Editor’s Spotlight/Take 5: Cigarette Smoking Was Not Associated With Lower Odds of Radiographic Fusion After Combined TLIF and Posterolateral Lumbar (270°) Arthrodesis: A CT-based Retrospective Cohort Evaluation

Nissim Ohana MDOne doesn’t have to be terribly well read to know that cigarette smoking is unhealthy. Tobacco smoking cures no illnesses, and no robust research suggests that it mitigates the symptoms of any condition, except, perhaps, nicotine withdrawal. Yet in this month’s Clinical Orthopaedics and Related Research®, we’re not just publishing an article that demonstrates how (at least in one surgical setting) smoking didn’t diminish the likelihood of spinal fusion following surgery [9], we’re also featuring it in our Editor’s Spotlight/Take 5 section. There are good reasons for this seemingly noncanonical selection, and even if you’re not a spine surgeon, I encourage you to read on. If smoking—or any other clinical variable—increases the risks associated with the treatments that we offer, we should share that information with our patients. The problem is, too often, surgeons use strict cutoffs or dichotomous criteria [10] to deny patients surgery who might otherwise benefit from it rather than engaging in shared decision-making. Denying patients a role in the surgical decision is paternalistic; it lacks a solid basis in good-quality evidence, and it flies in the face of a common-sense understanding of risk, which nearly always works as a sliding scale rather than a binary switch [6]. It’s true that quitting smoking, improving glycemic control, and losing weight if one has obesity will decrease the risk of complications after many kinds of orthopaedic surgery. The problem is that many patients can’t achieve those goals. Fortunately, most can be helped to understand a fair risk-reward trade-off, and for that reason, cutting patients out of the decision about whether to operate is wrong because it removes the only person with actual skin in the game from the conversation. And using hard cutoffs in these decisions is particularly silly. A BMI of 40 is little different from a BMI of 39 (and the same can be said of a hemoglobin A1c of 8.0 versus one of 7.9), yet too many surgeons treat patients as though operating below some threshold is safe, while offering surgery at or above that cutoff is unsafe. That simply ain’t so, and acting as though it is ain’t fair, if for no other reason than because most of these so-called modifiable risk factors are far less modifiable than most surgeons believe [6]. For example, prior to the era of GLP-1 drugs—which most patients can’t afford or have reasonable fears about taking—the odds a patient could lose a serious amount of weight and keep it off were lower than the odds of kicking heroin using methadone [1, 3]. More than 90% of smokers who try to quit in a typical year are unable to do so, and for many of them, it may take more than 30 quit attempts before they succeed [2, 4]. Diabetes is easier to manage, but it’s still not easy. These challenges have real-world impacts. One mind-changing modeling study [11] found that inflexible cutoffs involving BMI, hemoglobin A1c, and smoking would disproportionately reduce the odds that non-Hispanic Blacks and individuals of lower socioeconomic status would be offered lower-extremity arthroplasty, which is exactly the kinds of disparities our profession is working hard to avoid propagating. In a related interview [7] about that article, the senior author of that study [11]—a surgeon who happens also to be a bioethicist—dealt eloquently with the capriciousness of these kinds of cutoffs and the harms they bring to the lives of patients whose socioeconomic circumstances are less supportive. For these reasons, anything that causes us to re-evaluate our beliefs about using a black-and-white parameter in the gray world of shared decision-making deserves our attention. In this month’s CORR®, a group of spine surgeons from Israel, led by Nissim Ohana MD, found that cigarette smoking was not associated with a lower likelihood of or quality of radiographic fusion (based on CT scans), nor of cage subsidence, after transforaminal lumbar interbody fusion (TLIF) with adjunctive posterolateral arthrodesis [9]. The study was adequately powered, their imaging approaches were conscientious, and they did an especially nice job dealing with missing data, which is always my biggest concern in a study like this. In fact, they performed a sensitivity analysis in which they assumed alternately that all missing patients had fused, and that all missing patients developed pseudarthroses. Under both of those scenarios, the main study finding did not change. These authors are not handing out packs of cigarettes on street corners, and they also were modest in their recommendations. They suggest: “Rather than contradicting prior evidence, these results suggest that contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking in this setting. Our results suggest that although smoking cessation remains advisable for general health and perioperative safety, inability to quit should not, by itself, serve as an absolute cutoff for offering TLIF. Surgical decisions should be individualized rather than based on categorial exclusion” [9]. As a surgeon, as well as in my role as a journal editor, I spend most of my time fretting about what I perceive as the growing tendency of our profession toward more permissive indications, overdiagnosis, and overtreatment [5, 8]. Despite the fact that it may result in more patients having major surgery, I don’t see this month’s Spotlight article [9] as any part of those worrisome trends. Rather, I see it as a means to draw patients with one kind of problem into a deeper and more nuanced conversation with their surgeons. And I hope it will cause other clinician-scientists to re-examine some things we think we know, so as to enable a less paternalistic approach to patient counseling. Join me as I discuss those issues and others in the Take 5 interview with Nissim Ohana MD, first author of “Cigarette Smoking Was Not Associated With Lower Odds of Radiographic Fusion After Combined TLIF and Posterolateral Lumbar (270°) Arthrodesis: A CT-based Retrospective Cohort Evaluation” [9]. Take 5 Interview with Nissim Ohana MD, first author of “Cigarette Smoking Was Not Associated With Lower Odds of Radiographic Fusion After Combined TLIF and Posterolateral Lumbar (270°) Arthrodesis—A CT-based Retrospective Cohort Evaluation” Seth S. Leopold MD:Congratulations on this thought-provoking work [9]. I think many readers will approach your study with their defenses up, looking for a reason to disagree or find fault with it. Why do you think that is, and what would you suggest to them as they engage with your study for the first time? Nissim Ohana MD: I think some defensiveness arises because our findings seem to challenge a widely accepted belief. Surgeons genuinely dislike complications. We internalize them deeply. So when research identifies a “proven” risk factor for a complication, it can create a kind of moral shelter. It gives us a defensible reason not to operate in difficult situations, which can feel protective both for the patient and for ourselves. If a study suggests that a particular risk factor may be less determinative in a specific setting than we thought, it can feel as though that protective boundary is being challenged. That is why studies on smoking, obesity, or glycemic control can generate defensiveness when they appear to challenge the status quo. But we did not study whether smoking is good or safe; we studied whether it is associated with radiographic fusion failure in a specific, contemporary surgical setting. I would encourage readers to approach our paper [9] with that distinction in mind. Smoking is unquestionably harmful, and nothing in our study should be taken to suggest otherwise. But as spine surgeons know well, the patients who come to see us are suffering. They are in pain, often with substantial impairments that affect their quality of life. Our responsibility is to navigate the tension between the known health risks of smoking and our ability to relieve pain and restore function. The question is not whether smoking is harmful, but how we balance that harm against the potential benefit of surgery for each individual patient. That balance requires nuance, not reflexes. This is why I believe it is our responsibility, as clinician-scientists, to separate emotional comfort from empirical truth. If a risk factor truly increases complications, we should acknowledge that and act accordingly. If its effect is smaller, context-dependent, or mitigated by technique, or even absent despite careful evaluation, we should acknowledge that as well. The goal is not to find reasons to operate or not to operate, but to understand risk as accurately as possible so we can have honest, individualized conversations with patients. Dr. Leopold:Are there other operations (in the spine, and perhaps in other orthopaedic subspecialities) to which you think your findings may apply, and what is the basis for that belief? It seems likely that the answer to this is yes, but I’m not sure what they might be. Dr. Ohana: I think the most immediate relevance is to other spinal fusion procedures performed with contemporary techniques: rigid fixation, biologic augmentation, careful endplate preparation, and CT-based assessment. As our methods improve, it is possible that the relative impact of certain biological factors changes. That does not mean the risk disappears, but it may not be as large or pervasive as we once believed. Beyond spine surgery, my hope is more conceptual. In many orthopaedic subspecialties, certain risk factors have become dogma, treated almost as binary contraindications. Smoking, obesity, glycemic control, and others are often framed in categorical terms. I hope our work encourages colleagues in other fields to re-examine those assumptions within their own domains, using contemporary techniques and rigorous methodology. The purpose is not to weaken standards but to test them. Dogma should always remain open to scrutiny. Dr. Leopold:Why would it be so important to get the answer to that question with confidence? Dr. Ohana: It is important because these decisions have real consequences for patients. When we treat a risk factor as an absolute contraindication, we are not just modifying counseling; we may be denying surgery to someone who is in substantial pain and experiencing a real functional decline. If smoking truly and substantially compromises outcomes in a given procedure, then we should say so clearly and help patients understand that risk. But if its impact is smaller, context-dependent, or mitigated by contemporary techniques, then rigid exclusion may not be justified. Without high-quality data, we risk making decisions based on assumptions rather than evidence. Getting the answer with confidence allows us to counsel patients honestly. It strengthens shared decision-making and ensures that our policies are guided by measured risk, not by tradition or fear. Dr. Leopold:A couple of questions for the spine surgeons among us. First, how do you counsel your patients now who are contemplating these large procedures who also smoke cigarettes? What about those who smoke very heavily (let’s say a couple of packs per day or more)? Dr. Ohana: I am very clear with patients that smoking is harmful for their general health and in the perioperative setting. I strongly encourage cessation for all of my patients. That message has not changed. What has changed is that I do not automatically treat smoking as an absolute contraindication to fusion. I explain the data, including our findings [9], and frame risk in probabilistic terms. I offer time and support to patients who wish to quit, but I do not present cessation as a rigid prerequisite in every instance. For very heavy smokers, the conversation is more cautious. I emphasize that cumulative exposure likely increases overall surgical risk, beyond fusion alone. If a patient doesn’t have severe or progressive neurologic compromise and his or her pain is tolerable, I often suggest postponing surgery for a few months to allow for an opportunity to reduce or stop smoking and better prepare for the procedure. Ultimately, the decision is individualized. The goal is not to punish or exclude, but to help patients be as healthy as possible when they have surgery, and to make decisions transparently, together. Dr. Leopold:You looked only at radiographic endpoints, not other complications, including medical complications and infections [9]. Why shouldn’t a reader consider that a disqualifying shortcoming that undermines your conclusions, since so much research suggests that smoking is associated with those kinds of complications? Dr. Ohana: That is a fair concern, and I don’t think readers should ignore it. However, I would say this is not a disqualifying shortcoming but a reminder that surgical risk is multidimensional. Smoking is clearly associated with medical complications and wound problems in many surgical settings, and our study [9] was not designed to challenge that body of evidence. Rather, our primary question was very specific and focused on whether smoking was associated with radiographic fusion failure in the setting of contemporary 270° fusion assessed by CT. Fusion success is often the central justification for requiring smoking cessation before surgery. We felt that question deserved to be examined directly and rigorously. The fact that we did not study other complications does not invalidate our findings; it defines the scope of them. Our results should not be interpreted as “smoking is safe for surgery”; rather, our findings suggest that, in this specific context, fusion biology may be less sensitive to smoking than previously assumed. Other risks may still exist and should absolutely be part of patient counseling. Likewise, other important questions remain, and they should be studied with the same rigor.