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LETTER TO EDITOR
Year : 2015  |  Volume : 63  |  Issue : 5  |  Page : 788-789

Co-occurrence of trifid and bifid median nerves in a patient with bilateral carpal tunnel syndrome


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 Publication6-Oct-2015

Correspondence Address:
Leyla Sedighipour
Department of Physical Medicine and Rehabilitation, Physical Medicine and Rehabilitation Research Center, Shahid Beheshti University of Medical Sciences, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.166535

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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 Nov 17];63:788-9. Available from: http://www.neurologyindia.com/text.asp?2015/63/5/788/166535


Sir,

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.[1] 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.[2] Trifurcation of the median nerve has been very rarely reported in the literature.[3] It is one of the causes of CTS because of its relatively higher cross-sectional area compared with a non-bifid median nerve.[4] Surgical techniques with short incisions and endoscopic procedures demand a thorough knowledge of the anatomy and variations of the structures in the wrist.[5] 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.[5],[6]

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.[7]

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.[1],[2] 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.[4] Concomitant occurrence of trifid and bifid median nerves in the hands of a patient with severe CTS was reported by Duymus et al.[1] 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.[2] Agarwal et al., reported this anatomic variation to be 9.6% in a cadaveric study.[8] Even though these variations are not common, the accurate diagnosis is crucial for a successful surgical management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Duymus M, Yilmaz O, Ulasli AM, Asal N, Kosar U. Coexistence of trifid and bifid median nerve in a patient with bilateral carpal tunnel syndrome. Turk Neurosurg 2013;23:685-7.  Back to cited text no. 1
    
2.
Walker FO, Cartwright MS, Blocker JN, Arcury TA, Suk JI, Chen H, et al. Prevalence of bifid median nerves and persistent median arteries and their association with carpal tunnel syndrome in a sample of Latino poultry processors and other manual workers. Muscle Nerve 2013;48:539-44.  Back to cited text no. 2
    
3.
Demircay E, Civelek E, Cansever T, Kabatas S, Yilmaz C. Anatomic variations of the median nerve in the carpal tunnel: A brief review of the literature. Turk Neurosurg 2011;21:388-96.  Back to cited text no. 3
    
4.
Pierre-Jerome C, Smitson RD Jr, Shah RK, Moncayo V, Abdelnoor M, Terk MR. MRI of the median nerve and median artery in the carpal tunnel: Prevalence of their anatomical variations and clinical significance. Surg Radiol Anat 2010;32:315-22.  Back to cited text no. 4
    
5.
Sundaram S, Kumar M, Sethupathi B, Nayak S, Krishnamurthy A. Split median nerve with variation in its common digital branch – A case report. Neuroanatomy 2008;7:15-6.  Back to cited text no. 5
    
6.
Budhiraja V, Rastogi R, Asthana AK, Sinha P, Krishna A, Trivedi V. Concurrent variations of median and musculocutaneous nerves and their clinical correlation – A cadaveric study. Ital J Anat Embryol 2011;116:67-72.  Back to cited text no. 6
    
7.
Dumitru D, Zwarts M. Focal peripheral neuropathies. In: Dumitru D, Amato A, Zwarts M, editors. Electrodiagnostic Medicine. Philadelphia: Hanley and Belfus Inc.; 2002. p. 1043-126.  Back to cited text no. 7
    
8.
Agarwal P, Gupta S, Yadav P, Sharma D. Cadaveric study of anatomical variations of the median nerve and persistent median artery at wrist. Indian J Plast Surg 2014;47:95-101.  Back to cited text no. 8
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