High Prevalence of Double Crush Syndrome Diagnosed in Patients with Brachial Plexus Injury using Ultrasound Imaging
Rebecca Nicholas, MBBS, MSc, FRCS(Plast), Dip.Hand Surg.(Eu)1; Communale Victoria, BS1, Claudia González García, MD2; Paul Izard, BS1; Sallie Yassin, Division of Hand Surgery1; Ronald Adler, MD, PhD1; Jacques H. Hacquebord, MD3
1NYU Langone Health, New York, NY; 2Hospital Universitario Virgen de la Victoria, Málaga, Málaga, Spain; 3New York University Langone Health, New York, NY
INTRODUCTION
Double Crush Syndrome (DCS) is a condition that involves two or more discrete points of injury along the course of a peripheral nerve. The pathophysiology remains unclear but is believed to be related to axonal transport disruption. The reported incidence of DCS in the literature is 6.7-73%.[1-5] This study seeks to explore the relationship between ultrasound-confirmed brachial plexus injury (BPI) and distal, non-contiguous peripheral nerve pathology (PNP).
HYPOTHESIS
(i) Patients with BPI will have a high incidence of PNP, which will be visible on ultrasound imaging. (ii) DCS will be more frequent among males, smokers, patients with diabetes, hypothyroidism or alcoholism.
METHODS
We conducted a single-site retrospective review of all patients who underwent high resolution US imaging of the entire upper extremity for suspected Brachial Plexus Injury from March 2016-August 2023 in our institution. Medical records were reviewed for age, sex, smoking status, and comorbidities. Ultrasound imaging and reports were reviewed and BPI and PNP characteristics were recorded.
Univariate and bivariate statistics were conducted. Mean and standard deviation were reported for continuous variables. Count and proportion were reported for categorical variables. A chi-square test or a t-test, was conducted to determine an association between clinical and demographic characteristics and PNP and between BPI and PNP. Last, Cohen’s kappa was calculated to determine interobserver agreement between detecting BPI on US and MRI.
RESULTS
A total of 117 suspected brachial plexus injury cases (in 110 patients (7 bilateral)) underwent ultrasound imaging of the entire upper extremity during the study period. Of these ultrasound studies, 86 demonstrated BPI (74%) whilst 31 (26%) did not show evidence of BPI. [univariate]
Patients with BPI had a mean age of 46 years and were approximately equal in sex distribution (49% male).[univariate] Cases of US-confirmed BPI and non-BPI patients were statistically similar with respect to age, sex, smoking status, alcohol status and comorbidities.
Non-contiguous peripheral nerve pathology (double crush syndrome) was identified in the limb with ultrasound-confirmed Brachial Plexus Injury in 94.2% (n=81), whereas 54.8% (n=17) of non-BPI cases had evidence of isolated peripheral nerve pathology (p<0.001).
For those patients who underwent MRI in addition to US imaging (n=61), the two imaging modalities were found to have moderate agreement for detection of Brachial Plexus Injury and their agreement was statistically significant (Cohen’s k=0.327, p=0.006).
No independent risk factors for double crush syndrome were identified: Bivariate analyses demonstrated the patients with and without peripheral nerve pathology were similar with respect to sex, age, smoking status, alcohol consumption and comorbidities. In addition, brachial plexus cases with and without double crush syndrome were similar with respect to mechanism (high vs low-energy) and level of injury (supra vs infraclavicular).
The additional sites of distal nerve pathology detected on ultrasound of patients with confirmed BPI (DCS) affected the radial nerve in 67.4% (n=58), the median nerve in 77.9% of cases (n=67), and the ulnar nerve in 70.9% (n=61). 77.9% (n=67) of all patients with DCS had multiple nerves involved and for each of the peripheral nerves that were affected by DCS, 37.2% (n=32) had multi site PNP within the same nerve in addition to BPI (10.5% for radial, 22.1% for median, 17.4% for ulnar nerve).
SUMMARY
- We found a high prevalence of Double Crush Syndrome in patients with Brachial Plexus Injury on ultrasound imaging (94.4%): BPI cases were significantly more likely to have at least one discrete site of peripheral nerve pathology compared with non-BPI cases.
- No independent risk factors for DCS were identified.
- Therefore, clinicians should have a high index of suspicion for double crush syndrome in patients with BPI, and consider ultrasound to look for additional sites of peripheral nerve pathology for all suspected brachial plexus injury patients.
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