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The Impact of Tobacco Cigarette Smoking on Spinal Cord Stimulation Effectiveness in Chronic Spine–Related Pain Patients

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The Impact of Tobacco Cigarette Smoking on Spinal Cord Stimulation Effectiveness in Chronic Spine–Related Pain Patients CHRONIC AND INTERVENTIONAL PAIN ORIGINAL ARTICLE The Impact of Tobacco Cigarette Smoking on Spinal Cord Stimulation Effectiveness in Chronic Spine–Related Pain Patients Nagy Mekhail, MD, PhD,* Gerges Azer, MD,* Youssef Saweris, MD,*† Diana S. Mehanny, MD,* Shrif Costandi, MD,* and Guangmei Mao, PhD‡ According to the US Centers for Disease Control and Pre- Background and Objectives: Despite the observation that select nic- vention, smoking remains the single most preventable cause otine receptor agonists have analgesic effects, smokers report higher pain of death in the United States.12 Although efforts to reduce the scores and more functional impairments than lifelong nonsmokers, attrib- number of smokers in the United States have been successful, utable to exaggerated stress responses, receptor desensitization, and altered accounting for an overall decrease of smokers from 20.9% to pharmacokinetics compounded by accelerated structural damage result- 18.1% from the year 2005 to 2012,13 a rising trend in the rate of ing from impaired bone healing, osteoporosis, and advancement of disk smoking among chronic pain patients has been observed. Preva- disease. We hypothesized that smoking diminishes the analgesic response lence of smokers in adults with chronic pain has increased from – to spinal cord stimulation (SCS) in patients with chronic spine related 24.2% to 25.7% to 28.3% corresponding to the years 2000, pain conditions. 2005, and 2010, respectively.14 Of interest is the observation that Methods: A retrospective cohort study was performed at Cleveland smokers with chronic pain also have a tendency of consuming Clinic by collecting and assessing data of 213 patients who had been more opioids than former smokers and lifelong nonsmokers.14–16 implanted with SCS for spine-pain indications. History of tobacco smoking In this study, we focus primarily on the spinal cord–related was subcategorized into 3 categories: past (former smoker), present (cur- chronic pain, treated using spinal cord stimulator (SCS), and the rent smoker), or those who had never previously smoked (lifelong non- effect of smoking on the success of this treatment modality. smokers), and a multivariable linear regression was run to measure the Limited information is known about how smoking frequency correlation, if any, between smoking status and numerical rating scale pain and duration impact chronic spine–related pain disorders and their score. In addition, opioid consumption at baseline and 12-month follow- therapeutic options. Generally speaking, there is evidence to sup- up, expressed in milligram oral morphine equivalents, was collected port the association of tobacco use with increased risk of surgical and compared. infection17–19 and delayed wound healing.20–23 On a more specific Results: Adjusted for differences, at 1-year follow-up, current smokers level, focusing on the effect of tobacco on SCS, only 2 studies are (n = 62) reported numerical rating scale pain score of 7.0, which is 1.93 availabletodate.24,25 Although both studies are composed of a lim- (P < 0.001) and 1.32 (P = 0.001) points higher than those of lifelong non- ited sample size (<60 patients), both found an association between smokers (n = 77) and former smokers (n = 74), respectively. Opioid intake smoking and an increased chance of lead migration and revision. was2.4timeshigher(P = 0.004) in smokers than in lifelong nonsmokers. Because of the lack of evidence on the effect of tobacco Conclusions: Among our SCS-implanted sample, a positive correlation smoking on the efficacy of the SCS in terms of pain relief and was observed between tobacco use and degree of pain reduction as early opioid use, utilizing a large sample size, we aimed to further in- as 12 months postimplant; this was evident by the reported higher pain vestigate the correlation, if any, between 3 different smoking scores and opioid use in current smokers in comparison with former categories diagnosed with chronic spinal pain in a retrospective smokers and lifelong nonsmokers. cohort study. Our primary outcome was the degree of change in (Reg Anesth Pain Med 2018;43: 768–775) pain, and our secondary outcome was changes in opioid utilization compared among the 3 groups. We hypothesized that smokers, eculiarly, chronic pain is a more common occurrence than and possibly former smokers, will demonstrate worse pain control Pexpected with a once estimated prevalence of 46.5% among and higher opioid utilization than lifelong nonsmokers. the general population.1 In the United States alone, 116 million Americans are believed to suffer from some form of chronic pain.2 METHODS One common association to chronic pain is tobacco smoking. Despite the observation that smoking may provide analge- Study Population sic effects,3–5 however, smokers have previously reported higher pain scores6,7 and more associated functional impairments than Following institutional review board approval, a retrospec- lifelong nonsmokers.8–11 tive data collection was performed for all patients with chronic spine–related pain who were managed with SCS at Cleveland Clinic Pain Management Department between the years 1997 From the *Evidence-Based Pain Management Research, †Anesthesiology Insti- and 2013. Among the 986 patients who had undergone a suc- tute, and ‡Outcomes Research and Department of Quantitative Health Sciences, cessful SCS trial defined as pain relief of 50% or greater and Cleveland Clinic Foundation, Cleveland, OH. Accepted for publication April 25, 2018. had subsequently received SCS implant, 330 patients were identi- Address correspondence to: Nagy Mekhail, MD, PhD, Cleveland Clinic/C25, fied as having chronic spine–related condition per protocol in- 9500 Euclid Ave, Cleveland, OH 44195 (e‐mail: [email protected]). clusion criteria, of which 117 patients were excluded because The authors declare no conflict of interest. of incomplete records. Therefore, the final analysis included Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine 213 patients, who were further classified into current smokers ISSN: 1098-7339 (62 patients), former smokers (74 patients), and lifelong non- DOI: 10.1097/AAP.0000000000000870 smokers (77 patients) as illustrated in Figure 1. 768 Regional Anesthesia and Pain Medicine • Volume 43, Number 7, October 2018 Copyright © 2018 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited. Regional Anesthesia and Pain Medicine • Volume 43, Number 7, October 2018 Smoking and Spinal Cord Stimulation FIGURE 1. Flowchart of patient selection. Chronic spine–related pain conditions included post- For comparison and analysis purposes, history of tobacco laminectomy syndrome, cervical/lumbar degenerative disk disease, smoking was subcategorized into 3 categories: past (former cervical/lumbar radiculopathy, cervical/lumbar spondylosis, and smokers), present (current smokers), or those who had never cervical/lumbar spinal stenosis. previously smoked (lifelong nonsmokers). For current and former smokers, the duration of smoking in years and the number of packs smoked yearly along with whether they smoked cigarettes Measurements or cigars were documented. In addition, for former smokers, the Patient's demographic data, smoking status, body mass index number of years of smoking abstinence was also recorded. (BMI), duration of pain, and history of diabetes, disability, and depression were manually obtained from the electronic medical Statistical Analysis records (Table 1), in addition to reported numerical rating scale The patients with missing smoking status, pain scores, and (NRS) and opioid utilization, if any, at baseline and 12 months opioid use at 1-year follow-up were excluded from this study. after SCS implantation. All opioid doses collected were converted Baseline characteristics were compared among 3 study groups into their morphine sulfate (MSO4, mg) equivalent using their using standard descriptive statistics. Categorical data are pre- equianalgesic dosing shown in Table 2.26 sented as number and percent of total. All baseline variables listed All patients checking in for an appointment at Cleveland in Table 1 except for smoking history were used for adjustment in Clinic, once seated in the examination room, are required to all subsequent analyses. answer a set of standardized questions including, but not limited As for the primary hypothesis, the multivariable linear to, NRS pain score and smoking status and frequency. For NRS regression model was used to assess the association between pain score, patients are asked to report their average pain intensity smoking status (current smokers vs never smokers) and pain relief for the last 24 hours on a scale of 0 to 10, with 0 being no pain, after 1 year of SCS therapy. The primary outcome was pain score 5 corresponding to moderate pain, and 10 being the worst pain after 1 year, and the predictor was smoking status. The results imaginable.27 Smoking status is also collected as part of routine were adjusted for baseline pain score, baseline opioid consump- documentation with lifetime nonsmokers documented as such. tion, age, sex, BMI, duration of pain, spine-related pain diagnosis, Former smokers are further asked to provide an estimated quit and diabetes, disability, and depression history. The mean differ- date (of which the years of abstinence were calculated) and num- ence in 1-year pain scores between current smokers and lifelong ber of smoking years prior to quitting. Finally, smokers are
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