Impact of Smoking on the Outcome of Anterior Cervical Arthrodesis with Interbody or Strut-Grafting

Hilibrand, Alan S.; Fye, M.A. W. Bruce; Emery, Sanford E.; Palumbo, Mark A.; Bohlman, Henry H.

doi:10.2106/00004623-200105000-00004

Cited by 178 publications

(122 citation statements)

References 28 publications

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“…In agreement with Hilibrand et al [18], we believe that the negative impact of smoking on graft healing is additive with other factors, such as multi-level interbody grafting, the use of allograft bone, interbody grafting adjacent to a solid fusion and alcohol consumption. We did not have sufficient clinical material to prove this theory statistically.…”

Section: Discussionsupporting

confidence: 92%

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Autologous versus allogenic bone grafts in instrumented anterior cervical discectomy and fusion: a prospective study with respect to bone union pattern

et al. 2004

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IntroductionAnterior cervical discectomy and fusion (ACDF) in the subaxial cervical spine as originally suggested by Badgley in 1939 and described by Robinson and Smith in 1955 [28] and Cloward in 1958 [8] has established itself as a method of treatment for patients with neural compression by disc material or osteophytes.Although the interbody location of applied bone graft is a favourable healing environment, because of the relatively large surface area of subchondral cancellous bone Abstract Background. The purpose of this prospective semi-randomised comparative study was to compare fusion rates, course of fusion, and occurrence of collapse and subsidence of autologous and allogenic bone grafts in instrumented anterior cervical fusion. The number of fused levels and the smoking status were investigated as potential factors influencing the bone-healing process. No similar prospective study on instrumented anterior cervical discectomy and fusion was found in the literature. Methods. Seventy-nine consecutive patients were operated on using the Smith-Robinson technique with a single instrumentation system at one or two levels. Seventy-six cadaverous fibular bone grafts and 37 autologous iliac-crest bone grafts were inserted. All patients were followed up for at least 2 years. Results.The radiographs obtained during the follow-up were analysed, and showed no statistical difference in fusion and collapse rate between autografts and allografts. Allografts showed significantly longer time to union. No case of graft migration was observed. No difference was found between fusion and collapse rate with respect to the number of fused levels in general, but greater time to union was seen in two-level fusions. When one-and two-level subgroups were compared, there was no evidence of any significant difference in fusion or collapse rates between autografts and allografts, and the healing process took longer in allogenic grafts. Smoking status did not alter any of the fusion or collapse rates, or the course of bone fusion.Conclusions.This study demonstrates that allografts are suitable substitutes for autografts in instrumented ACDF. Prolonged time to union observed in allogenic bone grafts does not seem to be an important factor in instrumented procedures. Two-level grafting does not imply a significantly lower fusion rate, but longer time to union can be expected than with single-level instrumented procedures in both allograft and autograft subgroups. Our relatively small number of patients may not have been sufficient to decipher significant differences between smokers and nonsmokers in the rate or course of fusion as previously reported.

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Section: Discussionsupporting

confidence: 92%

“…Results of clinical observations attempting to demonstrate such a correlation between smoking and nonunion are variable. Some of the studies even describe a three-to fourfold relative risk of pseudoarthrosis in smokers [6,17,18], while others failed to find any statistically significant difference [5].…”

Section: Discussionmentioning

confidence: 99%

Autologous versus allogenic bone grafts in instrumented anterior cervical discectomy and fusion: a prospective study with respect to bone union pattern

et al. 2004

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“…15,21,30 In clinical studies, smoking has been shown to be associated with poor wound and bone healing and increased rates of pseudarthrosis and nonunion. 10,14 Decreased recovery in smokers is therefore likely due to a combination of vascular changes, impaired bone remodeling, and increased risk of complications. Future research is required to evaluate whether smoking cessation improves outcomes.…”

Section: Discussionmentioning

confidence: 99%

Predicting the minimum clinically important difference in patients undergoing surgery for the treatment of degenerative cervical myelopathy

Tetreault

Wilson

Kotter

et al. 2016

FOC

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OBJECTIVE The minimum clinically important difference (MCID) is defined as the minimum change in a measurement that a patient would identify as beneficial. Before undergoing surgery, patients are likely to inquire about the ultimate goals of the operation and of their chances of experiencing meaningful improvements. The objective of this study was to define significant predictors of achieving an MCID on the modified Japanese Orthopaedic Association (mJOA) scale at 2 years following surgery for the treatment of degenerative cervical myelopathy (DCM). METHODS Seven hundred fifty-seven patients were prospectively enrolled in either the AOSpine North America or International study at 26 global sites. Fourteen patients had a perfect preoperative mJOA score of 18 and were excluded from this analysis (n = 743). Data were collected for each participating subject, including demographic information, symptomatology, medical history, causative pathology, and functional impairment. Univariate log-binominal regression analyses were conducted to evaluate the association between preoperative clinical factors and achieving an MCID on the mJOA scale. Modified Poisson regression using robust error variances was used to create the final multivariate model and compute the relative risk for each predictor. RESULTS The sample consisted of 463 men (62.31%) and 280 women (37.69%), with an average age of 56.48 ± 11.85 years. At 2 years following surgery, patients exhibited a mean change in functional status of 2.71 ± 2.89 points on the mJOA scale. Of the 687 patients with available follow-up data, 481 (70.01%) exhibited meaningful gains on the mJOA scale, whereas 206 (29.98%) failed to achieve an MCID. Based on univariate analysis, significant predictors of achieving the MCID on the mJOA scale were younger age; female sex; shorter duration of symptoms; nonsmoking status; a lower comorbidity score and absence of cardiovascular disease; and absence of upgoing plantar responses, lower-limb spasticity, and broad-based unstable gait. The final model included age (relative risk [RR] 0.924, p < 0.0001), smoking status (RR 0.837, p = 0.0043), broad-based unstable gait (RR 0.869, p = 0.0036), and duration of symptoms (RR 0.943, p = 0.0003). CONCLUSIONS In this large multinational prospective cohort, 70% of patients treated surgically for DCM exhibited a meaningful functional gain on the mJOA scale. The key predictors of achieving an MCID on the mJOA scale were younger age, shorter duration of symptoms, nonsmoking status, and lack of significant gait impairment.

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“…In the cervical spine, high pseudarthrosis rates are associated with smoking, osteoporosis, and multilevel procedures. [3][4][5] The use of autologous iliac crest bone grafting has historically been the gold standard to achieve bony union in fusion procedures; however, there are welldocumented complications with its use. Although wound issues, hematoma formation, and re-operations have all been reported with the use of iliac crest autograft, [6][7][8] the most serious and common untoward effect is continued pain after surgery.…”

mentioning

confidence: 99%

Nanocomposite therapy as a more efficacious and less inflammatory alternative to bone morphogenetic protein‐2 in a rodent arthrodesis model

Hsu¹,

Polavarapu²,

Riaz³

et al. 2011

Journal Orthopaedic Research

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The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in spine fusion has led to concerns regarding a potential accompanying inflammatory response. This study evaluates a combination therapy (TrioMatrix 1 ; Pioneer Surgical, Inc., Marquette, MI) comprised of a demineralized bone matrix (DBM), hydroxyapatite, and a nanofiber-based collagen scaffold in a rodent spine fusion model. Thirty-six athymic rats that underwent a posterolateral intertransverse spinal fusion were randomly assigned to 1 of 5 treatment groups: absorbable collagen sponge alone (ACS, negative control), 10 mg rhBMP-2 on ACS (positive control), TrioMatrix 1 , Grafton 1 (Osteotech, Inc., Eatontown, NJ), and DBX 1 (Synthes, Inc., West Chester, PA). Both TrioMatrix 1 and rhBMP-2-treated animals demonstrated 100% fusion rates as graded by manual palpation scores 8 weeks after implantation. This rate was significantly greater than those of the ACS, Grafton 1 , and DBX 1 groups. Notably, the use of TrioMatrix 1 as evaluated by microCT quantification led to a greater fusion mass volume when compared to all other groups, including the rhBMP-2 group. T2-weighted axial MRI images of the fusion bed demonstrated a significant host response associated with a large fluid collection with the use of rhBMP-2; this response was significantly reduced with the use of TrioMatrix 1 . Our results therefore demonstrate that a nanocomposite therapy represents a promising, cost-effective bone graft substitute that could be useful in spine fusions where BMP-2 is contraindicated.

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Impact of Smoking on the Outcome of Anterior Cervical Arthrodesis with Interbody or Strut-Grafting

Cited by 178 publications

References 28 publications

Autologous versus allogenic bone grafts in instrumented anterior cervical discectomy and fusion: a prospective study with respect to bone union pattern

Autologous versus allogenic bone grafts in instrumented anterior cervical discectomy and fusion: a prospective study with respect to bone union pattern

Predicting the minimum clinically important difference in patients undergoing surgery for the treatment of degenerative cervical myelopathy

Nanocomposite therapy as a more efficacious and less inflammatory alternative to bone morphogenetic protein‐2 in a rodent arthrodesis model

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