Background Double-crush syndrome involves concurrent nerve compression at two points, typically in the cervical spine and peripherally in the upper extremity, such as the ulnar nerve at the elbow or the median nerve at the wrist. Surgical management of this condition, including which decompression to perform first, remains controversial. We aim to explore the effect of surgical technique, timing, and relative order on outcomes in patients with combined cervical and peripheral upper extremity nerve compression. Methods This retrospective study included adult patients treated at a Level 1 trauma center between 2015 and 2022. All patients underwent primary cervical decompression and either carpal tunnel release, cubital tunnel release, or both, with open and endoscopic procedures included. Collected data included patient demographics, electrodiagnostic findings, surgical dates, and postoperative PROMIS scores (Physical Function [PF], Pain Interference [PI], and Depression [D]) collected over a minimum 6-month follow-up. We compared outcomes based on whether cervical decompression or peripheral nerve decompression was performed first. Multivariable logistic regression assessed the impact of surgical order and other factors on achieving the minimal clinically important difference (MCID) in PROMIS scores. Results Patients who underwent cervical spine decompression first showed significantly better outcomes in PROMIS PF and D categories at multiple postoperative time points, including 1 month (PF, p = 0.03; D, p = 0.02), 6 months (PF, p = 0.02; D, p < 0.01), and 1 year (PF, p < 0.01; D, p < 0.01). Regression analysis revealed that primary cervical decompression was significantly associated with greater odds of achieving MCID in both PF (OR 2.5, p = 0.03) and D (OR 2.3, p = 0.05). Undergoing both carpal and cubital tunnel release, as opposed to only one, was also associated with improved outcomes (OR 3.1, p = 0.03). No significant differences were found between groups for pain interference (PI) scores. Conclusion Performing cervical spine decompression prior to peripheral nerve decompression was associated with superior functional and emotional recovery in patients with double-crush syndromes. These findings suggest that cervical pathology may have a greater impact on overall patient outcomes and should be prioritized in surgical planning. Future research should further investigate optimal management strategies for patients with multiple nerve compressions to guide surgical decision-making. Level of Evidence III.

Order of surgical intervention in double-crush syndrome

期刊论文
发表日期：

2025年8月29日

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Melissa Holloway,
Clarke Cady-McCrea,
Thomas Carroll,
Danielle Wilbur,
Robert Molinari

摘要

Background

Double-crush syndrome involves concurrent nerve compression at two points, typically in the cervical spine and peripherally in the upper extremity, such as the ulnar nerve at the elbow or the median nerve at the wrist. Surgical management of this condition, including which decompression to perform first, remains controversial. We aim to explore the effect of surgical technique, timing, and relative order on outcomes in patients with combined cervical and peripheral upper extremity nerve compression.

Methods

This retrospective study included adult patients treated at a Level 1 trauma center between 2015 and 2022. All patients underwent primary cervical decompression and either carpal tunnel release, cubital tunnel release, or both, with open and endoscopic procedures included. Collected data included patient demographics, electrodiagnostic findings, surgical dates, and postoperative PROMIS scores (Physical Function [PF], Pain Interference [PI], and Depression [D]) collected over a minimum 6-month follow-up. We compared outcomes based on whether cervical decompression or peripheral nerve decompression was performed first. Multivariable logistic regression assessed the impact of surgical order and other factors on achieving the minimal clinically important difference (MCID) in PROMIS scores.

Results

Patients who underwent cervical spine decompression first showed significantly better outcomes in PROMIS PF and D categories at multiple postoperative time points, including 1 month (PF, p = 0.03; D, p = 0.02), 6 months (PF, p = 0.02; D, p < 0.01), and 1 year (PF, p < 0.01; D, p < 0.01). Regression analysis revealed that primary cervical decompression was significantly associated with greater odds of achieving MCID in both PF (OR 2.5, p = 0.03) and D (OR 2.3, p = 0.05). Undergoing both carpal and cubital tunnel release, as opposed to only one, was also associated with improved outcomes (OR 3.1, p = 0.03). No significant differences were found between groups for pain interference (PI) scores.

Conclusion

Performing cervical spine decompression prior to peripheral nerve decompression was associated with superior functional and emotional recovery in patients with double-crush syndromes. These findings suggest that cervical pathology may have a greater impact on overall patient outcomes and should be prioritized in surgical planning. Future research should further investigate optimal management strategies for patients with multiple nerve compressions to guide surgical decision-making.

Level of Evidence

III.