Tobacco use, back pain, and the need for vertebral surgery among patients referred for pre-operative evaluation

1. Tobacco use, back pain, and the need for vertebral surgery among patients referred for pre-operative evaluation Young K1, Saito H2, Suyama A2, Fukunaga B, Atebara K, Golden S, Fern BD1, Tam EK1. 1Department of Medicine, 3John A. Burns School of Medicine and 2Queen’s Medical Center

2. Introduction/Background • In Hawaii, 17% of the population continues to smoke (1). More than 1,100 deaths each year are due to tobacco-related causes(1). • Preparation for surgery provides a unique opportunity to promote tobacco cessation, and to learn if other conditions or surgeries are associated with tobacco use.

3. The Anesthesia Preoperative Evaluation Center (APEC) at Queen’s Medical Center collects pre-operative data for more than 1,000 surgeries each year. We retrospectively reviewed this data to determine the overall smoking prevalence among patients scheduled for surgery and to test for associations between smoking and particular conditions or surgeries.

4. Early findings indicated a high frequency of cervical, thoracic, and lumbar vertebral or spinal surgeries. New data suggests that tobacco smoke impairs inter-vertebral disc regeneration (4) • We tested the hypotheses that smoking prevalence is higher among patients who require surgery and smoking is associated with the need for surgery on the spine and intervertebral discs.

5. Methods • Retrospective review approved by Queen’s Medical Center Institutional Review Board. • Data was abstracted from consecutive telephone interviews of adults referred by their surgeons to APEC between March and June, 2005. Data was entered in a relational database (Filemaker Pro).

6. Statistics • Fischer Exact T-test to test for associations between smoking history and history of back pain or scheduled surgeries of the cervical, thoracic or lumbar spine. • A p-value of ≤ 0.05 was considered statistically significant.

7. APEC Questionnaire

8. Demographics, smoking status, and frequency of chronic conditions in patients referred to APEC, n=1009

9. Most frequent surgeries for which patients were referred to APEC

10. Is there an association between smoking status and back pain or vertebral surgery? p=0.06 p=0.02

11. Conclusions/Discussion • Smoking prevalence of 16% is comparable to statewide prevalence, and lower than we had hypothesized for this group. • Current or former smoking is associated with the need for spinal surgery. • These findings indicate a need for prospective studies of larger sample size that use objective measures of tobacco use • Tobacco cessation is an important part of pre-operative evaluation and management

12. Acknowledgments Supported by the Hawaii Tobacco Prevention and Control Trust Fund, the American Lung Association of Hawaii, the Leahi Fund, and the Hawaii Community Foundation. We thank James Fernandez , Eileen Gaspar and Laura Hsu for data assistance.

13. References • Behavioral Risk Factor Surveillance Survey. Hawaii Smoking Prevalence. Center for Disease Control, 2005. <www.cdc.gov>. • Le Maitre, C. L., A. J. Freemont, et al. (2005). "The role of interleukin-1 in the pathogenesis of human intervertebral disc degeneration." Arthritis Res Ther7(4): R732-45. • Moller, A. and Tonnesen H. Risk reduction: Perioperative Smoking Intervention. Best Practice Research Clinical Anaesthesiology. 2006: 20(2), 237-48. • Ogawa, T., H. Matsuzaki, et al. (2005). "Alteration of gene expression in intervertebral disc degeneration of passive cigarette- smoking rats: separate quantitation in separated nucleus pulposus and annulus fibrosus." Pathobiology72(3): 146-51. • Uei, H., H. Matsuzaki, et al. (2006). "Gene expression changes in an early stage of intervertebral disc degeneration induced by passive cigarette smoking." Spine31(5): 510-4.