Whether you smoke cigarettes, e-cigarettes (electronic cigarettes), use other types of tobacco or not—you will be interested in what five spine surgeons had to say. SpineUniverse asked five of its Editorial Board members—orthopaedic spine surgeons and neurosurgeons—questions about tobacco use, vaping and spinal surgery.

The questions we asked:

• What do spine surgeons tell their patients who smoke cigarettes, use other types of tobacco, and/or vape?
• Do you consider e-cigarettes similar to other nicotine-related products?
• Why are people who smoke at greater risk for back pain and potentially increased risk during and after spine surgery? How does this affect your decision to perform surgery?

What do you tell your patients who smoke cigarettes, use other types of tobacco, and/or vape?

Joshua M. Ammerman, MD — Neurosurgeon
Obviously smoking cessation is the key, and I emphasize to my patients that it often requires multiple attempts to stop smoking and that failure after the first try should not discourage them from trying again. That said, simply reducing the amount smoked can lead to a meaningful reduction in overall mortality and death due to cardiovascular disease.

Choll W. Kim, MD, PhD — Orthopaedic Spine Surgeon
Smoking remains an important issue when it comes to back pain and spinal surgery. Smoking affects circulation of blood in the small vessels. Blood carries oxygen and nutrients to cells. This is important because there is little circulation to the the shock-absorbing discs that cushion our spine. Cigarette smoking further reduces blood flow, meaning blood flow to the discs is less.The same problem affects wound healing after surgery. Smokers have a higher risk of wound problems, including infections.

In addition to the blood flow issue, nicotine in cigarettes inhibits bone healing. In patients who undergo spinal surgery involving fusion, smoking increases the risk of non-union, also known as pseudarthrosis. I recommend that patients who plan to have spinal surgery give up smoking for about 6 weeks after surgery. This includes e-cigarettes until more information about their effects are known.

Although we do not require smoking cessation prior to fusion surgery, we make every effort to assist patients in this regard. For patients, who cannot stop smoking, we mitigate risks by using minimally invasive techniques to decrease the likelihood of wound problems and optimize fusion by using interbody fusion and bone morphogenetic protein (BMP).

Reginald Q. Knight, MD, MHA — Orthopaedic Spine Surgeon
I tell patients who smoke that there are several reasons to consider stopping outside of the cardiopulmonary (heart/lungs) concerns. First, patients who smoke are known to have an increased risk of back pain. Stop smoking, and your back pain may improve. Second, if a smoker requires surgery, they have an increased risk of complications, including lower rates of fusion and increased infection rates. Lastly, many insurance companies no longer approve surgery for smoking patients in the absence of neural (nerve) compression.

Praveen V. Mummaneni, MD — Neurosurgeon/Todd Vogel, MD — Neurosurgeon
We require all elective spinal fusion patients to quit tobacco products.

Lali Sekhon, MD, PhD, FACS, FAANS — Neurosurgeon
Smoking accelerates degenerative disc disease. If spinal surgery is performed, the outcomes are impaired. Anesthesia is more challenging and spinal fusions are less likely to heal. Patients can’t stop smoking if others in the family continue to smoke, so spouses/partners need to stop at the same time. Nicotine is the culprit, so nicotine patches and gums are to be avoided if fusion surgery is to be performed. I suggest patients talk to their primary care physician. Options, such as Chantix, hypnosis, acupuncture, and even laser therapy are used. Often smokers need to try to stop smoking many times in order to succeed. Cutting down is also better than nothing.

Do physicians consider e-cigarettes similar to other nicotine-related products?

Joshua M. Ammerman, MD — Neurosurgeon
Yes. While e-cigarettes appear to contain lower levels of potentially carcinogenic compounds, there is still a significant amount of nicotine in the aerosol created by e-cigarettes. Nicotine has been demonstrated to have a detrimental effect on the cells of the spinal disc (nucleus pulposus) and therefore, may potentiate degenerative disc disease. Furthermore, nicotine has been implicated as a risk factor for the loss of bone density in the skeleton, including the spine; a condition known as osteoporosis. Osteoporosis can lead to spontaneous fractures of the skeleton, including the spinal bones (vertebrae).

Reginald Q. Knight, MD, MHA — Orthopaedic Spine Surgeon
Nicotine is the problem with smoking and spinal surgery. Anything that continues to provide nicotine to the system should be discontinued prior to elective spinal surgery. Particularly, if there are no indications that surgery or neural (nerve) decompression is urgent.

Praveen V. Mummaneni, MD — Neurosurgeon/Todd Vogel, MD — Neurosurgeon
Yes. These agents also have nicotine, which has some effect on wound healing.

Lali Sekhon, MD, PhD, FACS, FAANS — Neurosurgeon
Probably. Nicotine impairs fusion healing.

Why are people who smoke at greater risk for back pain and potentially increased risk during and after spine surgery? How does this affect your decision to perform surgery?

Joshua M. Ammerman, MD — Neurosurgeon
In addition to the effects nicotine has on the cells of the spinal discs, the substances contained in tobacco reduce blood flow to the spine. Reduced blood flow can potentially accelerate degeneration of the spine, and is a well-documented risk factor for failure of spinal bones to heal (fuse) after surgery. Additionally, this reduction in blood flow can impair healing of the surgical wound and potentially increase the risk of an infection at the surgical site.

With regards to surgery, we aggressively encourage patients to stop smoking at least 8 weeks prior to surgery, particularly any procedure involving spinal fusion, in an effort to enhance their chances for a successful outcome and to minimize their risks related to their lung function. In some cases, I will order an external bone stimulator to try to help overcome some of the effects of tobacco use in patient who needs surgery urgently or is unable to stop smoking.

Reginald Q. Knight, MD, MHA — Orthopaedic Spine Surgeon
I believe the working hypothesis is nicotine causes vasoconstriction. Vasoconstriction affects soft tissues by decreasing blood flow and increasing the risk for infection. During fusion, a healthy blood flow is essential to the formation of new bone. Vasoconstriction stunts the development of new bone and may result in failure of the fusion process. In the absence of clear spinal instability or the need for neural (nerve) decompression, I prefer not to operate on elective surgical patients who smoke. This being said, smoking is the most difficult addiction to fight. Of course, there are exceptions to every rule. Smokers need to be educated about the risks they take and the reduced improvement in outcomes associated with smoking.

Praveen V. Mummaneni, MD — Neurosurgeon/Todd Vogel, MD — Neurosurgeon
Cigarette smokers are at an increased risk for low back pain caused by disc degeneration and spinal instability. This process is accelerated as a result of increases in serum proteolytic activity (cellular breakdown) by releasing proteolytic enzymes (proteins) from neutrophils (white blood cells) and inhibiting the activity of alpha-1-antiprotease (cellular breakdown). This increased proteolytic activity largely targets discs, but may also target spinal ligaments leading to spinal instability. This degeneration may lead to increased back pain.
 
Smoking affects the body’s ability to heal by causing ischemia (insufficient blood flow) at the cellular level. This affects the ability of a fusion to heal and create solid bone between vertebral bodies. As a result of this, we ask our elective spinal patients to stop smoking prior to surgery as it is in their best interest.

Lali Sekhon, MD, PhD, FACS, FAANS — Neurosurgeon
Surrounding bone delivers necessary oxygen to the discs’ cartilage cells (chondrocytes). In smokers, the oxygen level drops and the cells die. Oxygen is also necessary for the production of cells that hold water inside the discs (glycosaminoglycans). When glucosaminoglycan cells die, the discs dry out, degenerate and become prone to cracking—all of which accelerates wear and tear, and may lead to chronic back pain.