Spine. 2026;51(20):1456-1463
Preoperative assessment before anterior lumbar interbody fusion (ALIF) should look beyond cigarette smoking. Hirpara and colleagues found that coded nontobacco nicotine dependence was associated with more pseudarthrosis and revision surgery. The findings support a broader nicotine history and individualized counseling, but do not establish causation or quantify the risks of individual products.
Study and key findings
This retrospective TriNetX study included patients older than 18 undergoing primary ALIF. Investigators identified nicotine dependence through diagnostic codes while excluding specified tobacco-dependence and tobacco-use codes. Propensity matching produced two groups of 2,296 patients, balanced for demographic factors, relevant comorbidities and recorded surgical characteristics.
At two years, coded pseudarthrosis occurred in 20.1% of patients with nontobacco nicotine dependence versus 11.3% of controls: odds ratio 1.97, 95% confidence interval 1.67-2.33. Revision surgery occurred in 12.1% versus 9.9%: odds ratio 1.25, 95% confidence interval 1.04-1.51. These represent absolute differences of 8.8 and 2.2 percentage points, respectively.
Emergency visits, pneumonia and sepsis were more frequent within 90 days. Cumulative opioid prescriptions were also higher; these measurements should not be interpreted as continuous opioid consumption at two years. Implant failure did not differ significantly.
Interpretation and limitations
The main contribution is identifying a potentially overlooked risk marker, not selecting an alternative approach or implant. Exposure and outcomes depended on administrative coding rather than biochemical verification or standardized imaging review. Residual confounding remains possible despite matching.
The database could not distinguish nicotine delivery methods, dose, frequency or duration. Consequently, the study cannot isolate the effects of vaping, pouches or therapeutic nicotine replacement, nor establish their comparative safety. Detailed ALIF construct subgroups were unavailable. Although the authors advocate perioperative abstinence, their analysis did not test a cessation intervention or establish an effective abstinence interval.
Clinical takeaway
Ask explicitly about non-cigarette nicotine products during ALIF planning and incorporate the findings into shared risk discussions and coordinated preoperative optimization. This observational evidence does not justify a blanket change in fusion technique or an automatic prohibition of prescribed nicotine-replacement treatment; cessation decisions require individualized clinical assessment.