Evolving Technique: The Effect of Smoking and Ketorolac on Spinal Surgery Stephen Curtin MD Tucson Orthopeadic Institute Tucson, AZ
Smoking • Inhaled organics/smoke • Nicotine • “Health” • Fusion • Wound/soft tissue problems • Philosophy and strategy
Smoking and Spinal Surgery The effect of nicotine on spinal fusion. DH Silcox III, T Daftari, SD Boden, JH Schimandle… - Spine, 1995 The effect of cigarette smoking and smoking cessation on spinal fusion SD Glassman, SC Anagnost, A Parker, D Burke… - Spine, 2000 Effects of a Perioperative Smoking Cessation Intervention on Postoperative Complications: A Randomized Trial Lindström, David MD, PhD*; Azodi, Omid Sadr MD†; Wladis, Andreas MD, PhD*; …Annals of Surgery: November 2008 -Volume 248 - Issue 5 - pp 739-745 Cigarette smoking increases complications following fracture: a systematic review JA Scolaro, ML Schenker, S Yannascoli, K Baldwin… - JBJS, 2014
Cigarette Smoke Cellular level 4000 Identified Substances Nicotine Alteration of Cytokine Genes • • associated with: Vasoconstrictive • Neovascularization Platelet aggregation • • Osteoblast differentiation Carbon monoxide • • BMP’s • Displaces oxygen from Hgb • Fibroblast growth factor • Hydrogen cyanide • Collagen synthesis • Inhibits mitochondrial cytochrome • oxidase
Smoking and Spinal Surgery Pseudo arthrosis • Multiple adverse affects • 2X-5X Pseudo arthrosis • Vaping • Nicotine is nicotine • Medical Marijuana • Inhaled organic • Strategies for quitting • Chantix, Zyban, NRT • BMP
Ketorolac and Spinal Surgery Pro Con • Non-narcotic • Bleeding pain relief • Gastrointestinal • Pseudo arthrosis
Ketorolac and Spinal Surgery The Effect of Postoperative Nonsteroidal Anti-inflammatory Drug • Administration on Spinal Fusion SD Glassman, SM Rose, JR Dimar, RM Puno… - Spine, 1998 • Ketorolac and spinal fusion: does the perioperative use of ketorolac • really inhibit spinal fusion? BB Pradhan, RL Tatsumi, J Gallina, CA Kuhns… - Spine, 2008 • High-dose ketorolac affects adult spinal fusion: a meta-analysis of the • effect of perioperative nonsteroidal anti-inflammatory drugs on spinal fusion QLi, Z Zhang, Z Cai - Spine, 2011 • The Effect of Ketorolac on Spinal Fusion: What Is the Evidence? • J Li, RM Ajiboye, A Sharma, AO Ashana… NASS 31 st Annual Meeting Proceedings,2016 •
Ketorolac and Spinal Surgery Non-fusion Surgery Fusion Surgery • Excellent for Post • Dose dependent operative pain • High dose(>120mg/day) management and long duration (>2days) • Standard GI precautions are bad for NSAIDs • Low dose(<120mg/day) • Bleeding not an issue with and short duration(<2days) normal clotting parameters are OK • Dose limitations (5 days) • Adversely synergistic with smoking
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