How Smoking Can Cause Spinal Fusion Failure
Smoking killed my mom’s older sister, Aunt Bertha. Even now, so many years later, my mom still remembers with a hurt heart my Aunt Bertha’s last days on Earth. Even as her face turned blue from the lost of oxygen and her lungs were dying, my aunt still wanted her cigarette. Her death was not peaceful. My aunt Bertha’s story is not unique, but fortunately more people are becoming aware that cigarette smoking is associated with an increased risk of lung problems. However, most people don’t know that smoking is also bad for your bones and can result in such things as spinal fusion failure.
Here Are Some Stats to Think About
Currently, there are more than 50 million smokers in this country, and approximately 800 billion cigarettes are smoked each year. Smoking is now the leading avoidable cause of morbidity and mortality in the United States. According to one report, over 500,000 deaths per year in the United States alone can be attributed to smoking
However, how smoking can cause spinal fusion failure is also becoming a major issue for those needing back fusion surgery.
This post examines the issue in depth with the hope that if you or a loved one is in need of a spinal fusion surgery you understand completely how smoking can effect the outcome.
With that said, let’s jump in and discuss what exactly is spinal fusion surgery?
In that procedure, surgeons remove discs between two or more vertebrae. The bones in the spine are then attached with hardware and treated with growth factors. As the spine heals, new bone begins to form, and the vertebrae fuse together.
Orthopedic Patients and Spinal Fusion Surgery
It’s becoming increasingly clear that orthopedic patients who smoke have worse outcomes than those who don’t. The clinical effects of smoking on bone and wound healing include longer times to union, higher rates of nonunion, and higher rates of infection and wound complications.
Here is an Illustrative Story of a Smoker With a Spinal Fusion Problem.
“I had spinal fusion on L4/L5 with bone graph and cadaver bone. I’m almost 3 months post op. While I feel better I still have pain and have muscle spasms. My Dr. said my fusion is not fusing . My hardware is 4 screws and 2 rods. I did smoke until weeks b4 surgery and quit..well I started back (5 cigarettes a day)”—smoker from spinal fusion forum
In a study of more than 75,000 Canadian adults, daily smoking was associated with increased odds of having chronic LBP; this is consistent with the results of similar studies that were conducted in the USA 
At Jefferson Medical College/Rothman Institute, reviewed several studies that highlighted the effects of smoking on fracture healing, reconstructive procedures, and wound healing.
” Smoking is the only significant predictor of nonunion in open tibial fractures,” said Dr. Hilibrand. “Spinal fusion studies have found higher nonunion rates among smokers, compared to nonsmokers. 
3 factors That May Determine How Smoking Prevents Fusion of The Spine
- Low Level of Vitamin D
- Smoking reduces bone mineral content
- Smoking accelerates spinal degenerative processes 
In the last post I covered how Vitamin D Deficiency can cause back pain. Well, researchers have found that the main risk factors for inadequate Vitamin D were smoking.There is now enough evidence that shows a link between low Vitamin D and poor outcomes following spinal fusion. In other words, the vertebrae didn’t fuse. The evidence is so strong that some doctors are recommending that patients having orthopedic surgery ensure they’re getting enough vitamin D.
Smoking Can Cause Spinal Fusion Failure by Reducing Bone Mineral Content
Smoking has been shown to adversely affect bone mineral density, lumbar disk disease, the rate of hip fractures, and the dynamics of bone and wound healing. I should point out that scientific and clinical information on smoking and its consequences suggests differing degrees of correlation between smoking and orthopedic conditions. Some studies say there is a strong correlation and some say the correlation may not be impactful on some people. most available data however do suggest a real and reproducible relationship between smoking and slow bone healing. In a word, smoking makes it much harder for a spine to fuse.
Effect of Nicotine on Spinal Disc Cells: a Cellular Mechanism For Disc Degeneration
When studies confirm that smoking is a strong risk factor for back pain, the most widely accepted explanations for the association between smoking and disc degeneration is malnutrition of spinal disc cells. In other words, nicotine, a constituent of tobacco smoke, present in most body fluids of smokers may be the culprit that prevents nutrients from reaching spinal disc cells. In essence, the bone graft does not get enough nutrients due to a lack of blood supply and, therefore, does not grow and cannot form a fusion.
Return-to-Work Study of Smokers Vs. Non-smokers
A study by Glassman, Anagnost et al. (200) investigated the effects of smoking and smoking cessation on spinal fusion out comes. As part of their analysis, they looked at the return to work rate in smokers versus non-smokers, all of whom had s successful spinal fusion surgery ( they had a solid fusion). The investigators found the following return to work rates:
- 51% for patients who never quit smoking before or after surgery
- 68% for patients who quit smoking for longer than one month after surgery
- 77% for patients who quit smoking for longer than 6 months after surgery
- 71% for patients who were non-smokers 
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I don’t want anyone walking away feeling that this post offers a conclusive connection between smoking and lower back pain. The truth is that few reports have demonstrated a definitive relationship between smoking dose and lumbar disk herniation (LDH), a cause of lower back or sciatic pain. There are other factors to also consider such as how big, how tall, how strenuous one works. One has to also look at the contribution of genetics to LBP. This post was focused more on the risk of smoking as it relates to spinal fusing. Smoking has been found to accelerate the rate of disc degeneration and this might contribute to ongoing spine problems even after a spine fusion. If you or a loved one is in need of spinal fusion surgery, the doctor may have to postpone the operation. I present this information so that you or a loved one takes the time to stop smoking before the due date of the operation and perhaps 6 weeks after the operation.
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I like to hear from the readers so please leave me a comment below to let me know if this post helped you or if you have any questions.
J Am Acad Orthop Surg. 2001 Jan-Feb;9(1):9-17.
The musculossleletal effects of smoking.
Porter SE, Hanley EN Jr.
Kelly, Frank B. “Ask, advise, refer to improve surgical outcomes: perioperative smoking cessation forum reviews the evidence” AAOS NOW, 2012, p. 1+
“LOW Vitamin D Common In Spine Surgery Patients.” States News Service, 3 Nov. 2111
5 See Note 2
Chiang, Shang-Lin, et al “Cigarette smoking dose as a predictor of need for surgical intervention in patients with lumbar disk herniation.” Journal of Medical Sciences, vol. 34, no. 1, 2014, p. 23.