standard error) between smoking and nonsmoking groups. There was no difference between pre- and postoperative ROM in the smokers, whereas a decreased ROM was demonstrated in the nonsmokers. *p < 0.05.



Ajiro YTokuhashi YMatsuzaki HNakajima SOgawa T: Impact of passive smoking on the bones of rats. Orthopedics 33:90952010


Andersen TChristensen FBLaursen MHøy KHansen ESBünger C: Smoking as a predictor of negative outcome in lumbar spinal fusion. Spine (Phila Pa 1976) 26:262326282001


Bisson EFBowers CAHohmann SFSchmidt MH: Smoking is associated with poorer quality-based outcomes in patients hospitalized with spinal disease. Front Surg 2:202015


Chang HKChang CCTu THWu JCHuang WCFay LY: Can segmental mobility be increased by cervical arthroplasty? Neurosurg Focus 42(2):E32017


Chang PYChang HKWu JCHuang WCFay LYTu TH: Differences between C3–4 and other subaxial levels of cervical disc arthroplasty: more heterotopic ossification at the 5-year follow-up. J Neurosurg Spine 24:7527592016


Daftari TKWhitesides TE JrHeller JGGoodrich ACMcCarey BEHutton WC: Nicotine on the revascularization of bone graft. An experimental study in rabbits. Spine (Phila Pa 1976) 19:9049111994


De la Garza Ramos RGoodwin CRQadi MAbu-Bonsrah NPassias PGLafage V: Impact of smoking on 30-day morbidity and mortality in adult spinal deformity surgery. Spine (Phila Pa 1976) 42:4654702017


Dickman CAFessler RGMacMillan MHaid RW: Transpedicular screw-rod fixation of the lumbar spine: operative technique and outcome in 104 cases. J Neurosurg 77:8608701992


Elsamadicy AAAdogwa OSergesketter AVuong VDLydon EBehrens S: 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 107:2332382017


Fay LYHuang WCTsai TYWu JCKo CCTu TH: Differences between arthroplasty and anterior cervical fusion in two-level cervical degenerative disc disease. Eur Spine J 23:6276342014


Fay LYHuang WCWu JCChang HKTsai TYKo CC: Arthroplasty for cervical spondylotic myelopathy: similar results to patients with only radiculopathy at 3 years’ follow-up. J Neurosurg Spine 21:4004102014


Ganbat DKim YHKim KJin YJPark WM: Effect of mechanical loading on heterotopic ossification in cervical total disc replacement: a three-dimensional finite element analysis. Biomech Model Mechanobiol 15:119111992016


Glassman SDAnagnost SCParker ABurke DJohnson JRDimar JR: The effect of cigarette smoking and smoking cessation on spinal fusion. Spine (Phila Pa 1976) 25:260826152000


Gornet MFBurkus JKShaffrey MEArgires PJNian HHarrell FE Jr: Cervical disc arthroplasty with PRESTIGE LP disc versus anterior cervical discectomy and fusion: a prospective, multicenter investigational device exemption study. J Neurosurg Spine 23:5585732015


Gornet MFBurkus JKShaffrey MENian HHarrell FE Jr: Cervical disc arthroplasty with Prestige LP disc versus anterior cervical discectomy and fusion: seven-year outcomes. Int J Spine Surg 10:242016


Hermann PCWebler MBornemann RJansen TRRommelspacher YSander K: Influence of smoking on spinal fusion after spondylodesis surgery: a comparative clinical study. Technol Health Care 24:7377442016


Hilibrand ASFye MAEmery SEPalumbo MABohlman HH: Impact of smoking on the outcome of anterior cervical arthrodesis with interbody or strut-grafting. J Bone Joint Surg Am 83-A:6686732001


Lanman THBurkus JKDryer RGGornet MFMcConnell JHodges SD: Long-term clinical and radiographic outcomes of the Prestige LP artificial cervical disc replacement at 2 levels: results from a prospective randomized controlled clinical trial. J Neurosurg Spine 27:7192017


Lau DChou DZiewacz JEMummaneni PV: The effects of smoking on perioperative outcomes and pseudarthrosis following anterior cervical corpectomy: clinical article. J Neurosurg Spine 21:5475582014


McAfee PCCunningham BWDevine JWilliams EYu-Yahiro J: Classification of heterotopic ossification (HO) in artificial disk replacement. J Spinal Disord Tech 16:3843892003


Mummaneni PVAmin BYWu JCBrodt EDDettori JRSasso RC: Cervical artificial disc replacement versus fusion in the cervical spine: a systematic review comparing long-term follow-up results from two FDA trials. Evid Based Spine Care J 3 (S1):59662012


Park SBJin YJKim KJ: Heterotopic ossification and clinical outcome in nonconstrained cervical arthroplasty. J Spine Surg 2:3513522016


Seicean ASeicean SAlan NSchiltz NKRosenbaum BPJones PK: Effect of smoking on the perioperative outcomes of patients who undergo elective spine surgery. Spine (Phila Pa 1976) 38:129413022013


Sloan AHussain IMaqsood MEremin OEl-Sheemy M: The effects of smoking on fracture healing. Surgeon 8:1111162010


Tian WFan MXLiu YJHan XYan KWang H: An analysis of paravertebral ossification in cervical artificial disc replacement: a novel classification based on computed tomography. Orthop Surg 8:4404462016


Tu THWu JCHuang WCChang HKKo CCFay LY: Postoperative nonsteroidal antiinflammatory drugs and the prevention of heterotopic ossification after cervical arthroplasty: analysis using CT and a minimum 2-year follow-up. J Neurosurg Spine 22:4474532015


Tu THWu JCHuang WCGuo WYWu CLShih YH: Heterotopic ossification after cervical total disc replacement: determination by CT and effects on clinical outcomes. J Neurosurg Spine 14:4574652011


Tu THWu JCHuang WCWu CLKo CCCheng H: The effects of carpentry on heterotopic ossification and mobility in cervical arthroplasty: determination by computed tomography with a minimum 2-year follow-up: clinical article. J Neurosurg Spine 16:6016092012


Upadhyaya CDWu JCTrost GHaid RWTraynelis VCTay B: Analysis of the three United States Food and Drug Administration investigational device exemption cervical arthroplasty trials. J Neurosurg Spine 16:2162282012


Wu JCHuang WCTsai HWKo CCFay LYTu TH: Differences between 1- and 2-level cervical arthroplasty: more heterotopic ossification in 2-level disc replacement: Clinical article. J Neurosurg Spine 16:5946002012


Wu JCHuang WCTsai TYFay LYKo CCTu TH: Multilevel arthroplasty for cervical spondylosis: more heterotopic ossification at 3 years of follow-up. Spine (Phila Pa 1976) 37:E1251E12592012


Wu JCLiu LWen-Cheng HChen YCKo CCWu CL: The incidence of adjacent segment disease requiring surgery after anterior cervical diskectomy and fusion: estimation using an 11-year comprehensive nationwide database in Taiwan. Neurosurgery 70:5946012012


Yi SShin DAKim KNChoi GShin HCKim KS: The predisposing factors for the heterotopic ossification after cervical artificial disc replacement. Spine J 13:104810542013




All Time Past Year Past 30 Days
Abstract Views 180 180 180
Full Text Views 52 52 52
PDF Downloads 41 41 41
EPUB Downloads 0 0 0


Google Scholar