AAOS Now

Published 4/1/2012
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Terry Stanton

Smoking, Workers’ Comp Status Push Disability and Pain Scores Up

A review of more than 13,000 patients undergoing treatment for spine pain found that patients who smoked had the worst disability scores, followed by previous smokers; nonsmokers had the least pain.

The study, conducted by Mark L. Prasarn, MD, and colleagues and presented at the AAOS 2012 Annual Meeting, also found that patients with workers’ compensation claims or litigation—so-called “secondary gain” issues—had worse pain and disability scores than other patients.

As part of a prospectively maintained database, every patient with axial spine pain (with or without radicular symptoms) treated at two institutions completed a questionnaire that included a modified Oswestry Disability Index (ODI) and a visual analog scale. Patients also reported their workers’ compensation status and malpractice or other legal proceeding.

Among these patients, 24 percent were current smokers, 30 percent were previous smokers, and 46 percent had never smoked. Of the patients who answered the question about litigation or workers’ compensation, approximately one fourth had an association between their condition and the litigation or workers’ compensation.

Current smokers had a mean ODI score of 44.33, while previous smokers scored at 38.11 and nonsmokers at 36.02. The differences were significant (P < 0.001). Patients with workers’ compensation or litigation issues had significantly worse ODI scores than those without those issues (43.73 vs. 37.36, P < 0.001). Current smokers with secondary issues had the highest mean ODI (47.43). The lowest ODI scores (35.04) were found among nonsmokers without secondary gain.

A significant interaction was noted for workers’ compensation/litigation and smoking status for current pain. Post hoc analysis for smoking status revealed a significant difference in current pain scores between nonsmokers and current smokers (4.73 vs. 5.73, P < 0.001) and between previous smokers and current smokers (4.76 vs. 5.73, P < 0.001). Pain scores of previous smokers and nonsmokers were not significantly different. Patients with workers’ compensation/litigation had a mean pain score of 5.61 compared with a mean score of 4.81 for patients not involved in workers’ compensation/litigation (P < 0.001).

Among patients who reported the worst pain, significant interaction was noted for smoking status and secondary gain. Post hoc analysis for smoking status revealed a significant difference in worst pain scores between nonsmokers and current smokers (7.98 vs. 8.69, P < 0.001) and between previous smokers and current smokers (8.01 vs. 8.69, P < 0.001). Patients with workers’ compensation/litigation issues had worse pain scores than patients without such issues (8.49 vs. 8.07, P < 0.001).

The authors note that, although the differences seen between the best and the worst ODI scores would not be regarded as significant, the difference is “dramatic” in a sample as large as this.

Regarding the connection between smoking/secondary gain issues and disability and pain scores, the authors conclude, “We must take these factors into consideration from the first moment of interaction with these patients. These factors may also play a role in the treatment pathway and goal setting for recovery success. It has been shown that, with the assistance of a spinal surgeon, up to 40 percent of patients are able to quit smoking.”

The other authors of the study are MaryBeth Horodyski, EdD, ATC; Caleb Behrend, MD; John Wright, MS; and Glenn R. Rechtine, MD.

Disclosure information: Dr. Horodyski—Exactech Inc; Dr. Rechtine—The Spine Journal, Journal of Spinal Cord Medicine. The other authors report no conflicts.

Terry Stanton is the senior science writer for AAOS Now; he can be reached at tstanton@aaos.org

Bottom Line

  • This study of more than 13,000 patients undergoing treatment for back pain found that those who smoked had the worst pain and the highest disability scores.
  • Patients who had secondary gain issues (workers’ compensation or litigation) had worse pain than patients without those issues.
  • Current smokers with secondary gain issues had the worst pain and highest disability scores of all.
  • Orthopaedic surgeons should be aware of a patient’s smoking and secondary gain status, because these factors might affect outcomes.