Incidence and predictive factors of double crush syndrome in patients undergoing cervical surgery: a database study.

BACKGROUND: Double crush syndrome (DCS) is characterized by multiple compression sites along a single peripheral nerve. It commonly presents with persistent distal symptoms despite surgical treatment for cervical radiculopathy. Management typically involves nerve release of the most symptomatic site. However, due to overlapping symptoms with cervical radiculopathy, patients may undergo cervical surgery prior to DCS diagnosis. Due to its rarity and frequent misdiagnosis, the authors aim to utilize a large national database to investigate the incidence and associations of DCS. METHODS: The Pearldiver database was utilized to identify patients undergoing cervical surgery for the management of cervical radiculopathy. Patients were stratified into three cohorts based on their clinical course before and after cervical surgery. The primary outcome was the prevalence of DCS, and secondary outcomes included an evaluation of predictive factors for each Group, using a significance level of P < 0.05. RESULTS: Among 195,271 patients undergoing cervical surgery for cervical radiculomyelopathy, 97.95% were appropriately managed, 1.42% had potentially mids-diagnosed DCS, and 0.63% were treatment-resistant. Diabetes and obesity were significant predictors of potentially misdiagnosed DCS (P < 0.05). CONCLUSION: This study presents data indicating that 1.42% of patients who receive cervical surgery may have underlying DCS and potentially benefit from nerve release prior to undergoing surgery. A concurrent diagnosis of diabetes and obesity may predict an underlying DCS.

Mortality Factors in Crush Syndrome.

BACKGROUND: Crush Syndrome is a major cause of morbidity and mortality following large-scale catastrophic earthquakes. Since there are no randomized controlled studies on Crush Syndrome, knowledge on this subject is limited to expert experience. The primary objective is to analyze the epidemiological and demographic characteristics, clinical outcomes, and mortality factors of earthquake victims after the Pazarcik and Elbistan earthquakes on February 6, 2023. METHODS: This cross-sectional and observational retrospective study evaluated 610 earthquake victims who presented to our center between February 6 and April 30, 2023. Among these patients, 128 with Crush Syndrome were included in the study. Patient information was gathered from hospital records during their stay and from national registries upon referral. The primary outcome was to identify risk factors for mortality. Demographic and laboratory data were analyzed by acute kidney injury (AKI) stages; mortality-affecting factors were identified through regression analysis. RESULTS: Of the 128 Crush Syndrome patients (100 adults, 28 children), 64 were female. The AKI rate was 32.8%. Among patients with AKI, the frequency of hemodialysis requirement was 69%, and the mortality rate was 14.2%. The overall mortality rate for patients with Crush Syndrome was 4.6%, compared to 3.9% (19/482) in earthquake victims without Crush Syndrome (p=0.705). Notably, low systolic blood pressure at admission was the only factor significantly affecting mortality in Crush Syndrome patients (Hazard Ratio [HR]: 1.088, p=0.021, 95% Confidence Interval [CI]). CONCLUSION: Our study highlights low systolic blood pressure upon admission as a significant risk factor for increased mortality in Crush Syndrome patients. This finding may contribute to the literature by emphasizing the importance of monitoring blood pressure under rubble and administering more aggressive fluid therapy to patients with low systolic blood pressure.

The prevalence of double- and multiple crush syndromes in patients surgically treated for peripheral nerve compression in the upper limb.

OBJECTIVE: The double crush syndrome describes a condition characterized by multifocal entrapment of a nerve. In the upper limb, the high prevalence of carpal tunnel syndrome makes it a common diagnosis of assumption in the setting of median neuropathy. More proximal compressions may tend to be overlooked, under-diagnosed and under-treated in the population. This study aims to map the prevalence of peripheral upper limb nerve compressions among patients undergoing peripheral nerve decompression. METHODS: A prospective case series was conducted on 183 patients undergoing peripheral nerve decompression in a private hand surgery clinic. Level(s) of nerve compression in the median, ulnar and radial nerves were determined by history and physical examination. The prevalence of each nerve compression syndrome or combination of syndromes was analyzed. RESULTS: A total of 320 upper limbs in 183 patients were analyzed. A double crush of the median nerve at the levels of the lacertus fibrosus and carpal tunnel was identified in 78% of upper limbs with median neuropathy, whereas isolated lacertus syndrome and carpal tunnel syndrome were present in only 5% and 17% of affected limbs respectively. Cubital tunnel syndrome affected 12.5% of upper limbs, and 80% of these had concomitant lacertus and carpal tunnel syndromes, compared to only 7.5% with isolated cubital tunnel syndrome. CONCLUSION: A high prevalence should prompt clinicians towards more routine assessment for double crush syndrome to avoid misdiagnosis, inadequate treatment, recurrence, and revision surgeries.

Double crush syndrome: Epidemiology, diagnosis, and treatment results.

BACKGROUND: Double Crush Syndrome (DCS) is a clinical condition that involves multiple compression sites along a single peripheral nerve. The present study aims to describe the epidemiology of DCS and surgical results. METHODS: A retrospective observational analytic study included patients with clinical diagnosis of cervical radiculopathy and carpal tunnel syndrome who underwent surgery between January 2009 and January 2019. General demographic characteristics were noted, and 3 groups were distinguished: spinal surgery, carpal tunnel release, and bimodal decompression (BD); statistical differences were analyzed between them. RESULTS: The sample comprised 32 patients. DCS prevalence was 10.29%. Mean age at presentation was 59.25±10.98 years. There was female predominance (75%). Paresthesia was the main symptom (65.6%). Post-surgical results of BD showed significant improvement in sensory nerve conduction velocity, motor nerve conduction velocity (both P=0.008), and disability on Douleur Neuropathique 4 questions, Neck Disability Index, and Boston Carpal Tunnel Questionnaire (P=0.001, 0.004, 0.008, respectively). CONCLUSIONS: Diagnosis and management of DCS are a challenge. It is necessary to determine the site with maximal compression and risk of complications to decide on treatment. If first-line surgery is adequate, proximal and distal symptomatology can be improved. To maximize success, we recommend BD, according to the present results.

Forklift-Related Crush Injuries of the Foot and Ankle.

BACKGROUND: Forklift-related crush injuries of the foot and ankle are relatively common in cities with shipping and construction industries. There is a paucity of literature on the incidence and sequelae of such injuries. We aimed to describe the incidence, patterns of injuries, sequelae, and morbidity associated with this type of injury. METHODS: A retrospective review of all patients with forklift-related crush injuries of the foot and ankle for 4 years was conducted. Patients' demographics, mechanisms and patterns of injury, fracture type, compartment syndrome, number of reconstructive operations, operative details, length of hospital stay, medical leave, repeat evaluation in emergency room, and complications were recorded and analyzed. RESULTS: There were 113 (2.17%) patients with forklift-related crush injuries out of 5209 patients seen in our institution for injuries of the foot and ankle. Crush injury from the wheels of the forklift truck was the most common mechanism at 71 (62.8%) patients. The forefoot was the most commonly injured region, followed by the midfoot, hindfoot, and ankle, with almost one-third (28.3%) of the patients having multiple injuries to the foot. Nine (8%) had open fractures, while 5 (4.4%) had compartment syndromes. Forty (35.4%) patients required hospitalization, and 35 (87.5%) of those hospitalized required operative intervention. Those who had surgery were more likely to have complications compared with those who did not require operative intervention (16 [45.7%] of 35 patients vs 7 [9%] of 78 patients; P < .05) and more likely to require longer medical leave (mean, 183 vs 30 days, P < .05). CONCLUSION: Forklift-related crush injuries of the foot and ankle are increasingly common in industrialized cities. The forefoot is commonly affected with involvement of multiple regions. Up to one-third of affected patients required hospitalization and multiple operative interventions resulting in loss of productivity, income, and significant morbidity. The possibility of residual disabilities must be clearly defined to the patients and their employers to manage potential workplace limitations and long-term expectations. LEVEL OF EVIDENCE: Level IV retrospective case series.

Medical evacuation management and clinical characteristics of 3,255 inpatients after the 2010 Yushu earthquake in China.

BACKGROUND: A catastrophic earthquake struck the Yushu prefecture of China's Qinghai province on April 14, 2010. Supported by the China National Ministry of Health, this study performed a detailed medical analysis of injuries and diseases, based on comprehensive medical data of hospitalized patients to share the experiences and lessons learned from emergency medical aid operations in high-altitude regions. METHODS: To survey the management of medical relief, more than 10 interviews with rescuers were held and more than 100 documents were reviewed. Medical records of 3,255 patients from 57 hospitals were analyzed retrospectively. Patient demographic data, complaints, diagnoses, prognoses, injury types, dispositions, and means of transportation were all reviewed. RESULTS: A total of 3,255 patients were admitted to hospitals. Of these, 1,426 (43.8%) were middle-aged (31-50 years), 2,574 (79.07%) were transported by plane, and the first 3 days were the peak period for air transportation. The records of 2,622 patients with earthquake-related injuries were analyzed, and 1,775 (68.32%) of them were admitted to hospital within the first 3 days. Bone fractures were diagnosed in 1,431 (55.08%) patients and crush syndrome was observed in 23 (0.89%). Illnesses accounted for 657 patients who were admitted to surveyed hospitals. Of these, 143 (20.63%) suffered from respiratory diseases and 259 (39.97%) from acute high-altitude sickness. Of the latter, 224 (86.49%) were rescuers. The overall mortality rate was 0.2% (7 of 3,255). Four patients died from earthquake-related injuries and three from other illnesses. CONCLUSIONS: A devastating earthquake occurring in a remote, high-altitude region presented a variety of challenges for external medical aid. Air transportation for those with severe injuries and diseases played a crucial role in decreasing the mortality and morbidity. It is necessary for hospitals to initiate effective emergency measures while facing the peak admission flow within the initial 72-hour period. Characteristic factors such as high altitude, low-oxygen content, local construction features, and lifestyle may contribute to complex injuries and illnesses. More attention should be paid to medical aid training for rescuers, and effective measures should be developed to deal with destructive natural disasters occurring in special geographical environments. LEVEL OF EVIDENCE: Epidemiological study, level III.

The double crush syndrome revisited--a Delphi study to reveal current expert views on mechanisms underlying dual nerve disorders.

A high prevalence of dual nerve disorders is frequently reported. How a secondary nerve disorder may develop following a primary nerve disorder remains largely unknown. Although still frequently cited, most explanatory theories were formulated many years ago. Considering recent advances in neuroscience, it is uncertain whether these theories still reflect current expert opinion. A Delphi study was conducted to update views on potential mechanisms underlying dual nerve disorders. In three rounds, seventeen international experts in the field of peripheral nerve disorders were asked to list possible mechanisms and rate their plausibility. Mechanisms with a median plausibility rating of ≥7 out of 10 were considered highly plausible. The experts identified fourteen mechanisms associated with a first nerve disorder that may predispose to the development of another nerve disorder. Of these fourteen mechanisms, nine have not previously been linked to double crush. Four mechanisms were considered highly plausible (impaired axonal transport, ion channel up or downregulation, inflammation in the dorsal root ganglia and neuroma-in-continuity). Eight additional mechanisms were listed which are not triggered by a primary nerve disorder, but may render the nervous system more vulnerable to multiple nerve disorders, such as systemic diseases and neurotoxic medication. Even though many mechanisms were classified as plausible or highly plausible, overall plausibility ratings varied widely. Experts indicated that a wide range of mechanisms has to be considered to better understand dual nerve disorders. Previously listed theories cannot be discarded, but may be insufficient to explain the high prevalence of dual nerve disorders.

Orthopaedic management in a mega mass casualty situation. The Israel Defence Forces Field Hospital in Haiti following the January 2010 earthquake.

Following the January 2010 earthquake in Haiti, the Israel Defence Forces (IDF) established a field hospital in Port au Prince. The hospital started operating 89 h after the earthquake. We describe the experience of the orthopaedic department in a field hospital operating in an extreme mass casualty situation. The hospital contained 4 operating table and 72 hospitalization beds. The orthopaedic department included 8 orthopaedic surgeons and 3 residents. 1111 patients were treated in the hospital, 1041 of them had adequate records for inclusion. 684 patients were admitted due to trauma with a total of 841 injuries. 320 patients sustained 360 fractures, 18 had joint dislocations and 22 patients were admitted after amputations. 207 patients suffered 315 soft tissue injuries. 221 patients were operated on under general or regional anaesthesia. External fixation was used for stabilization of 48 adult femoral shaft fractures, 24 open tibial fractures and 1 open humeral fracture. All none femoral closed fractures were treated non-operatively. 18 joint reductions and 23 amputations were performed. Appropriate planning, training, operational versatility, and adjustment of therapeutic guidelines according to a constantly changing situation, enabled us to deliver optimal care to the maximal number of patients, in an overwhelming mass trauma situation.

Clinical profile of musculoskeletal injuries associated with the 2008 Wenchuan earthquake in China.

BACKGROUND: The Wenchuan earthquake was an enormous devastating disaster and caused mass casualties. The descriptive analysis presented here serves as a reference not only for present injury intervention but also for future earthquake disaster response. METHODS: A total of 205 patients with a musculoskeletal injury were admitted in two teaching hospitals. We conducted a retrospective review of medical records to document the injury profile, chief complaints, damage locations and types, subsequent treatment, and prognosis. RESULTS: Of the 205 patients, fracture was the major type of injury (78.0%). Forty patients were determined to have crush injuries and 19 patients had crush syndromes. Open fractures, multiple fractures and comminuted fractures were common. Fracture-associated neural injuries and trauma-associated infections were also common. Surgical treatments included debridement, bone traction, external fixation, open reduction and internal fixation, and spinal fixation. All the patients were effectively treated with few complications, a low deformity rate and no death. CONCLUSION: For emergency conditions after a major earthquake, pre-hospital emergency care is highly important. After the patients are transported to the hospital, we should plan individualized treatment according to the patients' respective clinical features, and at the same time, prevent and cure the related complications in a timely manner in order to reduce mortality and disability rates.

Challenges for rear hospital care of Wenchuan earthquake casualties: experience from West China Hospital.

To review the challenges and countermeasures in the hospital care for Wenchuan earthquake casualties and draw lessons for the protective response in the future. Medical records and laboratory findings of the victims admitted in West China Hospital (WCH) were retrospectively analyzed. Related data were compared between beforemath and aftermath of the earthquake and between WCH and frontier county hospitals. One thousand and thirty-one earthquake survivors were hospitalized, 1 358 victims underwent surgery and 142 victims were transferred to intensive care unit. The incidence of infection, crush syndrome and multiple organ dysfunction syndrome (MODS) was 39.6%, 20.7% and 2.3% respectively. Wound classification showed that the incidence of extremity damage was 72%, while the incidence of chest trauma, abdominal trauma and brain trauma was less than 10% respectively. Isolating rates of environmental pathogens were increased in the aftermath of earthquake, and the spectrum of the pathogens and related antibiotic sensitivities were quite different from those in the beforemath of earthquake. The social economic and population conditions in the earthquake-stricken areas affected the composition of the victims and the geographic features restricted the efficiency of rescue. Trauma-induced MODS, crush syndrome and severe infections all constituted the dilemma for the hospital care, to resolve whether the multidiscipline team work was proved to be an optimizing choice. For a more effective disaster protective response in the future, the study on rescue plan and the ladder therapies for massive casualties should be potentiated.

The epidemiological analyses of trauma patients in Chongqing teaching hospitals following the Wenchuan earthquake.

BACKGROUND: Well-equipped comprehensive hospitals may provide better emergency and patient services for the recovery of injured patients from the earthquake zone. This study aimed to provide an overview of injuries among the patients admitted to the six teaching hospitals in Chongqing, China, after the 2008 Wenchuan earthquake. MATERIALS AND METHODS: The medical records of 533 earthquake victims who were treated and followed-up by the six hospitals were analysed retrospectively. Patients' demographic data, diagnosis, microbiological assessment and dispositions were reviewed. RESULTS: Of the 533 patients, 45.0% patients had an Injury Severity Score (ISS) below 8, 41.1% had an ISS between 9 and 14 and 13.9% had an ISS above 15. The patients were classified based on their fracture sites as follows: head and neck (7.9%), face (1.3%), chest (21.4%), abdomen and pelvis (15.2%), limb and pelvis (58.9%) and body surface (38.5%). Of the 533 patients, 41.6% had a single fracture site, 32.1% had two combined fracture sites and 26.3% had more than three combined fracture sites, while 32 (6.0%) patients suffered from amputation, 3.9% suffered from crush syndrome and 52.7% underwent surgical operations at the hospitals. Seventy-nine (14.8%) patients suffered from infections, including 87.3% of pre-hospital infections. The results from bacterial culture and antibiotic susceptibility assays showed that the infectious bacteria mainly involved Escherichia coli, Staphylococcus aureus, Staphylococcus haemolyticus, Baumanii, Aerobacter cloacae, Pseudomonas aeruginosa, C type chain coccus and Bacillus aerogenes capsulatus. The sensitivity of various bacterial strains to antibiotics did not exhibit obvious changes, except that the previously multi-drug-resistant hospital bacteria were sensitive to antibiotics. CONCLUSIONS: For emergency conditions after a catastrophe, comprehensive hospitals must be prepared to meet the massive numbers of severely injured patients. Trauma patients from delayed rescue and admission should be given broad-spectrum antibiotics, such as cephalosporin and macrolide antibiotics. The selection of antibiotics in the combination therapy, as described in this study, may greatly enhance the effectiveness of early specific treatments and prevent severe trauma complications in future natural disasters.

[The analysis of traumatized patients who were admitted to the Uludag University Medical School Hospital after the Marmara earthquake]. / Marmara depremi sonrasi Uludag Universitesi Tip Fakültesi hastanesine basvuran travmali olgularin analizi.

The aim of this study was to analyze the victims of the Marmara earthquake who injured, especially had the crush syndrome. Our hospital received a total of 645 victims after the earthquake and admitted 330. Victims were classified into five different groups according to their diagnosis (crush syndrome, vital organ injury, vertebral and pelvic injuries, others and unknown) and their mortality rates were determined. Mortality was highest (21%) in the crush syndrome group. Second and third highest mortality were in the unknown (20%) and vital organ injury (20%) groups. The overall mortality rate was 8%. In conclusion the earthquake victims with crush syndrome and vital organ injury had the highest mortality and morbidity rates. Because of that so many departments (General Surgery, Emergency Medicine, Orthopedics Surgery, Plastic Surgery, Nephrology, Infection Disease etc.) had to be study in a great harmonious.

[Evaluation of patients wounded in the 17 August 1999 Marmara earthquake]. / Depremde yaralanan hastalara yaklasim: 17 Agustos 1999 Marmara depremi deneyimimiz.

This study describes the experience of Kartal Research and Training Hospital in the Marmara Earthquake. We reviewed medical records of 698 patients admitted to our hospital in a 30 days' period after the earthquake and analysed the types of injuries, treatment, morbidity and mortality rates. The hospitalized 273 patients were grouped according to the major injury; patients with crush syndrome were analysed separately. The most frequent injuries were crush injury (23.1%), extremity fractures (16.8%) and pelvis and spine injuries (16.1%). More than two system injuries were seen most frequently in the abdominal injury (45.5%), crush injury (24.4%), and pelvis and spine injury (27.3%) groups (p < 0.05). Overall mortality rate was 7.3%. The highest mortality rates were seen in the abdominal injury (27.3%) and crush injury (20%) groups (p < 0.05). 61.9% of the patients with crush syndrome underwent fasciotomy due to the compartment syndrome; hemodialysis was performed in 31 patients. The most serious problem with earthquake is organization in the earthquake area, between hospitals and in hospitals. Crush injury is the major injury seen earthquakes. Early diagnosis and proper treatment should be done to improve survival.

Analysis of 33 pediatric trauma victims in the 1999 Marmara, Turkey earthquake.

BACKGROUND/PURPOSE: The Marmara earthquake, which destroyed more than 150,000 buildings and caused 15,000 deaths and 40,000 casualties, resembled the Hanshin-Awaji earthquake in many respects. Previous reports from similar disasters from several centres have not addressed trauma in the pediatric age group. The aim of this study was to analyze the clinical and laboratory data of pediatric trauma patients referred to a tertiary center after the 1999 Marmara earthquake. METHODS: The medical records of 33 injured children, aged from 14 days to 16 years, were reviewed retrospectively. The time spent buried under rubble, type of injury, treatment given, complications, laboratory data, and development of acute renal failure (ARF) were noted. Patients in whom ARF developed were treated with a standard regimen of fluid replacement, alkalinization, and diuretics. Limbs with crush injuries were managed as conservatively as possible. RESULTS: All except 3 cases were evacuated from under the debris of collapsed buildings after 1 to 110 (mean, 30.04 +/- 6.48) hours. Seventy-eight percent were transported to our center within the first 3 days. Crush injury (CI) was present in 15 cases, and in 10 of them ARF had already developed by admission. Although serum levels of creatinine were elevated (1.2 to 5 mg/dL) in all cases with ARF, hyperkalemia was observed in only 4. The mean serum creatinine kinase (CK) level of cases with crush syndrome (CS) was 6,040 +/- 4,158 U/L. No significant correlations were detected between the development of CS, age, the time spent under the rubble, the time before admission, or the number of crushed extremities. CONCLUSIONS: CI and CS were the most common entities encountered among our pediatric patients after the 1999 Marmara earthquake. The high incidence of ARF indicates the importance of medical management of this age group during rescue. Because neither laboratory data nor clinical findings predicted CS in our patients, we recommend close observation and monitoring of children with CI for the development of ARF.