Non-tobacco nicotine use and complications in single-level posterior lumbar and transforaminal lumbar interbody fusion

Over 300,000 lumbar fusion surgeries are performed annually for various indications. Tobacco use has previously been demonstrated to increase rates of nonunion and mechanical complications, but the impact of non-tobacco nicotine (NTN) products is less well known. Given the increasing NTN use, the present study aimed to explore their effect on postoperative outcomes following single-level posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) procedures.

The TriNetX database was retrospectively reviewed using Current Procedural Terminology (CPT) codes to identify all patients who underwent single-level PLIF or TLIF. Patients were excluded if they underwent multilevel PLIFs/TLIFs, concomitant or adjunct anterior fusion, or underwent surgery for infection, fracture, tumor, or deformity. Patients were stratified into cohorts based on preoperative NTN use, excluding those with tobacco use or dependence determined by International Classification of Disease (ICD)-10 codes. 1:1 propensity score matching was performed using age at surgery, sex, BMI, anticoagulant use, and Charlson Comorbidity Index. Outcomes of interest were 90-day medical complications (including venous thromboembolism, wound infection, dysphagia) and two-year primary implant-related complications (e.g., pseudarthrosis, adjacent segment disease, hardware failure).

43,683 patients were identified (3,879 and 39,804 patients for NTN and control), which produced cohorts of 3,523 patients each after propensity matching. NTN patients had significantly higher odds of emergency department (ED) visits and opioid abuse/dependence at 90-days (9.3% vs. 7.2%; p = 0.001), (0.9% vs. 0.5%; p = 0.038) and 2-years (21.9% vs. 16.7%; p < 0.001), (2.7% vs. 1.1%, p < 0.001) respectively. Groups did not differ in the rates of any studied medical complication, including infection (2.3% vs. 2.2%; p = 0.69), or dysphagia (0.4% vs. 0.4%; p = 0.70). At 2 years postoperative, NTN patients had significantly higher odds of pseudarthrosis (22.2% vs. 14.1%; p < 0.001) and adjacent segment degeneration (ASD) (10.6% vs. 7.5%; p < 0.001). There was no significant difference in implant failure (0.8% vs. 0.7%; p = 0.67).

The present analysis finds NTN use to be associated with increased rates of ED visits, opioid dependence, pseudarthrosis, and ASD following single-level PLIF/TLIF. The results suggest NTN may negatively impact fusion outcomes in a manner similar to conventional tobacco products.