By Dr. Benjamin Caplan, MD | Board-Certified Family Physician, CMO at CED Clinic | Evidence Watch
A new observational study in Neurosurgery Practice found that preoperative marijuana use did not significantly increase complication rates or worsen functional recovery after complex spinopelvic fusion surgery. For patients and surgeons navigating this question together, the findings add useful nuance to a conversation that has often defaulted to blanket warnings.
Impact of Preoperative Marijuana Use on Functional Recovery and Complications After Spinopelvic Fusion in Adult Spinal Deformity.
Cannabis Before Spine Surgery: What the 2026 Evidence Actually Shows
Patients using cannabis before complex spinal procedures have long been told to stop, but the clinical evidence is more complicated than that directive suggests. A 2026 cohort study examining spinopelvic fusion outcomes is one of the most direct looks yet at what preoperative marijuana use actually does and does not do in a real surgical population.
72 Strong Clinical Relevance
Directly addresses a question patients and surgeons raise daily; peer-reviewed primary source published April 2026.
Cannabis use is common among adults with chronic back pain and spinal conditions. Many of these patients proceed to surgery. Surgeons and anesthesiologists currently lack consistent guidance on how to counsel them. A reflexive “stop using it” recommendation ignores what patients are actually experiencing and what the evidence is starting to show. When the published literature offers a more textured picture, clinicians need to know.
Adult spinal deformity requiring spinopelvic fusion is among the most demanding procedures in spine surgery. Patients in this population are often older, frequently managing chronic pain, and carry a high preoperative burden of comorbidity. Cannabis use is not rare in this group. Given the complexity of the surgery and the stakes attached to outcomes, researchers from the neurosurgery literature have been building a body of work examining whether preoperative cannabis use changes what happens after the procedure.
This April 2026 cohort study, published in Neurosurgery Practice (PMID 41982324), examined exactly that question in a spinopelvic fusion population. The headline finding: preoperative marijuana use was not associated with statistically significant differences in complication rates or with inferior functional recovery at follow-up. The authors note that their cohort showed mixed results in prior surgical literature, with some spine subspecialties reporting higher complication rates in cannabis users while arthroplasty cohorts more often found no difference. The researchers call for prospective designs with standardized exposure definitions to clarify these specialty-specific patterns.
Dr. Caplan’s Analysis
Let me be direct about something this study does not say. It does not say cannabis is safe before spine surgery. It does not say patients should keep using it in the weeks leading up to a procedure. What it says is more specific and, in some ways, more useful: in this cohort of patients undergoing spinopelvic fusion for adult spinal deformity, preoperative marijuana use was not associated with significantly worse outcomes. That distinction matters.
The surgical cannabis literature is a mess right now, and I mean that as a clinical observation, not a criticism. Across the studies I’ve reviewed, outcome signals shift depending on the procedure. Spine surgery, particularly fusion, seems to sit in a zone where the evidence is genuinely mixed. Cervical decompression and fusion data looks more concerning. Arthroplasty data often shows no meaningful difference. Ankle fracture fixation has raised flags around infection and nonunion. The endocannabinoid system is not a single switch, and cannabis does not interact with surgical biology in a uniform way. That’s what the data is telling us, and it’s important that clinicians stop treating it as though there’s a clean, universal answer.
In my practice in Massachusetts, the question I hear most from pre-surgical patients who use cannabis is whether they need to stop. The honest answer involves more questions: What are you using it for? How are you consuming it? How much? For how long? These variables are almost never captured in the studies we have. This particular paper, like most observational cohort work, relied on documented cannabis use status, usually a yes or no drawn from the clinical record. That kind of binary classification tells you something. It doesn’t tell you nearly enough.
What I find clinically meaningful here is the absence of the worst-case signal. If preoperative cannabis use were strongly associated with complications after spinopelvic fusion, we’d expect to see it consistently across cohorts. We don’t. That doesn’t mean there’s no risk. It means the risk, if it exists, is not dominant enough to show up reliably in observational data. For a procedure as high-stakes as adult spinal deformity correction, that’s not a trivial finding. It creates space for a real conversation rather than a reflexive prohibition.
The opioid picture is where things get interesting and frustrating in equal measure. Chronic cannabis users presenting for spine surgery often have higher baseline pain scores and greater opioid exposure before the procedure. Some studies show they consume more opioids postoperatively. Others show no difference. A smaller body of evidence suggests that resuming cannabis after discharge may be associated with reduced persistent opioid use. None of this is clean. But taken together, it points toward a patient population that is managing difficult pain in multiple ways simultaneously and whose perioperative course may be meaningfully different from the non-cannabis user in ways the standard analgesic protocol hasn’t fully accounted for.
Surgeons in Massachusetts and across New England are operating on patients who use cannabis legally and routinely. If the perioperative counseling they receive is based on overgeneralized caution rather than procedure-specific evidence, we’re not doing our job well. This study is one data point. It belongs in the conversation. The honest clinical message right now is: what we know depends heavily on which surgery we’re talking about, and we need better data to know more. Until then, individualized assessment beats blanket policy.
Interest in the perioperative implications of cannabis use has grown steadily as legalization expanded across U.S. states, bringing a more medically complex and candid patient population into surgical settings. The American Society of Regional Anesthesia and Pain Medicine issued consensus guidelines on perioperative cannabis management, acknowledging that surgical patients using cannabinoids face potential increased risk for negative outcomes while stopping short of uniform contraindication. The research base has been built largely through retrospective cohort studies drawing on large administrative databases, which provide sample size at the cost of exposure granularity.
The 2026 Neurosurgery Practice findings sit within a larger pattern in which spine surgery subspecialties show divergent results depending on procedure type, patient population, and how cannabis exposure is defined. A January 2026 narrative review in Cureus synthesized the orthopaedic surgical literature and found that while the endocannabinoid system plausibly modulates bone healing and nociception, clinical evidence did not support routine perioperative cannabis use to reduce opioid requirements. A February 2026 narrative review in Journal of Clinical Anesthesia analyzed 42 studies and found that preoperative cannabis exposure was associated with higher postoperative pain and opioid requirements in some but not all surgical contexts, with mixed cohorts and spine populations showing more consistent signals than arthroplasty populations. The spinopelvic fusion cohort published this month fills a specific gap in that picture.
The preoperative cannabis and spine surgery literature now spans anterior cervical discectomy and fusion, lumbar fusion, total joint arthroplasty, ankle fracture fixation, and adult spinal deformity correction. The overall picture is one of procedure-specific heterogeneity. ACDF and cervical spine procedures have shown the most concerning signals, including elevated reoperation rates and higher complication frequencies. Lumbar and thoracic fusion data, including the current spinopelvic cohort, has been more equivocal. Arthroplasty data most often shows no significant difference.
The proposed mechanisms are real: CB1 receptors modulate nociception and may alter anesthetic requirements; CB2 receptor activity influences immune function and could plausibly affect surgical site healing; cannabis smoke has known pulmonary effects relevant to perioperative respiratory management; and the opioid-endocannabinoid receptor crosstalk is well-documented in basic science literature. The challenge is that these mechanisms do not translate into consistent clinical signals at the population level, at least not with the exposure measures currently available in surgical registry and EMR data.
Misreading 1: “No significant difference means cannabis is safe before spine surgery.” This cohort found no significant increase in complications, which is a useful finding. It is not a clearance. Observational data cannot establish safety the way a well-controlled trial can, and exposure measurement in this study was not granular enough to account for dose, frequency, or product type.
Misreading 2: “This applies to all spine surgery.” It does not. The study specifically examined spinopelvic fusion for adult spinal deformity. Other spine subspecialties have shown different patterns. Extrapolating to all spinal procedures is not supported by the current evidence base.
For patients using cannabis who are preparing for spinopelvic fusion surgery, this study is one piece of evidence suggesting that the relationship between preoperative cannabis use and surgical outcomes may be less alarming than previously assumed for this particular procedure. It does not settle the question. It does make it harder to justify a uniform prohibition without a procedure-specific conversation. Clinicians and patients need better data. In the meantime, individualized counseling grounded in the actual evidence available for the specific procedure is the appropriate standard.
Do I need to stop using cannabis before spine surgery?
That depends on the specific procedure, your surgical team’s protocols, and your individual situation. This 2026 study found no significant increase in complications for spinopelvic fusion patients who used cannabis preoperatively, but other spinal procedures have shown different results. Tell your surgeon and anesthesiologist about your cannabis use. They can give you guidance based on your specific case.
Will cannabis use affect my pain management after spine surgery?
Possibly. Some studies have found that patients who use cannabis before surgery report higher postoperative pain scores and require more opioids in certain surgical settings. Others have found no difference. The picture is not uniform across procedures. Your surgical team should account for your cannabis use when building your perioperative analgesic plan.
Can I resume cannabis use after surgery to reduce opioid use during recovery?
Some limited evidence suggests that resuming cannabis after discharge may be associated with lower persistent opioid use in surgical recovery, though this data is preliminary and observational. Discuss timing and method with your care team before making any changes to your postoperative pain management approach.
- Observational cohort design: associations reported, not causal relationships. Residual confounding cannot be excluded.
- Cannabis exposure was defined as documented use status (yes/no from clinical records), without data on dose, frequency, method of consumption, or duration of use.
- Findings are specific to spinopelvic fusion for adult spinal deformity and may not generalize to other spinal procedures or surgical populations.
- Self-reporting bias likely: stigma and medicolegal concerns may result in underreporting of cannabis use in surgical EMR documentation.
- Impact of Preoperative Marijuana Use on Functional Recovery and Complications After Spinopelvic Fusion in Adult Spinal Deformity. Neurosurgery Practice. 2026 Apr;7(2):e000218. PMID 41982324 / CED review: https://cedclinic.com/impact-of-preoperative-marijuana-use-on-functional-recovery-and-complications-af/
- King DD, Temmermand R, Greenwood JE. Preoperative cannabinoid exposure and postoperative pain: A narrative review. Journal of Clinical Anesthesia. 2026 Feb;109:112097. PMID 41406677
- Luigi Martinez HE, Rivera Troia FM, Babilonia Beltran PA, et al. Cannabis Use in Orthopaedic Surgery: Effects on Fracture Healing, Opioid Requirements, and Clinical Outcomes. Cureus. 2026 Jan 6;18(1):e100930. PMC12875395
- Shah SS, et al. ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids. Regional Anesthesia and Pain Medicine. 2023. PMID 36596580
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