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|LETTER TO EDITOR
|Year : 2015 | Volume
| Issue : 5 | Page : 788-789
Co-occurrence of trifid and bifid median nerves in a patient with bilateral carpal tunnel syndrome
Seyed Mansoor Rayegani1, Leyla Sedighipour1, Seyed Ahmad Raeissadat1, Fatemeh Hojjati1, Hamid Reza Aghayousefi1, Farivar Lahiji2, Morteza Sanei Taheri3
1 Department of Physical Medicine and Rehabilitation, Physical Medicine and Rehabilitation Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Department of Orthopedic Surgery, Akhtar Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3 Department of Radiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
|Date of Web Publication||6-Oct-2015|
Department of Physical Medicine and Rehabilitation, Physical Medicine and Rehabilitation Research Center, Shahid Beheshti University of Medical Sciences, Tehran
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Rayegani SM, Sedighipour L, Raeissadat SA, Hojjati F, Aghayousefi HR, Lahiji F, Taheri MS. Co-occurrence of trifid and bifid median nerves in a patient with bilateral carpal tunnel syndrome. Neurol India 2015;63:788-9
|How to cite this URL:|
Rayegani SM, Sedighipour L, Raeissadat SA, Hojjati F, Aghayousefi HR, Lahiji F, Taheri MS. Co-occurrence of trifid and bifid median nerves in a patient with bilateral carpal tunnel syndrome. Neurol India [serial online] 2015 [cited 2019 Oct 15];63:788-9. Available from: http://www.neurologyindia.com/text.asp?2015/63/5/788/166535
Carpal tunnel syndrome (CTS) is the most common upper extremity neuropathy in the wrist that may be associated with anatomic variations of the median nerve. High division of the median nerve proximal to the carpal tunnel (known as a trifid or bifid median nerve) is an uncommon median nerve anomaly that has an incidence rate of 2.8% for bifid variation. Trifurcation of the median nerve has been very rarely reported in the literature. It is one of the causes of CTS because of its relatively higher cross-sectional area compared with a non-bifid median nerve. Surgical techniques with short incisions and endoscopic procedures demand a thorough knowledge of the anatomy and variations of the structures in the wrist. In these cases, obtaining preoperative magnetic resonance and ultrasound imaging to detect those median nerves with an anatomic variation helps surgeons in avoiding potential surgical complications.,
We report the case of a 54-year-old female patient who had the rare co-occurrence of trifid and bifid median nerves leading to bilateral CTS. She had pain and paresthesia in both hands at the time of her visit to our center. A systemic examination and her past medical history revealed no remarkable findings. On physical examination, the Phalen's test and Tinel's sign at the wrist were bilaterally positive. Other neurological and musculoskeletal tests were normal. Nerve conduction studies (NCS) revealed the bilateral absence of median sensory nerve action potential and bilateral low amplitude compound muscle action potential with prolonged latency. The electromyographic (EMG) examination was normal.
Ultrasonographic assessment of the wrist demonstrated a trifid right and a bifid left median nerve [Figure 1] and [Figure 2]. A consistent and well-defined median artery was not seen. Sonographic findings were confirmed by a magnetic resonance imaging (MRI) study [Figure 3]. The patient underwent carpal tunnel release surgery. At surgical exploration, trifid and bifid median nerves were demonstrated [Figure 4] and [Figure 5]. At a follow up of 3 and 5 months, the patient's symptoms had improved significantly.
|Figure 1: Sonographic image of the right carpal tunnel depicting trifid median nerve (depicted by arrows)|
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|Figure 2: Sonographic image of the left carpal tunnel depicting bifid median nerve (depicted by arrows)|
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|Figure 3: Magnetic resonance image of the right and left hands (depicting trifid and bifid median nerves by arrows)|
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|Figure 4: Right carpal tunnel exploration. Three branches of median nerve are tagged by asterisk|
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|Figure 5: Left carpal tunnel exploration. Median nerve branches are tagged by asterisk|
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We report a rare case with a right trifid and a left bifid median nerve documented by ultrasonography and MRI. One of the most common variations accompanying these anomalies is a persistent median artery, which has a significant relevance during surgical management., We ruled out the existence of this anatomical variation by color Doppler sonography. In 2010, Pierre-Jerome et al., reported a patient with a trifid median nerve demonstrated by MRI. Concomitant occurrence of trifid and bifid median nerves in the hands of a patient with severe CTS was reported by Duymus et al. No other case of trifid median nerve variation has been reported in the literature. However, a bifid variation is more common. Walker et al., reported the prevalence of bifid median nerve variation to be present in 8.6% of the population. Agarwal et al., reported this anatomic variation to be 9.6% in a cadaveric study. Even though these variations are not common, the accurate diagnosis is crucial for a successful surgical management.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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