An Unrecognized Bifid Median Nerve in Revision Carpal Tunnel Release: Lessons for Surgical Exploration

When patients experience persistent or worsening symptoms within the first 6-12 weeks following carpal tunnel release (CTR), surgeons should remain vigilant for underlying anatomical variations such as a bifid median nerve (BMN), which may contribute to incomplete decompression if unrecognized. Postoperative imaging may fail to identify this variant, especially when bifurcation occurs proximally in the forearm. Surgeons should consider extended-field magnetic resonance imaging (MRI) or high-resolution ultrasound (US) in revision cases. Patients should be counseled on an extended surgical approach for adequate nerve decompression and identification of a potential variety of anatomical variants leading to these symptoms. We present a case of progressive postoperative symptom worsening after primary open CTR in which a proximally bifurcated BMN, missed on MRI, was identified during revision surgery.