Double Crush Syndrome in the Lower Extremity: Evidence for an Unfamiliar Clinical Entity
Gabrielle Santangelo, MD1, Aman Singh, BS1, Michael F Catanzaro, MD2, Sandra Catanzaro, BS3, Robert J. Spinner, MD4 and Jonathan Stone, MD1, 1University of Rochester, Rochester, NY, 2University of Rochester Medical Center, Rochester, NY, 3Suny Upstate Medical University, Syracuse, NY, 4Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
Introduction
Double crush syndrome (DCS) is classically defined as multiple sites of compression along a single nerve. The combination of a compressive proximal lesion in the lumbar spine and a distal common peroneal nerve entrapment may result in compound nerve dysfunction. The two injuries may occur together or separately, and little is known about the possible pathophysiological implications of one injury on the other. We present a series of DCS patients with both active L5 radiculopathy and active peroneal mononeuropathy as found on electromyography (EMG) studies.
Materials and Methods
A retrospective analysis of 101 consecutive patients who underwent peroneal release and had a diagnosis of L5 radiculopathy between January 2000-April 2023 at two quaternary academic institutions was performed. Patients were included if they had both an active L5 radiculopathy and active peroneal mononeuropathy on EMG findings. Of the 101 patients identified with both diseases, 12 patients had a “pure” DCS of the lower extremity, meaning the co-occurrence of both active diseases, based on EMG. The Medical Research Council scale for muscle strength was used. Descriptive statistics of patient demographics, clinical presentation, surgical details and outcomes were performed.
Results
The mean age of patients was 64.3 years old, ranging from 47-80 years. 7 of 12 patients were female (58.3%). All 12 patients included in this analysis underwent peroneal release, while only 4 of 12 patients underwent a lumbar spine surgery to address their L5 radiculopathy. All 4 of these patients had lumbar surgery less than 3 years prior to undergoing peroneal release. 1 patient had a second lumbar surgery less than 1 year following the peroneal release. 2 of the patients had an intraneural ganglion cyst of the peroneal nerve. The average dorsiflexion strength on presentation was 1.6 out of 5, while the average dorsiflexion strength following peroneal release was 3.1. 10 of the 12 patients (83.3%) presented with pain or numbness, or both, in the lateral leg/dorsal foot. 6 of the 12 (50%) patients continued to have these symptoms following peroneal release. 2 of the 6 patients (33.3%) with persistent symptoms had prior lumbar surgery.
Conclusions
This is the first series to report double crush syndrome with two active points of compression in the lumbar spine and lower extremity based on EMG findings. Nerve release alone was found to improve average dorsiflexion strength and reduce leg symptoms in the setting of simultaneous diagnoses of peroneal mononeuropathy and L5 radiculopathy.
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