Order of surgical intervention in double-crush syndrome.

backgroundDouble-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.

methodsThis 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.

resultsPatients 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.

conclusionPerforming 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.