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Double Crush Syndrome of the Cervical Spine and Carpal Tunnel: National Analysis of Prevalence, Surgical Management, and Complications
Neill Yun Li, MD1, Daniel Yang, BS1, Shashank Dwivedi, BS1, Kalpit N Shah, MD1, Joseph Gil, MD1 and Alan H Daniels, MD2, (1)Brown University, Providence, RI, (2)Brown University, Warren Alpert Medical School, Providence, RI


Purpose: Double crush syndrome (DCS) consists of compression of a peripheral nerve at two distinct locations. The purpose of this study was to utilize a national multi-payer database to determine the prevalence, proportion of operative intervention, and associated complications of DCS patients. We further sought to determine which procedure performed first in DCS patients would minimize postoperative complications and future revision procedures.


Methods: The PearlDiver Patient Records Database (, a national multi-payer deidentified database housing Humana Inc. and Medicare data from 2007 to 2016 were queried. Patients with concomitant carpal tunnel syndrome and cervical radiculopathy were queried with ICD-9-CM/ICD-10-CM codes. Patients were isolated for carpal tunnel release (CTR: 29848, 64721) and anterior cervical discectomy and fusion (ACDF: 22551, 22552, 22554, 22585). Patient demographics, comorbidities, postoperative complications, and prolonged opioid use were evaluated. Prolonged opioid use was filling prescriptions three months from index procedure. Multivariable logistic regressions controlling for age, gender, CCI were performed with P < 0.05 considered statistically significant.


Results: Overall, 75,479 patients were identified with DCS. 15,829 (21%) underwent operative intervention in which significantly more patients initially underwent CTR (n=12,201, 16.2%) compared to ACDF (n=3,628, 4.8%) (p<0.001). Of the 12,201 patients undergoing CTR, 356 (2.9%) subsequently underwent ACD. In contrast, of the 3,628 patients undergoing ACDF, 314 (8.7%) patients subsequently underwent CTR.


DCS patients who underwent CTR, followed by ACDF, demonstrated significantly increased risk of complications and readmission within 30 days of ACDF compared to ACDF alone (Table 1).



Patients that underwent ACDF followed by CTR had no significant complications and significantly less opioid use postoperatively compared to CTR alone (Table 2).



When comparing patients undergoing ACDF without DCS, DCS patients undergoing CTR followed by ACDF had greater risk of revision at one year, readmission, and surgical site infection than ACDF followed by CTR (Table 3).



When compared against CTR without DCS, DCS patients with CTR, followed by ACDF had increased risk of revision at one year, readmission within 30 days, surgical site infection, and prolonged opioid use, than ACDF followed by CTR (Table 4).



Conclusion: In patients with DCS, ACDF after CTR had a greater number of complications compared to ACDF before CTR. With these findings, providers may be better able to counsel patients with known cervical and carpal tunnel compression regarding potentially reduced risk of postoperative complications, readmission, and revision procedures when considering ACDF and CTR should ACDF be initially performed followed by CTR.

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