Bifid Median Nerve in Patients

With Carpal Tunnel Syndrome

Ilkay Koray Bayrak, MD, Ayse Oytun Bayrak, MD,
Melike Kale, MD, Hande Turker, MD, Bars Diren, MD
Objective. The aim of this study was to investigate the frequency of the anatomic variation of a bifid
median nerve in patients with carpal tunnel syndrome (CTS) and to determine the size criteria for
sonography. Methods. On axial sonograms of 320 hands of 170 patients with CTS and 240 hands of
120 unaffected individuals, the median nerve was evaluated morphologically for a bifid median nerve,
and the cross-sectional area was measured at 3 levels (radial-ulnar junction, pisiform, and hook of the
hamate). Electrophysiologic studies were performed in addition to clinical and sonographic evaluations
in all patients, controls with a bifid median nerve, and controls with a cross-sectional area of greater
than 0.09 cm
2
. Results. A bifid median nerve was seen in 32 (19%) of 170 patients and 11 (9%) of
120 controls. It occurred relatively frequently in patients with CTS (P < .01). The cross-sectional area of
the bifid median nerve was relatively higher than that of the nonbifid median nerve in controls at 2 of
the 3 levels (P < .001; P = .226; P < .01). The cutoff values for the cross-sectional area at the level of
the pisiform were 0.11 cm
2
(sensitivity, 90%; specificity, 99%; P < .001) for patients with a bifid medi-
an nerve and 0.10 cm
2
(sensitivity, 98%; specificity, 81%; P < .001) for patients with a nonbifid medi-
an nerve. Conclusions. A bifid median nerve occurs relatively frequently in patients with CTS. It may
facilitate compression of the median nerve in the carpal tunnel because of its relatively higher cross-
sectional area compared with a nonbifid median nerve. The size criterion for CTS in patients with a
bifid median nerve is slightly higher than in those with a nonbifid median nerve. Key words: bifid
median nerve; carpal tunnel syndrome; electrophysiology; high division of median nerve; sonography.
Received December 17, 2007, from the Departments
of Neurology (I.K.B., M.K., B.D.) and Radiology
(A.O.B., H.T.), Ondokuz Mays University, School
of Medicine, Samsun, Turkey. Revision requested
January 4, 2008. Revised manuscript accepted for
publication May 7, 2008.
Address correspondence to Ilkay Koray Bayrak,
MD, Department of Radiology, Ondokuz Mays
University Medical Faculty, Kurupelit, 55139 Samsun,
Turkey.
E-mail: ilkaykoray@hotmail.com
Abbreviations
CTS, carpal tunnel syndrome; ROC, receiver operating
characteristic
arpal tunnel syndrome (CTS) is a common neu-
ropathy that is caused by entrapment of the
median nerve in the wrist.
1
A high division of the
median nerve proximal to the carpal tunnel, also
known as a bifid median nerve, is an anatomic variation
that may be associated with CTS.
2
The occurrence of a
bifid median nerve has been widely reported in the surgi-
cal literature, and in most cases it coexists with a persis-
tent median artery.
28
The diagnosis of CTS is based on the patients clinical
history, physical examination, and electrophysiologic
studies. Recently, sonography at high frequencies has
been proven a useful diagnostic tool in patients with
CTS.
911
Sonography can also depict the nerve along its
course and can effectively show median nerve variations
in cases of atypical clinical and electrophysiologic abnor-
malities.
1215
A bifid median nerve that would be associat-
ed with CTS can also be depicted by sonography. To our
knowledge, no previous study has determined the fre-
2008 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2008; 27:11291136 0278-4297/08/$3.50
C
Article
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quency of a bifid median nerve on sonography in
patients with CTS and compared it with that in
controls. Cross-sectional area cutoff values that
can be used to diagnose CTS in bifid median
nerves have not been reported before. The aim of
this study was to investigate the frequency of
bifid median nerves in patients with CTS and to
determine the size criteria for CTS in bifid medi-
an nerve cases.
Materials and Methods
Study Participants
Three hundred twenty hands of 170 patients with
a diagnosis of CTS both clinically and electro-
physiologically who were referred to our neuro-
physiology laboratory between December 2006
and May 2007 were evaluated sonographically.
For the clinical diagnosis of CTS, patients were
questioned about their primary symptoms
(paresthesias, a needling sensation, clumsiness,
and nocturnal symptoms) in the area of median
nerve distribution. On the basis of 2 or more of
these primary symptoms, CTS was diagnosed
clinically. If only 1 of these symptoms was pre-
sent, we looked for at least 2 of the secondary
symptoms (swelling, sensations of burning and
cold, tightness, and pain/discomfort).
16
Patients
were excluded if they had any symptoms or signs
of polyneuropathy on neurologic examinations
or a history of surgery for CTS.
Two hundred forty hands of 120 controls were
selected from patients who underwent sono-
graphic evaluations for other reasons. They were
excluded if they described 1 of the CTS symp-
toms mentioned above or had systemic disease
that may have been associated with CTS. Patients
with diseases and conditions such as diabetes
mellitus, hypothyroidism, rheumatoid arthritis,
amyloidosis, chronic renal failure treated by
hemodialysis, and pregnancy were excluded.
Electrophysiologic evaluations were performed
in all patients and controls with a bifid median
nerve. Electrophysiologic evaluations were per-
formed to exclude CTS when a cross-sectional
area of greater than 0.09 cm
2
at the level of pisi-
form was measured by sonography in controls
without a bifid median nerve. All patients and
controls were asked to sign an informed consent
form.
Electrophysiologic Evaluations
Routine nerve conduction studies for CTS were
conducted with a Neuropack-8 electromyogra-
phy system (Nihon Kohden, Tokyo, Japan). The
skin temperature was kept between 31C and
32C. Motor nerve conduction studies of both
median and ulnar nerves were performed using
supramaximal stimuli at the wrist and recording
from the abductor pollicis brevis and the abduc-
tor digiti minimi muscles, respectively. Sensory
conduction studies were done antidromically,
stimulating at the wrist and recording from dig-
its 1 and 3 for the median nerve and from digit
5 for the ulnar nerve. We compared the findings
with the reference values used in our laboratory
and looked for median nerve neuropathy related
to a median nerve action potential latency
abnormality at the palm-wrist segment. When
routine nerve conduction study results were nor-
mal (standard negative hand results), a median-
ulnar sensory latency difference (0.4) was
required.
17
In accordance with the results provid-
ed in electrophysiologic studies, all of the hands
were categorized into 5 stages
18
: (1) minimal
CTS, characterized by standard negative hand
results and abnormal comparative test results;
(2) mild CTS, characterized by slowing of the
median digit-wrist segment and normal distal
motor latency; (3) moderate CTS, characterized
by slowing of the median digit-wrist segment
and abnormal distal motor latency; (4) severe
CTS, characterized by the absence of a median
sensory response and abnormal distal motor
latency; and (5) extreme CTS, characterized by
the absence of a thenar motor (and sensory)
response.
Sonographic Evaluations
Sonography was performed in real time with an
Aplio SSA-770A system (Toshiba Medical
Systems Co, Ltd, Tokyo, Japan) and a 12-MHz
linear probe. Each hand involved in the study
was placed on a hard surface in a neutral posi-
tion. The full course of the median nerve in the
tunnel was evaluated first in the sagittal plane.
The median nerve was located just beneath the
flexor retinaculum in the axial section. The nerve
was accepted as bifid if and when it branched out
before the level of the distal radial-ulnar junc-
tion. Three internal anatomic landmarks were
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Bifid Median Nerve in Carpal Tunnel Syndrome
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used for the axial images. Axial images of the
nerve were obtained at the radial-ulnar junction
(just proximal to the flexor retinaculum) and at
the level of the pisiform (proximal tunnel) and the
hook of the hamate (mid tunnel); the cross-
sectional area at each level was measured. A man-
ual tracing method was used for cross-sectional
area measurements (Figure 1A). The area mea-
surements were done for lateral and medial
branches of a bifid median nerve separately, and 2
measurements were added to obtain a total cross-
sectional area value at each level. Bifid median
nerves were also grouped according to the thick-
ness of the medial and lateral branches (equal
branches, thicker lateral branch, or thicker medial
branch; Figure 1). Palmar displacement of the
flexor retinaculum was not assessed, but the
median nerve was traced until it reached the deep
antecubital fossa for possible nerve or surround-
ing structure abnormalities. If needed, Doppler
sonography was used to differentiate vessels
between the 2 branches. All sonographic evalua-
tions were performed by the same radiologist.
Statistical Analysis
A statistical analysis was performed with SPSS
version 11 software for Windows (SPSS Inc,
Chicago, IL). To determine optimal cutoff points
for cross-sectional area measurements at the 3
different levels of the median nerve in patients
with CTS, a receiver operating characteristic
(ROC) curve analysis was done. The student t test
was used to compare cross-sectional area mea-
surements at the 3 levels of the bifid and nonbi-
fid median nerves of patients and controls.
Before the t test was performed, data were tested
for normality by a Wilks-Shapiro test. The
2
test
was used to determine the frequency of a bifid
median nerve in patients with CTS compared to
those without CTS. The Fisher exact test was
used to compare patients and controls with a
bifid median nerve according to findings of
branch dominance (thicker lateral, thicker medi-
al, or equal) and the presence or absence of a
persistent median artery.
Results
Study Participants
Among 170 patients with CTS, 32 (19%) had a
bifid median nerve. There were no significant
differences in age (P > .05) or sex (P > .05)
between the patients with CTS with and without
a bifid median nerve. The bifid median nerve
was unilateral in 22 patients (13%, 14 [64%] in
nondominant and 8 [36%] in dominant hands)
and bilateral in 10 (6%). We determined a high
division of the median nerve in 12 hands of 11
(9%) of 120 patients. A bifid median nerve was
relatively frequent in patients with CTS (P < .01;

2
= 9.48). Patient and control characteristics are
summarized in Table 1.
Electrophysiologic Findings
Electrophysiologic studies were done in all
patients with CTS and patients and controls with
a bifid median nerve. Carpal tunnel syndrome
was excluded by electrophysiologic studies in 18
controls with a cross-sectional area of greater
than 0.09 cm
2
at the level of the pisiform and a
J Ultrasound Med 2008; 27:11291136
1131
Bayrak et al
Figure 1. A, Bifid median nerve with almost equal branches (branches A and B). B, Bifid median nerve with a thicker lateral (L) than
medial (M) branch. Persistent median arteries (arrowheads) are shown along both bifid median nerves.
A B
278jumonline.qxp:Layout 1 7/11/08 1:05 PM Page 1131
nonbifid median nerve. Similar to the remaining
102 participants, they did not have any of the pri-
mary or secondary symptoms of CTS. In 2 partic-
ipants with no clinical symptom of CTS but a
large cross-sectional area on sonography, CTS
was confirmed by electrophysiologic studies,
and these participants were excluded.
Electrophysiologic findings of the patients with
a bifid median nerve are summarized in Table 2.
A unilateral bifid median nerve was in the non-
dominant hand of 14 patients. Twelve of them
had CTS in both hands; the electrophysiologic
stages of the 2 sides were comparable (difference
not more than 1 stage) in 10 patients, whereas
the electrophysiologic stage was more advanced
in the nondominant hand in 2 patients. We did
not observe any atypical electrophysiologic evi-
dence in the patients with a bifid median nerve.
Sonographic Findings
A bifid median nerve was observed in 42 wrists of
32 patients with CTS. In the control group, a bifid
median nerve was seen in 12 wrists of 11 individu-
als. No significant difference was noted between
patients and controls with a bifid median nerve
according to the thickness of the branches (P =
.078) and the presence of a persistent median
artery (P = .32; Table 3). The 2 (lateral and medial)
branches were measured individually, and a total
cross-sectional area value was obtained for each
level. Mean total cross-sectional area measure-
ments of bifid and nonbifid median nerves in both
patients and controls are summarized in Table 4.
Between patients and controls with or without a
bifid median nerve, a significant difference was
noted in cross-sectional area measurements at all
measured levels of the median nerve (P < .001;
Table 4). Between bifid and nonbifid median
nerves in patients, no significant difference was
noted in cross-sectional areas at any of the mea-
sured levels (radial-ulnar junction, P= .961; level of
pisiform, P= .584; level of hamate, P= .067; Table 4).
The cross-sectional area of the bifid median
nerve was significantly higher than that of the
nonbifid median nerve in controls at the levels
of the radial-ulnar junction (P < .001) and
hamate (P < .01). At the level of pisiform, how-
ever, the difference was not statistically signifi-
cant (P = .226; Table 4).
On the ROC curve analysis, cutoff values for cross-
sectional area measurements for CTS in patients
with a bifid median nerve were 0.11 cm
2
at the level
of the radial-ulnar junction (sensitivity, 88%; speci-
ficity, 99%; P< .001), 0.11 cm
2
at the level of the pisi-
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Bifid Median Nerve in Carpal Tunnel Syndrome
Table 1. Characteristics of Patients and Controls
Patients Without Patients With Controls Without Controls With
Characteristic BMN (n = 138) BMN (n = 32 [19%]) BMN (n = 109) BMN (n = 11 [9%])
Mean age, y
Male 49 53 46 22.5
Female 50 48.8 48 47
Total 48 49.3 47 42.5
Sex, n (%)
Male 16 (12) 4 (12.5) 20 (18) 2 (18)
Female 122 (88) 28 (87.5) 89 (82) 9 (82)
CTS, n/BMN, n (%)
Bilateral 120 10 (31) 0 1 (9)
Unilateral 18 22 (69) 0 10 (81)
BMN indicates bifid median nerve.
Table 2. Carpal Tunnel Syndrome Stage Distribution
in Patients With a Bifid Median Nerve
CTS Stage Dominant Nondominant
Unilateral BMN (n = 22)
Minimal 1 1
Mild 4 7
Moderate 2 2
Severe 1 4
Extreme 0 0
Bilateral BMN (n = 10)
Minimal 4 0
Mild 1 3
Moderate 4 4
Severe 1 3
Extreme 0 0
BMN indicates bifid median nerve.
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form (sensitivity, 90%; specificity, 99%; P < .001),
and 0.12 cm
2
at the level of the hook of the
hamate (sensitivity, 95%; specificity, 99%; P <
.001). These cutoff values for the cross-sectional
area of the nonbifid median nerve were 0.09 cm
2
(sensitivity, 96%; specificity, 81%; P < .001), 0.1
cm
2
(sensitivity, 98%; specificity, 81%; P < .001),
and 0.1 cm
2
(sensitivity, 96%; specificity, 87%;
P < .001), respectively. The ROC curves of cross-
sectional area measurements for detection of
CTS in patients with and without a bifid median
nerve are shown in Figure 2.
No space-occupying lesion (dislocated bone,
mass, or accessory muscle) was noted around the
median nerves. It was not easy to differentiate iso-
lated compression of the branches of the nerve
because the 2 branches were so close to each
other (not more than 2 mm in all participants).
Although there are cases of a bifid median nerve
with branches having a marked difference in
cross-sectional areas, we observed no apparent
difference in echogenicity.
Discussion
Carpal tunnel syndrome, compression of the
median nerve by the flexor retinaculum at the
wrist, is the most common nerve entrapment
syndrome. It may be idiopathic or associated
with various conditions such as space-occupying
lesions, Colles fractures, and systemic diseases
such as diabetes mellitus, hypothyroidism, and
rheumatoid arthritis.
1
Recently, Tanzer
19
suggest-
ed that an anatomic variation may be a pre-
disposing factor in the etiology of CTS. A bifid
median nerve and persistent median artery are
anatomic variations that have been reported
extensively in the surgical literature.
28
The bifid
median nerve anomaly has been reported to
have an incidence of 0.8% to 2.8% in patients
with CTS, and in most cases it has been reported
with a concomitant persistent median artery.
24,6
J Ultrasound Med 2008; 27:11291136
1133
Bayrak et al
Table 3. Sonographic Characteristics of a Bifid Median Nerve
Characteristic BMN With CTS (n = 42) BMN Without CTS (n = 12) P
Thicker lateral branch (2-fold), n (%) 22 (52) 8 (67)
Thicker medial branch (2-fold), n (%) 4 (10) 3 (25) .078
Almost equal branches, n (%) 16 (38) 1 (8)
Persistent median artery 19 (45) 3 (25) .32
BMN indicates bifid median nerve.
Table 4. Cross-sectional Area Measurements of All Nerves in Patients and Controls With and Without a Bifid Median Nerve
CTS Controls
Measurement Mean SD Range Mean SD Range P t
BMN, CTS (n = 42) vs controls (n = 12)
Radial-ulnar junction, cm
2
0.14 0.026 0.090.21 0.094 0.021 0.070.14 <.001 5.185
Level of pisiform, cm
2
0.15 0.035 0.090.26 0.092 0.015 0.070.12 <.001 5.495
Level of hamate, cm
2
0.15 0.037 0.080.25 0.095 0.017 0.070.12 <.001 5.389
Non-BMN, CTS (n = 278) vs controls (n = 228)
Radial-ulnar junction, cm
2
0.14 0.038 0.090.29 0.08 0.011 0.050.1 <.001 22.97
Level of pisiform, cm
2
0.15 0.045 0.090.26 0.09 0.01 0.050.1 <.001 21.87
Level of hamate, cm
2
0.14 0.039 0.080.29 0.08 0.011 0.050.11 <.001 22.05
P t P t
BMN vs non-BMN
Radial-ulnar junction .961 0.049 <.001 5.131
Level of pisiform .584 0.551 .226 1.278
Level of hamate .067 1.87 <.01 3.204
BMN indicates bifid median nerve.
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Imaging of bifid median nerves has been
described in very few studies,
1214
whereas to the
best of our knowledge, electrophysiologic and
sonographic findings had not been fully described
in the literature. Iannicelli et al
13
compared sono-
graphic and magnetic resonance imaging find-
ings in 6 patients with a bifid median nerve
selected from a population of 294 patients with
CTS. In another study, the authors reported 3
cases of a bifid median nerve, 1 of which was in a
patient with CTS, whereas the remaining 2 were
found in cadaveric specimens.
12
Both studies
concluded that sonography can allow effective
diagnosis and delineation of a bifid median
nerve. In a recent study, Gassner et al
14
described
Doppler sonographic findings in 2 patients with
CTS associated with a persistent median artery,
and they reported 16 hands with a persistent
median artery among 50 asymptomatic volun-
teers. In 10 of 16 hands, the persistent median
artery was associated with a bifid median nerve.
To our knowledge, this was the largest study in
the literature that provided a discussion for the
imaging and electrophysiologic findings con-
cerning bifid median nerves. In our study of 170
patients with CTS, we found a bifid median nerve
in 32 cases, unilaterally in 22 and bilaterally in 10.
It is not clear why our data revealed a relatively
high percentage of bifid median nerves (19%).
Nineteen hands were associated with a persis-
tent median artery. Thus, the incidence of bifid
median nerves in our study was higher than the
previous rates, and in nearly half (45%) of our
cases, a concomitant persistent median artery
was found.
Radiologic criteria for diagnosing CTS on mag-
netic resonance imaging or sonography include
swelling of the median nerve proximal to the
carpal tunnel and bowing of the flexor retinacu-
lum.
11,12,20
There are many studies acknowledg-
ing that sonography is an effective choice in
patients with CTS, relying on enlargement of the
median nerve with an area of greater than 9 or 10
mm
2
at the level of the pisiform.
21,22
Our data
showed a cutoff value of 10 mm
2
for CTS in
nonbifid median nerves at the level of the pisi-
form. Interestingly, Propeck et al
12
indicated that
the sonographic size criteria for diagnosing CTS
in nonbifid median nerves may not be accurate
in evaluating bifid median nerves. To our knowl-
edge, no study attempted to establish the size cri-
teria for CTS in bifid median nerves. In patients
with a bifid median nerve, our data revealed a
cutoff value of 11 mm
2
for CTS. This study deter-
mined a relatively higher cutoff value for CTS in
bifid median nerves than in nonbifid ones.
Singer and Ashworth
23
reviewed the surgical
findings of 147 hands that underwent carpal
tunnel release and reported 47 variations in 60
hands. They concluded that patient age and
hand dominance were important factors in pre-
dicting the presence of an anatomic variation.
1134
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Bifid Median Nerve in Carpal Tunnel Syndrome
Figure 2. Receiver operating characteristic curves of cross-sectional area measurements at the levels of the radial-ulnar articulation
(RUA), pisiform (LOP), and hook of the hamate (HOH) for detection of CTS in patients with (A) and without (B) a bifid median nerve.
A B
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For patients younger than 40 years, the odds of
observing an anatomic variation were higher
than for patients older than 40 years. The odds of
observing an anatomic variation in the domi-
nant hand were also higher than in the nondom-
inant hand. In our study, we investigated only
bifid median nerves and noted no significant age
difference. The occurrence of a bifid median
nerve in the nondominant hand was relatively
higher in patients with a unilateral bifid median
nerve in our study group. It is not clear why our
data showed a relatively high frequency of bifid
median nerves in the nondominant hand.
The major weakness of our study was the lack
of interobserver and intraobserver variability
measurements. In addition, although the con-
trols did not have any primary or secondary
symptoms, electrophysiologic studies were not
done in all of them.
In contrast to sonography, no atypical clinical
or electrophysiologic findings were noted in the
hands of participants with a bifid median nerve.
We also did not find a significant difference in
electrophysiologic stages between the 2 groups.
Only 2 patients with a bifid median nerve in the
nondominant hand had unilateral and severe
CTS, and 3 patients with a bifid median nerve in
the nondominant hand had more severe CTS
than in the dominant hand. It is known that in
idiopathic cases, the dominant hand is almost
always the affected hand. If symptoms are bilat-
eral, then the dominant hand is usually more
severely affected than the contralateral hand.
Unilateral CTS or bilateral CTS that is consider-
ably worse in the nondominant hand should
raise suspicion of the presence of a specific
underlying cause.
1
We think that it would be
important to investigate the bifid median
nerve and other variations or abnormalities
when unilateral CTS in the nondominant hand
is determined. Our data also showed a higher
cross-sectional area in controls with a bifid
median nerve than in those with a nonbifid
median nerve at the levels of the radial-ulnar
junction and hook of the hamate, but the differ-
ence at the level of the pisiform was not signifi-
cant. We think that these findings and the higher
incidence of bifid median nerves in patients with
CTS support the idea of the bifid median nerve
as the cause of CTS.
In conclusion, a bifid median nerve occurs rela-
tively frequently in patients with CTS. It may facil-
itate compression of the median nerve in the
carpal tunnel because of its relatively higher
cross-sectional area than that of a nonbifid medi-
an nerve. Although it has no electrophysiologic or
clinical differential diagnosis, in cases with uni-
lateral or severe CTS especially in the nondomi-
nant hand, physicians may consider the presence
of a median nerve variation. Because sonography
is a noninvasive and effective method for assess-
ing median nerve abnormalities such as a bifid
median nerve, we recommend its use in evalua-
tions of the median nerve. In addition, the sono-
graphic size criterion for CTS in patients with a
bifid median nerve is higher than in those with a
nonbifid median nerve.
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