The impact of smoking on neurosurgical outcomes

The Influence of Modifiable Risk Factors on Postoperative Outcomes in Patients Receiving Surgery for Resection for Acoustic Neuroma

Acoustic neuromas are the most common tumor of the cerebellopontine angle that are associated with a number of symptoms that negatively impact a patient's quality of life. While the mainstay of treatment for these benign tumors remains microsurgical resection, there is limited research exploring how certain modifiable risk factors (MRFs) may affect the perioperative course. The purpose of this study was to investigate how MRFs including malnutrition, obesity, dyslipidemia, uncontrolled hypertension, and smoking may affect postoperative rates of readmission and nonroutine discharges. We utilized the 2016 and 2017 Healthcare Cost and Utilization Project Nationwide Readmissions Database. MRFs were queried using appropriate International Classification of Diseases, Tenth Revision (ICD-10) coding for categories including malnutrition, obesity, dyslipidemia, smoking, alcohol, and hypertension. The statistical analysis was done using RStudio (Version 1.3.959). Chi-squared tests were done to evaluate differences between categorical variables. The Mann-Whitney U-testing was utilized to evaluate for statistically significant differences in continuous data. The "Epitools" package was used to develop logistic regression models for postoperative complications and post hoc receiver operating characteristic curves were developed. Pertaining to nonroutine discharge, predictive models using malnutrition outperformed all other MRFs as well as those with no MRFs (P < .05). In the case of readmission, models using malnutrition outperformed those of obesity and smoking (P < .05). Again, an increase in predictive power is seen in models using dyslipidemia when compared to obesity, smoking, or uncontrolled hypertension. Lastly, models using no MRFs outperformed those of obesity, smoking, and uncontrolled hypertension (P < .05). This is the first study of its kind to evaluate the role of MRFs in those undergoing surgical resection of their acoustic neuroma. We concluded that certain MRFs may play a role in complicating a patient's perioperative surgical course.

Early fusion outcome after surgical treatment of single-level and multi-level pyogenic spondylodiscitis: experience at a level 1 center for spinal surgery-a single center cohort study

STUDY DESIGN

Retrospective single center cohort study.

PURPOSE

Spinal instrumentation in combination with antibiotic therapy is a treatment option for acute or chronic pyogenic spondylodiscitis (PSD). This study compares the early fusion outcome for multi-level and single-level PSD after urgent surgical treatment with interbody fusion in combination with fixation.

METHODS

This is a retrospective cohort study. Over a 10 year period at a single institution, all surgically treated patients received surgical debridement, fusion und fixation of the spine to treat PSD. Multi-level cases were either adjacent to each other on the spine or distant. Fusion rates were assessed at 3 and 12 months after surgery. We analyzed demographic data, ASA status, duration of surgery, location and length of spine affected, Charlson comorbidity index (CCI), and early complications.

RESULTS

A total of 172 patients were included. Of these, 114 patients suffered from single-level and 58 from multi-level PSD. The most frequent location was the lumbar spine (54.0%) followed by the thoracic spine (18.0%). The PSD was adjacent in 19.0% and distant in 81.0% of multi-level cases. Fusion rates at the 3 month follow-up did not differ among the multi-level group (p = 0.27 for both adjacent and distant sites). In the single-level group, sufficient fusion was achieved in 70.2% of cases. Pathogen identification was possible 58.5% of the time.

CONCLUSIONS

Surgical treatment of multi-level PSD is a safe option. Our study demonstrates that there was no significant difference in early fusion outcomes between single-level and multi-level PSD, whether adjacent or distant.

Confronting the Negative Impact of Cigarette Smoking on Cancer Surgery

Smoking is a common health risk behavior that has substantial effects on perioperative risk and postoperative surgical outcomes. Current smoking is clearly linked to an increased risk of perioperative cardiovascular, pulmonary and wound healing complications. Accumulating evidence indicates that smoking cessation can reduce the higher perioperative complication risk that is observed in current smokers. In addition, continued smoking has a negative impact on the overall prognosis of cancer patients. Smoking cessation, on the other hand, can improve long-term outcomes after surgery. Smoking cessation services should be implemented in a comprehensive programmatic manner to ensure that all patients gain access to evidence-based care. Although the benefits of abstinence increase in proportion to the length of cessation, cessation should be recommended regardless of timing prior to surgery.

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.

The impact of cigarette smoking and nicotine on traumatic brain injury: a review

INTRODUCTION

Traumatic Brain Injury (TBI) and tobacco smoking are both serious public health problems. Many people with TBI also smoke. Nicotine, a component of tobacco smoke, has been identified as a premorbid neuroprotectant in other neurological disorders. This study aims to provide better understanding of relationships between tobacco smoking and nicotine use and effect on outcome/recovery from TBI.

METHODS

PubMed database, SCOPUS, and PTSDpub were searched for relevant English-language papers.

RESULTS

Twenty-nine human clinical studies and nine animal studies were included. No nicotine-replacement product use in human TBI clinical studies were identified. While smoking tobacco prior to injury can be harmful primarily due to systemic effects that can compromise brain function, animal studies suggest that nicotine as a pharmacological agent may augment recovery of cognitive deficits caused by TBI.

CONCLUSIONS

While tobacco smoking before or after TBI has been associated with potential harms, many clinical studies downplay correlations for most expected domains. On the other hand, nicotine could provide potential treatment for cognitive deficits following TBI by reversing impaired signaling pathways in the brain including those involving nAChRs, TH, and dopamine. Future studies regarding the impact of cigarette smoking and vaping on patients with TBI are needed .

Smoking as a Risk Factor for Surgical Site Complications in Implant-Based Breast Surgery

Background Smoking is a cause of many postoperative complications, including delayed wound healing, tissue necrosis, and reconstructive flap loss. However, there is a paucity of evidence-based guidelines for smoking cessation in patients undergoing implant-based breast surgery. Objective The objective of this study was to determine if smoking is associated with wound dehiscence or superficial/deep surgical site infection (SSI) in women undergoing implant-based breast surgery. Methods Using theAmerican College of Surgeons National Surgical Quality Improvement Program, data was obtained of U.S. adult females (n=10,077) between the ages of 18 and 70 who underwent insertion of a breast prosthesis from 2014 to 2016. The patient's preoperative smoking status, demographics, and comorbidities were analyzed to determine association with wound dehiscence, superficial SSI, and deep SSI. Unadjusted and adjusted logistic regression analyses were used to calculate odds ratios (OR) and 95% confidence intervals (95% CI). Results Patients who smoked had a statistically significant higher proportion of wound complications (2.4%) compared to non-smokers (1.3%; p<0.01). Adjusted analysis demonstrated a significantly higher odds of wound complications in smoking patients compared to those who did not smoke (OR 2.0; 95% CI 1.3-3.2). Conclusions Our study suggests that smoking is an independent risk factor for postoperative complications in patients undergoing implant-based breast surgery. These results have significant clinical implications, as increased precautions can be taken in smokers undergoing breast surgery to minimize postoperative wound complications. Future studies may determine the optimal amount of time that patients should abstain from smoking prior to implant-based breast surgery.

Pain During Sex Before and After Decompressive Surgery for Lumbar Spinal Stenosis: A Multicenter Observational Study

STUDY DESIGN

Observational multicenter study.

OBJECTIVE

The aim of this study was to evaluate changes in pain during sexual activity after surgery for lumbar spinal stenosis (LSS).

SUMMARY OF BACKGROUND DATA

There are limited data available on sexual function in patients undergoing surgery for LSS.

METHODS

Data were retrieved from the Norwegian Registry for Spine Surgery. The primary outcome was change in pain during sexual activity at 1 year, assessed by item number eight of the Oswestry disability index questionnaire. Secondary outcome measures included Oswestry Disability Index, EuroQol-5D, and numeric rating scale scores for back and leg pain.

RESULTS

Among the 12,954 patients included, 9908 (76.5%) completed 1-year follow-up. At baseline 9579 patients (73.9%) provided information about pain during sexual activity, whereas 7424 (74.9%) among those with complete follow-up completed this item. Preoperatively 2528 of 9579 patients (26.4%) reported a normal sex-life without pain compared with 4294 of 7424 patients (57.8%) at 1 year. Preoperatively 1007 (10.5%) patients reported that pain prevented any sex-life, compared with 393 patients (5.3%) at 1 year. At baseline 7051 of 9579 patients (73.6%) reported that sexual activity caused pain, and among these 3145 of 4768 responders (66%) reported an improvement at 1 year. A multivariable regression analysis showed that having a life partner, college education, and working until time of surgery were predictors of improvement in pain during sexual activity. Current tobacco smoking, pain duration >12 months, previous spine surgery, and complications occurring within 3 months were negative predictors.

CONCLUSION

This study clearly demonstrates that a large proportion of patients undergoing surgery for LSS experienced an improvement in pain during sexual activity at 1 year.Level of Evidence: 2.

The effect of smoking on achieving meaningful clinical outcomes one year after lumbar tubular microdecompression: a matched-pair cohort analysis

BACKGROUND CONTEXT

There has been a shift in the spine literature in reporting meaningful outcomes, including meaningful clinically important difference (MCID), after surgery. The evidence on the effect of tobacco smoking at the time of lumbar tubular microdecompression (LTMD) on meaningful outcomes is limited.

PURPOSE

To compare differences in 1-year functional outcomes and rates of achieving MCID between current smokers and non-smokers who underwent LTMD for lumbar spinal stenosis (LSS).

STUDY DESIGN

A nested case control study to compare the difference in patient reported outcomes (PROs) between smokers and non-smokers 1-year after undergoing LTMD.

PATIENT SAMPLE

This study included patients that underwent single level LTMD by a single surgeon between January 2014 through August 2019.

OUTCOME MEASURES

Preoperative and postoperative PROs were recorded using the questionnaires EQ-5D, Oswestry Disability Index (ODI), and the visual analog scale (VAS) for back pain and leg pain. The MCID was also used.

METHODS

Current tobacco smokers at the time of surgery were matched 1:2 to non-smokers by age (+/- 1year). Preoperative and postoperative functional scores were compared between the two groups using independent t-tests. Additionally, thresholds for achieving MCID were calculated for each individual functional score, and were compared using Fisher's exact test.

RESULTS

Of the 183 patients with 1-year follow-up who met inclusion criteria, 35 patients were identified as smokers and were matched to 70 non-smokers. No statistical differences were identified between age, BMI, or gender. Comparison of preoperative PROs showed no statistically significant differences between smokers and non-smokers (p>0.05 for all), while smokers had statistically lower EQ-5D (p<0.001) and higher ODI (p=0.05), VAS back (p=0.033), and VAS leg (p=0.03) score averages at a minimum of one year follow-up. Evaluation of meaningful outcomes demonstrated non-smokers had higher rates of achieving MCID on at least 1 threshold score as compared to smokers (98.5% vs. 91.1%; p=0.043).

CONCLUSIONS

Current smokers at the time of surgery have inferior postoperative EQ-5D scores, increased pain and disability, and lower odds of achieving the MCID at 1-year after undergoing LTMD when compared to patients without any smoking history.

Pain During Sex Before and After Surgery for Lumbar Disc Herniation: A Multicenter Observational Study

STUDY DESIGN

Observational multicenter study.

OBJECTIVE

The aim of this study was to evaluate changes in pain during sexual activity after surgery for lumbar disc herniation (LDH).

SUMMARY OF BACKGROUND DATA

There are limited data available on sexual function in patients undergoing surgery for LDH.

METHODS

Data were retrieved from the Norwegian Registry for Spine Surgery. The primary outcome was change in pain during sexual activity at one year, assessed by item number eight of the Oswestry disability index (ODI) questionnaire. Secondary outcome measures included ODI, EuroQol-5D (EQ-5D), and numeric rating scale (NRS) scores for back and leg pain.

RESULTS

Among the 18,529 patients included, 12,103 (64.8%) completed 1-year follow-up. At baseline, 16,729 patients (90.3%) provided information about pain during sexual activity, whereas 11,130 (92.0%) among those with complete follow-up completed this item. Preoperatively 2586 of 16,729 patients (15.5%) reported that pain did not affect sexual activity and at 1 year, 7251 of 11,130 patients (65.1%) reported a normal sex-life without pain. Preoperatively, 2483 (14.8%) patients reported that pain prevented any sex-life, compared to 190 patients (1.7%) at 1 year. At baseline, 14,143 of 16,729 patients (84.5%) reported that sexual activity caused pain, and among these 7232 of 10,509 responders (68.8%) reported an improvement at 1 year. A multivariable regression analysis showed that having a life partner, college education, working until time of surgery, undergoing emergency surgery, and increasing ODI score were predictors of improvement in pain during sexual activity. Increasing age, tobacco smoking, increasing body mass index, comorbidity, back pain >12 months, previous spine surgery, surgery in two or more lumbar levels, and complications occurring within 3 months were negative predictors.

CONCLUSION

This study clearly demonstrates that a large proportion of patients undergoing surgery for LDH experienced an improvement in pain during sexual activity at 1 year.

LEVEL OF EVIDENCE

2.

Tobacco Use Is Associated with Readmission within 90 Days after Craniotomy

OBJECTIVE

Tobacco use increases morbidity and mortality following craniotomy. Readmission is an important hospital metric of patient outcomes and has been used to inform reimbursement. This study aims to determine if tobacco use is associated with readmission within 90 days of hospital discharge among patients undergoing elective craniotomy.

METHODS

The Nationwide Readmissions Database (NRD), a population-based, nationally representative database, was queried from 2010-2014. Patients undergoing craniotomy for benign or malignant tumors, vascular pathologies, and epilepsy were identified. Readmissions within 90 days of index hospitalization were characterized by admitting diagnoses. Tobacco use was defined by ICD-9 coding for active or prior use. Descriptive and multivariable regression analyses evaluated patient and hospital factors associated with readmission.

RESULTS

The study population included 77,903 patients treated with craniotomy. Of these, 17,674 (22.6%) were readmitted within 90 days. The most common reasons for readmission were post-operative infection (5.8%), septicemia (4.2%), pulmonary embolism (3.9%), and pneumonia (2.9%). Tobacco use was associated with a 7% increased likelihood of 90-day readmission (OR 1.07, 95% CI 1.03-1.11, p = 0.0008) after accounting for other patient-, disease-, and hospital-level factors in multivariate analysis.

CONCLUSIONS

Tobacco use was associated with increased 90-day readmission in patients undergoing craniotomy. Recognizing tobacco use as a modifiable risk factor of readmission presents an opportunity to identify susceptible patients.

Impact of sufficient contact between the autograft and endplate soon after surgery to prevent nonunion at 12 months following posterior lumbar interbody fusion

OBJECTIVE

Nonunion after posterior lumbar interbody fusion (PLIF) is associated with poor long-term outcomes in terms of health-related quality of life. Biomechanical factors in the fusion segment may influence spinal fusion rates. There are no reports on the relationship between intervertebral union and the absorption of autografts or vertebral endplates. Therefore, the purpose of this retrospective study was to evaluate the risk factors of nonunion after PLIF and identify preventive measures.

METHODS

The authors analyzed 138 patients who underwent 1-level PLIF between 2016 and 2018 (75 males, 63 females; mean age 67 years; minimum follow-up period 12 months). Lumbar CT images obtained soon after the surgery and at 6 and 12 months of follow-up were examined for the mean total occupancy rate of the autograft, presence of a translucent zone between the autograft and endplate (more than 50% of vertebral diameter), cage subsidence, and screw loosening. Complete intervertebral union was defined as the presence of both upper and lower complete fusion in the center cage regions on coronal and sagittal CT slices at 12 months postoperatively. Patients were classified into either union or nonunion groups.

RESULTS

Complete union after PLIF was observed in 62 patients (45%), while nonunion was observed in 76 patients (55%). The mean total occupancy rate of the autograft immediately after the surgery was higher in the union group than in the nonunion group (59% vs 53%; p = 0.046). At 12 months postoperatively, the total occupancy rate of the autograft had decreased by 5.4% in the union group and by 11.9% in the nonunion group (p = 0.020). A translucent zone between the autograft and endplate immediately after the surgery was observed in 14 and 38 patients (23% and 50%) in the union and nonunion groups, respectively (p = 0.001). The nonunion group had a significantly higher proportion of cases with cage subsidence and screw loosening at 12 months postoperatively in comparison to the union group (p = 0.010 and p = 0.009, respectively).

CONCLUSIONS

A lower occupancy rate of the autograft and the presence of a translucent zone between the autograft and endplate immediately after the surgery were associated with nonunion at 12 months after PLIF. It may be important to achieve sufficient contact between the autograft and endplate intraoperatively for osseous union enhancement and to avoid excessive absorption of the autograft. The achievement of complete intervertebral union may decrease the incidence of cage subsidence or screw loosening.

Smoking Paradox in Stroke Survivors?: Uncovering the Truth by Interpreting 2 Sets of Data

Background and Purpose- The observation that smokers with stroke could have better outcome than nonsmokers led to the term "smoking paradox." The controversy of such a complex claim has not been fully settled, even though different case mix was noted. Analyses were conducted on 2 independent data sets to evaluate and determine whether such a paradox truly exists. Methods- Taiwan Stroke Registry with 88 925 stroke cases, and MJ cohort with 541 047 adults participating in a medical screening program with 1630 stroke deaths developed during 15 years of follow-up (1994-2008). Primary outcome for stroke registry was functional independence at 3 months by modified Rankin Scale score ≤2, for individuals classified by National Institutes of Health Stroke Scale score at admission. For MJ cohort, mortality risk by smoking status or by stroke history was assessed by hazard ratio. Results- A >11-year age difference in stroke incidence was found between smokers and nonsmokers, with a median age of 60.2 years for current smokers and 71.6 years for nonsmokers. For smokers, favorable outcome in mortality and in functional assessment in 3 months with modified Rankin Scale score ≤2 stratified by the National Institutes of Health Stroke Scale score was present but disappeared when age and sex were matched. Smokers without stroke history had a ≈2-fold increase in stroke deaths (2.05 for ischemic stroke and 1.53 for hemorrhagic stroke) but smokers with stroke history, 7.83-fold increase, overshadowing smoking risk. Quitting smoking at earlier age reversed or improved outcome. Conclusions- "The more you smoke, the earlier you stroke, and the longer sufferings you have to cope." Smokers had 2-fold mortality from stroke but endured stroke disability 11 years longer. Quitting early reduced or reversed the harms.

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.

Deep Vein Thrombosis After Complex Posterior Spine Surgery: Does Staged Surgery Make a Difference?

STUDY DESIGN

Retrospective review of a prospectively collected database.

OBJECTIVE

To assess the incidence of deep vein thrombosis (DVT) associated with single- versus multistage posterior-only complex spinal surgeries.

SUMMARY OF BACKGROUND DATA

Dividing the physiologic burden of spinal deformity surgery into multiple stages has been suggested as a potential means of reducing perioperative complications. DVT is a worrisome complication owing to its potential to lead to pulmonary embolism. Whether or not staging affects DVT incidence in this population is unknown.

METHODS

Consecutive patients undergoing either single- or multistage posterior complex spinal surgeries over a 12-year period at a single institution were eligible. All patients received lower extremity venous duplex ultrasonographic (US) examinations 2 to 4 days postoperatively in the single-stage group and 2 to 4 days postoperatively after each stage in the multistage group. Multivariate logistic regression was used to assess the independent contribution of staging to developing a DVT.

RESULTS

A total of 107 consecutive patients were enrolled-26 underwent multistage surgery and 81 underwent single-stage surgery. The single-stage group was older (63 years vs. 45 years; p < .01) and had a higher Charlson comorbidity index (2.25 ± 1.27 vs. 1.23 ± 1.58; p < .01). More multistage patients had positive US tests than single-stage patients (5 of 26 vs. 6 of 81; 19% vs. 7%; p = .13). Adjusting for all the above-mentioned covariates, a multistage surgery was 8.17 (95% CI 0.35-250.6) times more likely to yield a DVT than a single-stage surgery.

CONCLUSIONS

Patients who undergo multistage posterior complex spine surgery are at a high risk for developing a DVT compared to those who undergo single-stage procedures. The difference in DVT incidence may be understated as the multistage group had a lower pre- and intraoperative risk profile with a younger age, lower medical comorbidities, and less per-stage blood loss.

Predictors of primary autograft cranioplasty survival and resorption after craniectomy

OBJECTIVE

Craniectomy is a common neurosurgical procedure that reduces intracranial pressure, but survival necessitates cranioplasty at a later stage, after recovery from the primary insult. Complications such as infection and resorption of the autologous bone flap are common. The risk factors for complications and subsequent bone flap removal are unclear. The aim of this multicenter, retrospective study was to evaluate the factors affecting the outcome of primary autologous cranioplasty, with special emphasis on bone flap resorption.

METHODS

The authors identified all patients who underwent primary autologous cranioplasty at 3 tertiary-level university hospitals between 2002 and 2015. Patients underwent follow-up until bone flap removal, death, or December 31, 2015.

RESULTS

The cohort comprised 207 patients with a mean follow-up period of 3.7 years (SD 2.7 years). The overall complication rate was 39.6% (82/207), the bone flap removal rate was 19.3% (40/207), and 11 patients (5.3%) died during the follow-up period. Smoking (OR 3.23, 95% CI 1.50-6.95; p = 0.003) and age younger than 45 years (OR 2.29, 95% CI 1.07-4.89; p = 0.032) were found to independently predict subsequent autograft removal, while age younger than 30 years was found to independently predict clinically relevant bone flap resorption (OR 4.59, 95% CI 1.15-18.34; p = 0.03). The interval between craniectomy and cranioplasty was not found to predict either bone flap removal or resorption.

CONCLUSIONS

In this large, multicenter cohort of patients with autologous cranioplasty, smoking and younger age predicted complications leading to bone flap removal. Very young age predicted bone flap resorption. The authors recommend that physicians extensively inform their patients of the pronounced risks of smoking before cranioplasty.

Surgery for Herniated Lumbar Disc in Daily Tobacco Smokers: A Multicenter Observational Study

OBJECTIVE

To compare clinical outcomes at 1 year following single-level lumbar microdiscectomy in daily tobacco smokers and nonsmokers.

METHODS

Data were collected through the Norwegian Registry for Spine Surgery. The primary endpoint was a change in the Oswestry Disability Index (ODI) at 1 year. Secondary endpoints were change in quality of life measured with EuroQol 5 Dimensions (EQ-5D), leg and back pain measured with a numerical rating scale (NRS), and rates of surgical complications.

RESULTS

A total of 5514 patients were enrolled, including 3907 nonsmokers and 1607 smokers. A significant improvement in ODI was observed for the entire cohort (mean, 31.1 points; 95% confidence interval [CI], 30.4-31.8; P < 0.001). Nonsmokers experienced a greater improvement in ODI at 1 year compared with smokers (mean, 4.1 points; 95% CI, 2.5-5.7; P < 0.001). Nonsmokers were more likely to achieve a minimal important change (MIC), defined as an ODI improvement of ≥10 points, compared with smokers (85.5% vs. 79.5%; P < 0.001). Nonsmokers experienced greater improvements in EQ-5D (mean difference, 0.068; 95% CI, 0.04-0.09; P < 0.001), back pain NRS (mean difference, 0.44; 95% CI, 0.21-0.66; P < 0.001), and leg pain NRS (mean difference, 0.54; 95% CI, 0.31-0.77; P < 0.001). There was no difference between smokers and nonsmokers in the overall complication rate (6.2% vs. 6.7%; P = 0.512). Smoking was identified as a negative predictor for ODI change in a multiple regression analysis (P < 0.001).

CONCLUSIONS

Nonsmokers reported a greater improvement in ODI at 1 year following microdiscectomy, and smokers were less likely to experience an MIC. Nonetheless, significant improvement was also found among smokers.

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.

Assessment and classification of subsidence after lateral interbody fusion using serial computed tomography

OBJECT

Intervertebral cage settling during bone remodeling after lumbar lateral interbody fusion (LIF) is a common occurrence during the normal healing process. Progression of this settling with endplate collapse is defined as subsidence. The purposes of this study were to 1) assess the rate of subsidence after minimally invasive (MIS) LIF by CT, 2) distinguish between early cage subsidence (ECS) and delayed cage subsidence (DCS), 3) propose a descriptive method for classifying the types of subsidence, and 4) discuss techniques for mitigating the risk of subsidence after MIS LIF.

METHODS

A total of 128 consecutive patients (with 178 treated levels in total) underwent MIS LIF performed by a single surgeon. The subsidence was deemed to be ECS if it was evident on postoperative Day 2 CT images and was therefore the result of an intraoperative vertebral endplate injury and deemed DCS if it was detected on subsequent CT scans (≥ 6 months postoperatively). Endplate breaches were categorized as caudal (superior endplate) and/or cranial (inferior endplate), and as ipsilateral, contralateral, or bilateral with respect to the side of cage insertion. Subsidence seen in CT images (radiographic subsidence) was measured from the vertebral endplate to the caudal or cranial margin of the cage (in millimeters). Patient-reported outcome measures included visual analog scale, Oswestry Disability Index, and 36-Item Short Form Health Survey physical and mental component summary scores.

RESULTS

Four patients had ECS in a total of 4 levels. The radiographic subsidence (DCS) rates were 10% (13 of 128 patients) and 8% (14 of 178 levels), with 3% of patients (4 of 128) exhibiting clinical subsidence. In the DCS levels, 3 types of subsidence were evident on coronal and sagittal CT scans: Type 1, caudal contralateral, in 14% (2 of 14), Type 2, caudal bilateral with anterior cage tilt, in 64% (9 of 14), and Type 3, both endplates bilaterally, in 21% (3 of 14). The mean subsidence in the DCS levels was 3.2 mm. There was no significant difference between the numbers of patients in the subsidence (DCS) and no-subsidence groups who received clinical benefit from the surgical procedure, based on the minimum clinically important difference (p > 0.05). There was a significant difference between the fusion rates at 6 months (p = 0.0195); however, by 12 months, the difference was not significant (p = 0.2049).

CONCLUSIONS

The authors distinguished between ECS and DCS. Radiographic subsidence (DCS) was categorized using descriptors for the location and severity of the subsidence. Neither interbody fusion rates nor clinical outcomes were affected by radiographic subsidence. To protect patients from subsidence after MIS LIF, the surgeon needs to take care with the caudal endplate during cage insertion. If a caudal bilateral (Type 2) endplate breach is detected, supplemental posterior fixation to arrest progression and facilitate fusion is recommended.

Awake craniotomy to maximize glioma resection: methods and technical nuances over a 27-year period

OBJECT

Awake craniotomy is currently a useful surgical approach to help identify and preserve functional areas during cortical and subcortical tumor resections. Methodologies have evolved over time to maximize patient safety and minimize morbidity using this technique. The goal of this study is to analyze a single surgeon's experience and the evolving methodology of awake language and sensorimotor mapping for glioma surgery.

METHODS

The authors retrospectively studied patients undergoing awake brain tumor surgery between 1986 and 2014. Operations for the initial 248 patients (1986–1997) were completed at the University of Washington, and the subsequent surgeries in 611 patients (1997–2014) were completed at the University of California, San Francisco. Perioperative risk factors and complications were assessed using the latter 611 cases.

RESULTS

The median patient age was 42 years (range 13–84 years). Sixty percent of patients had Karnofsky Performance Status (KPS) scores of 90–100, and 40% had KPS scores less than 80. Fifty-five percent of patients underwent surgery for high-grade gliomas, 42% for low-grade gliomas, 1% for metastatic lesions, and 2% for other lesions (cortical dysplasia, encephalitis, necrosis, abscess, and hemangioma). The majority of patients were in American Society of Anesthesiologists (ASA) Class 1 or 2 (mild systemic disease); however, patients with severe systemic disease were not excluded from awake brain tumor surgery and represented 15% of study participants. Laryngeal mask airway was used in 8 patients (1%) and was most commonly used for large vascular tumors with more than 2 cm of mass effect. The most common sedation regimen was propofol plus remifentanil (54%); however, 42% of patients required an adjustment to the initial sedation regimen before skin incision due to patient intolerance. Mannitol was used in 54% of cases. Twelve percent of patients were active smokers at the time of surgery, which did not impact completion of the intraoperative mapping procedure. Stimulation-induced seizures occurred in 3% of patients and were rapidly terminated with ice-cold Ringer's solution. Preoperative seizure history and tumor location were associated with an increased incidence of stimulation-induced seizures. Mapping was aborted in 3 cases (0.5%) due to intraoperative seizures (2 cases) and patient emotional intolerance (1 case). The overall perioperative complication rate was 10%.

CONCLUSIONS

Based on the current best practice described here and developed from multiple regimens used over a 27-year period, it is concluded that awake brain tumor surgery can be safely performed with extremely low complication and failure rates regardless of ASA classification; body mass index; smoking status; psychiatric or emotional history; seizure frequency and duration; and tumor site, size, and pathology.

Does daily tobacco smoking affect outcomes after microdecompression for degenerative central lumbar spinal stenosis? - A multicenter observational registry-based study

BACKGROUND

There are limited scientific data on the impact of smoking on patient-reported outcomes following minimally invasive spine surgery. The aim of this multicenter observational study was to examine the relationship between daily smoking and patient-reported outcome at 1 year using the Oswestry Disability Index (ODI) after microdecompression for single- and two-level central lumbar spinal stenosis (LSS). Secondary outcomes were the length of hospital stays, perioperative and postoperative complications.

METHOD

Data were collected through the Norwegian Registry for Spine Surgery (NORspine).

RESULTS

A total of 825 patients were included (619 nonsmokers and 206 smokers). For the whole patient population there was a significant difference between preoperative ODI and ODI at 1 year (17.3 points, 95% CI 15.93-18.67, p < 0.001). There was a significant difference in ODI change at 1 year between nonsmokers and smokers (4.2 points, 95% CI 0.98-7.34, p = 0.010). At 1 year 69.6% of nonsmokers had achieved a minimal clinically important difference (≥10 points ODI improvement) compared to 60.8% of smokers (p = 0.008). There was no difference between nonsmokers and smokers in the overall complication rate (11.6% vs. 9.2%, p = 0.34). There was no difference between nonsmokers and smokers in length of hospital stays for either single-level (2.3 vs. 2.2 days, p = 0.99) or two-level (3.1 vs. 2.3 days, p = 0.175) microdecompression. Smoking was identified as a negative predictor for ODI change in a multiple regression analysis (p = 0.001) CONCLUSIONS: Nonsmokers experienced a significantly larger improvement at 1 year following microdecompression for LSS compared to smokers. Smokers were less likely to achieve a minimal clinically important difference. However, it should be emphasized that considerable improvement also was found among smokers.

Cancer prehabilitation and its role in improving health outcomes and reducing health care costs

OBJECTIVES

To examine the current state of cancer prehabilitation care and the impact that it may have on health-related and financial outcomes.

DATA SOURCES

Clinical trials, reviews and meta-analyses.

CONCLUSION

Research demonstrates that prehabilitation interventions may improve physical and/or psychological outcomes and help patients function at a higher level throughout their cancer treatment. Establishing a baseline status at diagnosis provides an opportunity to gain insight into the burden that cancer and its treatment can place on survivors with respect to physical and psychological impairments, function, and disability. Targeted interventions may reduce the incidence and/or severity of future impairments that often lead to reduced surgical complications, hospital lengths of stay, hospital readmissions, and overall health care costs. Thus, cancer prehabilitation is an opportunity to positively impact patient health-related and financial outcomes from diagnosis onward and, by decreasing the financial impact that cancer can have on individuals, may prove to be a sound investment for patients, hospitals, payers and society.

IMPLICATIONS FOR NURSING PRACTICE

Nurses, and particularly navigators, have an opportunity to significantly impact care through patient screening, prehabilitation assessments, documentation of baseline patient status and, in some cases, especially when impairments are not present at baseline, provide interventions designed to improve physical and psychological health before the start of upcoming oncology treatments and reduce the likelihood of patients developing future impairments.

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.