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Mir H. Ali, MD, PhD
Orthopedic Spine Surgery
Patient Educational Series

The Trouble with Smoking and Nicotine Products

One of the most surprising conversations I have with patients is that I recommend all patients with any disc or nerve problems stop the use of nicotine products immediately. This will not only help them possibly avoid surgery but also increase the chances of success if surgery should be needed in the future.

The reasons for nicotine worsening disc degeneration, nerve healing, and surgical healing have been well documented and strict rules have been implemented in other industrialized nations to limit the types of surgery that is performed in patients who use nicotine to minimize the adverse consequences of surgery in this patient population. For example, there certain surgeries that are performed routinely the United States on smokers that would not be allowed in Europe or Canada. This includes many orthopedic and spine procedures.

The role of nicotine in impairing nerve healing is well understood and not different from the way nicotine impairs wound healing and the way nicotine increases the chances of someone having a heart attack. Nicotine acts as an arteriolar vasoconstrictor, which means that it causes small blood passageways to become narrow. This causes delayed healing of a particular organ or structure due to the fact that blood flow is required for adequate healing. If there is less blood flowing to an organ, then there will be a slower healing process for that organ. Nicotine - by narrowing the passageway for the blood - impairs healing of nerves and wounds. Thus it is not uncommon to see a non-smoker heal from a herniated disc or a pinched nerve within 3 months while it may take a nicotine user 6 months or more to heal. Thus, it is very important that nicotine be stopped in order to maximize the body's healing potential.

The goal of spine surgery is to decompress the nerve and give it the best environment in which to heal. Because of the fact that in surgery the nerve is decompressed but still has to heal from within, I try to avoid doing elective spinal surgery in nicotine users. The reason for this is even if the nerve is decompressed and if there is poor blood flow because of the nicotine use, the patient may undergo surgery - and the surgery may be performed perfectly - but if the nerve does not heal then the patient's pain and/or weakness may persist. This is a common reason why smokers have poor outcomes from spinal surgery. I generally do not perform elective spine surgery in smokers but if there is a significant emergency (such as spinal cord compression, bowel/bladder problems, weakness of the legs/arms, etc.), then will perform surgery with the patient understanding the reasons clearly why nicotine is going to impair the optimal outcome of the surgery.

From a surgical standpoint, nicotine also delays all the aspect of healing that a person must undergo to have a successful outcome from spine surgery. First and foremost, wound healing is impaired in nicotine users because of the decreased blood flow to the skin. In order for skin to heal, blood flow must be present and the better blood flow there is, the faster the wound will heal. Delayed healing of the wound increases the risk for infection because the skin is one of the most important barriers towards infection. Secondly, if the nerve is decompressed, the nerve then can heal normally without the pressure or irritation/inflammation that it had prior to surgery. However, this nerve healing requires blood flow and if the blood is impaired due to nicotine use, the nerve - even though it is decompressed - may continue to function abnormally and continue to be a cause of pain because it is not able to heal fully. Thirdly, if a patient requires a fusion - where the bones are welded together - then blood flow is very important to get the bones to heal to one another. The process of fusion is very similar to bones' healing when a bone is broken. In both cases increased blood flow increases the rate of bone healing. Someone who breaks a bone has a much higher chance of the bones not healing if they are using nicotine as opposed to if they are not using nicotine. Thus fusion surgery is highly discouraged in patients who use nicotine.

When a person presents with a non-emergent spinal condition, we work with the patient's primary care physician to get the patient off of nicotine as soon as possible. This increases the chance having the nerve irritation/inflammation resolving without the need for surgery and also increases the chance of surgical success if surgery would be needed in the future. The effects of nicotine last about six weeks in the body. Thus, I recommend strongly that patients stop using the nicotine products 6 weeks prior to surgery and remain off nicotine products after surgery. Even then, some patients cannot help but return to nicotine products after surgery so in the process of surgery we take special safeguards to ensure/maximize the patient fuses in case they should return to nicotine use postoperatively.

Please discuss the adverse effects of nicotine to your general health with your primary care physician and discuss the specific ways in which nicotine worsens nerve and spine problems with your orthopedic spine surgeon.

Mir H. Ali, MD,PhD
Director - Deerpath Spine Institute
Orthopedic Spine Surgeon - Rezin Orthopedics & Sports Medicine

Dr. Ali is a board certified orthopedic spine surgeon trained in the diagnosis as well as the treatment of non-operative and operative spinal disorders. Dr. Ali practices in the far western and southwestern suburbs of Chicago and utilizes surgery as a last resort when all other non-operative treatments have failed to relieve pain and/or reduce risk of nerve damage/injury. All recommendations on this site are for general situations and a particular situation requires evaluation before specific treatment recommendations can be made.