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Authors: Alice A Hunter, MD, Barry P Simmons, MD

Section Editors: Charles E Butler, MD, FACS, Jeremy M Shefner, MD, PhD
Deputy Editor: Kathryn A Collins, MD, PhD, FACS

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jul 2022. | This topic last updated: Jul 26, 2021.

INTRODUCTION

Carpal tunnel syndrome (CTS) is a common nerve entrapment disorder. The symptoms of
carpal tunnel syndrome include numbness, tingling, and occasionally pain in the hand,
especially if confined to the median nerve distribution ( table 1). The symptoms are often
worse at night but can also be present in the daytime in the worker with a provocative job.
Symptoms are often worse with driving or holding a book, newspaper, or telephone [1].

Appropriate treatment can interrupt the progression of this disorder and avoid the
development of permanent disability. Conservative therapy may be sufficient, although many
patients require surgery. Surgical treatment may involve open or endoscopic technique. The
goal of either approach is to decrease pressure upon the median nerve at the wrist by dividing
the transverse carpal ligament and antebrachial fascia.

This topic review will discuss the surgical treatment of CTS. The clinical manifestations,
diagnosis, and conservative therapy of this disorder are reviewed elsewhere. (See "Carpal
tunnel syndrome: Clinical manifestations and diagnosis" and "Carpal tunnel syndrome:
Treatment and prognosis".)

INDICATIONS

Indications for surgery include mild CTS unresponsive to conservative measures, or moderate-
to severe CTS associated with axonal loss or denervation on electrodiagnostic testing (
algorithm 1).

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Diagnostic studies (eg, electrodiagnostic studies, ultrasound, and magnetic resonance [MR]
imaging) can be helpful to assess the severity of disease or provide more information if the
diagnosis is in question [2]. In addition, these studies provide baseline data and exclude other
pathology that presents with similar symptoms. Although median nerve entrapment at the
wrist is the most common and most well-studied manifestation, CTS is often confused with
other disorders. Prior to contemplating surgical carpal tunnel release, the surgeon must be
certain of the correct diagnosis. (See "Carpal tunnel syndrome: Clinical manifestations and
diagnosis", section on 'Differential diagnosis'.)

If electrodiagnostic studies are normal, which can occur with symptomatic CTS [3], surgical
intervention should only be considered if physical signs of median nerve dysfunction are
present in addition to classic symptoms of CTS. (See "Carpal tunnel syndrome: Clinical
manifestations and diagnosis", section on 'Electrodiagnostic testing'.)

ANATOMY OF THE CARPAL TUNNEL

To better appreciate the possible surgical approaches for carpal tunnel release, one must
understand the anatomy of the carpal tunnel and the median nerve at the wrist. The carpal
tunnel is a defined anatomic space with the following characteristics:

● The dorsal surface is formed by the carpal bones, while the volar surface is formed by
the transverse carpal ligament (flexor retinaculum), which attaches ulnarly to the hamate
and pisiform and radially to the trapezium and scaphoid tuberosity ( figure 1).

● The antebrachial fascia of the forearm is continuous with the transverse carpal ligament
of the palm. The four flexor digitorum profundus tendons, four flexor digitorum
superficialis tendons, the flexor pollicis longus tendon, and the median nerve pass within
this canal ( figure 2).

● The superficial palmar arch lies 1 to 4 mm from the distal edge of the transverse carpal
ligament.

Median nerve — The median nerve lies directly under the transverse carpal ligament (
figure 1). The median nerve at the level of the distal forearm and wrist has three main
branches: two sensory and one motor. The first sensory branch is the palmar cutaneous
nerve, which branches from the median nerve approximately 5 cm proximal to the wrist
crease. This nerve gives sensation to the thenar eminence and, because its takeoff is proximal
to the carpal canal, it is not affected by CTS. However, it can easily be injured in the release of
the transverse carpal ligament if the incision is not meticulously placed.
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The second sensory branch passes through the carpal canal as part of the main trunk. After
passing through the canal, it divides into multiple branches to innervate the thumb, index,
middle, and radial half of the ring finger. Because these sensory branches pass through the
canal, they are affected by compression of the median nerve at the level of the transverse
carpal ligament. Branches of these sensory nerves can also be injured during surgery, more
commonly with an endoscopic carpal tunnel release.

The motor branch innervates the two radial lumbricals, opponens pollicis, abductor pollicis
brevis, and the superficial head of the flexor pollicis brevis. The motor branch takes a more
variable route to its destination. It most often branches off distal to the transverse carpal
ligament. However, it may branch off within the tunnel or pass directly through the transverse
carpal ligament. The motor branch is in jeopardy during carpal tunnel release if meticulous
planning is not carried out.

SURGICAL TECHNIQUES

Surgery can be divided into two main techniques:

● The open carpal tunnel release, which can be performed through a standard incision or
a limited incision. (See 'Open technique' below.)

● Endoscopic carpal tunnel release, which can be performed through a single or double
portal. (See 'Endoscopic techniques' below.)

● Ultrasound-guided minimally invasive carpel tunnel release, which can be performed

through a minimal skin incision (skin nick) or entirely percutaneously. (See 'Ultrasound-
guided ultra-minimally invasive techniques' below.)

Each procedure has its risks and benefits, and there is controversy among prominent hand
surgeons as to the best technique. Surgeon experience and preference is therefore the main
determining factor in the technique selection. (See 'Outcomes' below.)

Surgery for carpal tunnel release is usually performed using local anesthesia only, or local
anesthesia with intravenous sedation, according to patient preference. It is usually carried out
with the use of a tourniquet. However, if the local anesthetic is used with epinephrine,
tourniquet use can be avoided.

In addition to performing the carpel tunnel release, some surgeons will selectively perform
tenosynovial biopsy in at-risk patients to identify early amyloidosis. Carpel tunnel syndrome is

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one of the earliest clinical manifestations of this disease [4,5]. (See "Musculoskeletal
manifestations of amyloidosis", section on 'Carpal tunnel syndrome'.)

Open technique — The open approach provides a complete view of the anatomy and
possible anomalies, thereby decreasing the risk of injury to critical structures. This approach
also allows exploration of the carpal canal (eg, mass) or biopsy of the tenosynovium to rule
out systemic inflammatory disease, which may not be possible with the endoscopic technique.

Prior to making an incision, the surgeon must keep in mind the anatomy of associated
structures ( figure 3) such as the superficial palmar arch, the motor branch of the median
nerve, the ulnar canal (Guyon's canal), and the palmar cutaneous branch.

Standard incision — A variety of longitudinal incisions can be employed. Most commonly,

the incision starts just proximal to Kaplan's cardinal line, which is drawn from the apex of the
interdigital fold between the thumb and index finger toward the ulnar side of the hand,
parallel with the middle crease of the hand ( figure 4) [6,7]. The incision is extended in a
curvilinear manner staying just ulnar to the thenar crease. This keeps the incision ulnar to the
palmaris longus, which reduces the likelihood of affecting the small palmar cutaneous nerve
branches that pass from radial to ulnar in the palm.

Few surgeons carry this incision proximal to the wrist crease unless the patient needs a repeat
release. If the incision does cross the crease, it should do so obliquely to avoid a flexion
contracture at the wrist, and it should be directed ulnarly to avoid the palmar cutaneous
nerve. The incision is then deepened either bluntly or sharply through the palmar fascia to the
transverse carpal ligament.

The transverse carpal ligament and antebrachial fascia are divided longitudinally, and the
median nerve may be identified. The division should occur along the ulnar border of the
transverse carpal ligament to avoid damage to the motor branch. Care must be taken to
obtain a complete release while avoiding damage to the vital structures. The flexor tendons
can be retraced radially to inspect the floor of the canal for lesions. Meticulous hemostasis
must be achieved prior to closure. A technique that includes subneural reconstruction of the
transverse carpal ligament has been described and, in one trial, appeared to improve
postoperative grip strength [8].

With open carpal tunnel release, the question often arises whether or not to perform internal
neurolysis. At one time, neurolysis was felt to be important to a primary carpal tunnel release
[9,10]. However, later studies found no significant difference between primary carpal tunnel
release performed with or without internal neurolysis [11,12]. This applies even to patients

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with severe CTS defined by thenar atrophy and/or a fixed sensory deficit [11]. Neurolysis is
accomplished by incising the epineurium to further decompress the nerve fascicles.

Small palmar incision — Open carpal tunnel release can also be performed through a small
palmar (or "limited") incision [13]. This permits better exposure to avoid complications and
keeps the incision out of the painful portion of the palm.

Carpal tunnel release through a small palmar incision uses a longitudinal palmar incision that
starts just proximal to Kaplan's cardinal line and moves proximally for 2 to 2.5 cm. This allows
visualization of the transverse carpal ligament; the more proximal portion of the ligament can
be identified by elevating the tissue proximally above and below it. Then, under direct vision,
the ligament can be incised or cut with a carpal tunnel tome.

The improved exposure with this technique decreases the risk of injury to vital structures and
avoids a longer scar at the base of the palm that increases morbidity. Furthermore, the
palmar fascia is left intact over the proximal portion of the transverse carpal ligament,
reducing postoperative incision pain [13].

Endoscopic techniques — Due to preservation of the palmar fascia, subcutaneous fat, and

skin, endoscopic median nerve decompression may result in less scar tenderness and an
earlier return to work compared with the open technique. However, good visualization is
essential for the endoscopic technique. If this cannot be achieved, one must switch to the
open technique.

Both a one-portal and a two-portal approach have been used [14-19]. The success rates are
equivalent, and the choice is surgeon dependent [17,18].

One-portal approach — The one- and two-portal techniques use a transverse portal at the
wrist. A flap of antebrachial fascia is elevated and dilators are passed distally. The path is just
radial to the hook of the hamate, in line with the ring finger. Care must be taken not to pass
Kaplan's cardinal line to avoid injury to the palmar arch. The neurovascular bundle is 1 to 4
mm from the distal edge of the transverse carpal ligament [20].

If the one portal technique is used, the endoscopic device is then passed. One should
immediately see the fibers of the transverse carpal ligament. If these are not seen, an attempt
to clear the ligament of synovial tissue from the ligament is carried out. If the exact position of
the transverse carpal ligament cannot be determined, the endoscopic approach must be
aborted. If the fibers are clearly seen, the device is inserted just distal to the fibers. The knife
device is then elevated and pulled proximally, cutting the transverse carpal ligament under
endoscopic vision. Assessment to verify complete transection of the fibers is carried out. The
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antebrachial fascia can be cut under direct vision, through the portal at the wrist, using
scissors.

Two-portal approach — If a second portal is desired, a transverse incision is made in the

palm just over the end of the transverse carpal ligament. This portal permits distal
visualization and can be used to depress structures, such as the superficial palmar arch, out of
the operative field.

Ultrasound-guided ultra-minimally invasive techniques — Ultrasound is commonly used in

the initial evaluation of carpel tunnel syndrome and can also be used to guide nonsurgical
therapies. (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis", section on
'Imaging' and "Carpal tunnel syndrome: Treatment and prognosis", section on 'Initial
nonsurgical treatment for most patients'.)

A novel technique to release the median nerve using an ultrasound-guided minimally invasive
technique has been described and may become an alternative to conventional open surgery
or endoscopic treatment [21,22]. Several techniques have been described that vary in access,
with some involving a very small incision and others describing a totally percutaneous
technique, access location, and approach to the flexor retinaculum (antegrade, retrograde)
[21,23-25].

Conceptually, the ultrasound-guided technique is like endoscopic carpal tunnel release but
instead of viewing anatomic structures directly using the endoscope, the operator visualizes
the contents of the carpal tunnel using ultrasound. With the hand sterilely prepared and
draped, a sterile ultrasound probe is used to identify and mark key anatomic structures. Local
anesthesia is administered over the predetermined incision site. Using ultrasound guidance,
local anesthetic is administered into the carpal canal, which improves visualization and allows
for hydrodissection. A small incision (3 to 5 mm), which must penetrate the fascia, is made
with a no. 15 blade at the level of the proximal flexion crease. Under ultrasound guidance, a
retrograde cutting tool is placed through the incision and advanced distally between the hook
of the hamate and the median nerve to the distal end of the transverse carpal ligament. The
cutting blade is deployed, and the transverse carpal ligament is released from distal to
proximal. Following confirmation that the transverse carpal ligament is completely released,
the cutting tool is removed. The wound can be closed with steristrips or a suture.

POSTOPERATIVE CARE

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A soft dressing is placed postoperatively and left in place for three days, after which it is
removed and replaced with a small adhesive dressing overlying just the wound [26,27]. The
hand is elevated postoperatively until all swelling resolves. Active motion of all the digits and
of the wrist should be encouraged. Postoperative immobilization (eg, splint, cast) is
unnecessary and may adversely affect rehabilitation [28].

COMPLICATIONS

With proper surgical training, experience, and technique, it is estimated that the combined
incidence of long-term disability related to complications from carpal tunnel release surgery
should not exceed 1 to 2 percent [29]. The types of complications seen with open, endoscopic
techniques and ultrasound-guided ultra-minimally invasive techniques are similar [30-33].

Complications of surgery for CTS include the following [29,34]:

● Inadequate division of the transverse carpal ligament

● Injuries of the recurrent motor and palmar cutaneous branches of the median nerve
● Lacerations of the median and ulnar trunk
● Vascular injuries of the superficial palmar arch
● Postoperative wound infections
● Painful scar formation
● Complex regional pain syndrome

Incomplete release of the transverse carpal ligament may be the most frequent complication
of surgery for CTS and is usually due to errors in surgical technique, such as poor choice of
incision and inadequate exposure [29]. It is also the most common problem leading to
reoperation for CTS, in one series accounting for 49 percent of 185 reoperations [35].

In an early series of 186 patients, 34 various complications occurred in 22 patients (12

percent), including incomplete division of the transverse carpal ligament in 11 (6 percent) and
development of complex regional pain syndrome in 4 (2 percent) [34].

OUTCOMES

Outcome studies have demonstrated that both open surgery and endoscopic release produce
subjective improvement in preoperative symptoms [13,17,30,36-38]. The choice of technique
is largely surgeon dependent. Each has its advantages and disadvantages, and each
technique has a learning curve, which is greatest with the endoscopic technique.

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Proponents of the ultrasound-guided ultra-minimally invasive and endoscopic techniques cite

evidence that it leads to less postoperative incision pain and an earlier return to work
compared with open techniques [30,39,40]. However, critics of the endoscopic approach cite
an apparent increased rate of complications, which are related to the experience of the
surgeon [41,42].

Evaluation of pain relief and function is essential in determining the effectiveness of

treatment for musculoskeletal disorders. One study used a standardized, self-administered
questionnaire to assess the severity of symptoms and functional status at six weeks, three
months, six months, and two years after open (primarily limited open) surgery [43]. The
following findings were noted:

● Nocturnal pain, tingling, and numbness improved within six weeks.

● Weakness and functional status improved more gradually, and grip and pinch strength
initially worsened, returned to preoperative levels at approximately three months, and
improved significantly by two years. Grip and pinch strength improve after carpal tunnel
release despite the effect of transverse carpal ligament release on flexor tendon pulley
function [44].

● Although 90 percent of patients had relief of either nighttime or daytime pain, only 73
percent said that they were completely or very satisfied with the results of the surgery.

These temporal patterns should be discussed with the patient to promote realistic
expectations about the results of surgery.

Using the same questionnaire, a prospective study was performed to determine the
predictors of return to work after carpal tunnel release (primarily open surgery) in a
community-based cohort [16]. Within six months, 77 percent had returned to their previous
employment. The major risk factors for poor outcome were scar tenderness and failure to
relieve symptoms. Other negative predictors of return to work included lack of an education
beyond high school, consumption of more than two drinks per day, smoking, female sex, use
of an attorney or workers' compensation before surgery, and the presence of physical
stresses such as multiple repetitive motion in the workplace. Later follow-up of a related
cohort showed that 82 percent of workers' compensation recipients had returned to work at
30 months [45].

A single-surgeon study involving 113 patients followed over a mean of 13 years also evaluated
patient satisfaction [38]. The most common residual complaint was very mild daytime tingling,
but 88 percent of the patients were "completely" or "very" satisfied with the results of the
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surgery; 74 percent reported complete relief of symptoms. Only 2 patients out of 113 (1.8
percent) required a repeat carpal tunnel release.

In a review of 42 operations in 35 patients, the outcomes of endoscopic carpal tunnel release

were "satisfactory" in 86 percent [37]. The mean time to return to ordinary daily activities and
work were 14 and 25 days, respectively. One year after surgery, night pain and paresthesia
were absent in 95 and 81 percent, respectively.

Open versus endoscopic techniques — In trials comparing open versus endoscopic carpal
tunnel release, the outcomes appear to be equivalent [46,47].

● While some trials suggest a more rapid postoperative recovery and earlier return to
work with the endoscopic technique [30,48,49], others have found no significant
difference for time to return to work between the two techniques [50-52].

● The endoscopic technique may result in less postoperative pain and tenderness of the
scar [30,53,54], but the degree of this benefit appears to be modest [52].

● Digital flexor tendon mechanics are closer to normal following endoscopic carpal tunnel
release than with the open technique [55].

● A trial that randomly assigned 128 patients to open or two-portal endoscopic carpal
tunnel release followed the patients over an extended period of time [56]. Complete data
for all outcome survey measures were available for 124 of the patients with a mean
follow-up of 12.9 years after surgery (range: 11.3 to 15.7 years). At extended follow-up,
there were no significant differences between open and endoscopic carpal tunnel
release.

Open versus ultrasound-guided ultra-minimally invasive techniques — The benefits of

ultrasound-guided ultra-minimally invasive techniques are potentially no incision and quick
recovery, but there is possibly a higher recurrence rate [22,57,58]. Two prospective studies
have compared mini-open techniques to the ultrasound-guided technique [39,40]. In one trial,
return to normal daily activities occurred significantly sooner in the ultrasound-guided
technique group (4.9 versus 25.4 days) [39]. In another trial, the ultrasound-guided technique
had lower scores on the Italian modified version of the Boston Carpal Tunnel syndrome
Questionnaire (BCTSQ) compared with the mini-open group at 19 months, but not at 30
months. Disease recurred in 7 of 82 patients in the ultrasound-guided technique group and
only 1 of 103 in the mini-open group. There are no prospective studies comparing the various
ultrasound-guided techniques.

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SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Carpal tunnel
syndrome".)

SUMMARY AND RECOMMENDATIONS

● Carpal tunnel syndrome is a common nerve entrapment disorder manifested by pain,

paresthesias, and ultimately muscle wasting of the hand. Conservative therapy may be
sufficient, although many patients require surgery. (See 'Introduction' above.)

● Indications for surgery include persistent numbness and pain, motor dysfunction with
diminished grip or pinch grasping, or thenar eminence flattening. Electrodiagnostic
studies are suggested, even if the history and/or physical examination is suggestive of
carpal tunnel syndrome. (See 'Indications' above.)

● Carpal tunnel release can be performed as an open procedure, endoscopically, or by

using ultrasound-guided ultra-minimally invasive techniques. (See 'Surgical techniques'
above.)

● The most frequent complication of carpal tunnel surgery is incomplete release of the
transverse carpal ligament, which often requires reoperation. (See 'Complications'
above.)

● The long-term outcomes of open, endoscopic, and ultrasound-guided ultra-minimally

invasive carpal tunnel release are equivalent. Ultra-minimally invasive techniques have
the advantage of quicker recovery but the potential for a higher rate of recurrence. (See
'Outcomes' above.)

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REFERENCES
1. Levine DW, Simmons BP, Koris MJ, et al. A self-administered questionnaire for the
assessment of severity of symptoms and functional status in carpal tunnel syndrome. J
Bone Joint Surg Am 1993; 75:1585.

https://www.uptodate.com/contents/surgery-for-carpal-tunnel-syndrome?search=carpal turnel syndrome surgert&source=search_result&selectedTitl… 10/16

8/14/22, 11:33 PM Surgery for carpal tunnel syndrome - UpToDate

2. Kasundra GM, Sood I, Bhargava AN, et al. Carpal tunnel syndrome: Analyzing efficacy
and utility of clinical tests and various diagnostic modalities. J Neurosci Rural Pract 2015;
6:504.

3. Concannon MJ, Gainor B, Petroski GF, Puckett CL. The predictive value of
electrodiagnostic studies in carpal tunnel syndrome. Plast Reconstr Surg 1997; 100:1452.

4. Shum C, Parisien M, Strauch RJ, Rosenwasser MP. The role of flexor tenosynovectomy in
the operative treatment of carpal tunnel syndrome. J Bone Joint Surg Am 2002; 84:221.

5. Zhang D, Makhni MC, Kang JD, Blazar P. Orthopaedic Manifestations of Amyloidosis. J Am

Acad Orthop Surg 2021; 29:e488.

6. Kaplan EB. Surface anatomy of the hand and wrist. In: Functional and Surgical Anatomy
of the Hand, Spinner E (Ed), J.B. Lippincott, Philadelphia 1953. p.227.

7. Panchal AP, Trzeciak MA. The Clinical Application of Kaplan's Cardinal Line as a Surface
Marker for the Superficial Palmar Arch. Hand (N Y) 2010; 5:155.

8. Zhang X, Li Y, Wen S, et al. Carpal tunnel release with subneural reconstruction of the
transverse carpal ligament compared with isolated open and endoscopic release. Bone
Joint J 2015; 97-B:221.

9. Curtis RM, Eversmann WW Jr. Internal neurolysis as an adjunct to the treatment of the
carpal-tunnel syndrome. J Bone Joint Surg Am 1973; 55:733.

10. Rhoades CE, Mowery CA, Gelberman RH. Results of internal neurolysis of the median
nerve for severe carpal-tunnel syndrome. J Bone Joint Surg Am 1985; 67:253.

11. Lowry WE Jr, Follender AB. Interfascicular neurolysis in the severe carpal tunnel
syndrome. A prospective, randomized, double-blind, controlled study. Clin Orthop Relat
Res 1988; 227:251.

12. Chapell R, Coates V, Turkelson C. Poor outcome for neural surgery (epineurotomy or
neurolysis) for carpal tunnel syndrome compared with carpal tunnel release alone: a
meta-analysis of global outcomes. Plast Reconstr Surg 2003; 112:983.

13. Lee WP, Plancher KD, Strickland JW. Carpal tunnel release with a small palmar incision.
Hand Clin 1996; 12:271.

14. Trumble TE, Diao E, Abrams RA, Gilbert-Anderson MM. Single-portal endoscopic carpal
tunnel release compared with open release : a prospective, randomized trial. J Bone Joint
https://www.uptodate.com/contents/surgery-for-carpal-tunnel-syndrome?search=carpal turnel syndrome surgert&source=search_result&selectedTitl… 11/16
8/14/22, 11:33 PM Surgery for carpal tunnel syndrome - UpToDate

Surg Am 2002; 84:1107.

15. Vanni D, Sirabella FS, Galzio R, et al. The double tunnels technique: an alternative
minimally invasive approach for carpal tunnel syndrome. J Neurosurg 2015; 123:1230.

16. Katz JN, Keller RB, Fossel AH, et al. Predictors of return to work following carpal tunnel
release. Am J Ind Med 1997; 31:85.

17. Biyani A, Downes EM. An open twin incision technique of carpal tunnel decompression
with reduced incidence of scar tenderness. J Hand Surg Br 1993; 18:331.

18. Chow JC, Hantes ME. Endoscopic carpal tunnel release: thirteen years' experience with
the Chow technique. J Hand Surg Am 2002; 27:1011.

19. Sabesan VJ, Pedrotty D, Urbaniak JR, Aldridge JM 3rd. An evidence-based review of a
single surgeon's experience with endoscopic carpal tunnel release. J Surg Orthop Adv
2012; 21:117.

20. Van Heest A, Waters P, Simmons B, Schwartz JT. A cadaveric study of the single-portal
endoscopic carpal tunnel release. J Hand Surg Am 1995; 20:363.

21. Petrover D, Hakime A, Silvera J, et al. Ultrasound-Guided Surgery for Carpal Tunnel
Syndrome: A New Interventional Procedure. Semin Intervent Radiol 2018; 35:248.

22. Petrover D, Richette P. Treatment of carpal tunnel syndrome : from ultrasonography to

ultrasound guided carpal tunnel release. Joint Bone Spine 2018; 85:545.

23. Sytsma TT, Ryan HS, Lachman N, et al. Anatomic Relationship Between the Hook of the
Hamate and the Distal Transverse Carpal Ligament: Implications for Ultrasound-Guided
Carpal Tunnel Release. Am J Phys Med Rehabil 2018; 97:482.

24. Burnham R, Playfair L, Loh E, et al. Evaluation of the Effectiveness and Safety of
Ultrasound-Guided Percutaneous Carpal Tunnel Release: A Cadaveric Study. Am J Phys
Med Rehabil 2017; 96:457.

25. Schrier VJMM, Shin AY, Brault JS. An Incision-less Ultrasound-guided Carpal Tunnel
Release Technique. Tech Hand Up Extrem Surg 2020; 25:14.

26. Finsen V, Andersen K, Russwurm H. No advantage from splinting the wrist after open
carpal tunnel release. A randomized study of 82 wrists. Acta Orthop Scand 1999; 70:288.

https://www.uptodate.com/contents/surgery-for-carpal-tunnel-syndrome?search=carpal turnel syndrome surgert&source=search_result&selectedTitl… 12/16

8/14/22, 11:33 PM Surgery for carpal tunnel syndrome - UpToDate

27. Henry SL, Hubbard BA, Concannon MJ. Splinting after carpal tunnel release: current
practice, scientific evidence, and trends. Plast Reconstr Surg 2008; 122:1095.

28. Huemer GM, Koller M, Pachinger T, et al. Postoperative splinting after open carpal tunnel
release does not improve functional and neurological outcome. Muscle Nerve 2007;
36:528.

29. Bland JD. Treatment of carpal tunnel syndrome. Muscle Nerve 2007; 36:167.

30. Brown RA, Gelberman RH, Seiler JG 3rd, et al. Carpal tunnel release. A prospective,
randomized assessment of open and endoscopic methods. J Bone Joint Surg Am 1993;
75:1265.

31. Agee JM, Peimer CA, Pyrek JD, Walsh WE. Endoscopic carpal tunnel release: a prospective
study of complications and surgical experience. J Hand Surg Am 1995; 20:165.

32. Murphy RX Jr, Jennings JF, Wukich DK. Major neurovascular complications of endoscopic
carpal tunnel release. J Hand Surg Am 1994; 19:114.

33. Nath RK, Mackinnon SE, Weeks PM. Ulnar nerve transection as a complication of two-
portal endoscopic carpal tunnel release: a case report. J Hand Surg Am 1993; 18:896.

34. MacDonald RI, Lichtman DM, Hanlon JJ, Wilson JN. Complications of surgical release for
carpal tunnel syndrome. J Hand Surg Am 1978; 3:70.

35. Assmus H. [Correction and reintervention in carpal tunnel syndrome. Report of 185
reoperations]. Nervenarzt 1996; 67:998.

36. Chow JC. Endoscopic release of the carpal ligament for carpal tunnel syndrome: 22-
month clinical result. Arthroscopy 1990; 6:288.

37. Ghaly RF, Saban KL, Haley DA, Ross RE. Endoscopic carpal tunnel release surgery: report
of patient satisfaction. Neurol Res 2000; 22:551.

38. Louie DL, Earp BE, Collins JE, et al. Outcomes of open carpal tunnel release at a minimum
of ten years. J Bone Joint Surg Am 2013; 95:1067.

39. Rojo-Manaute JM, Capa-Grasa A, Chana-Rodríguez F, et al. Ultra-Minimally Invasive

Ultrasound-Guided Carpal Tunnel Release: A Randomized Clinical Trial. J Ultrasound Med
2016; 35:1149.

https://www.uptodate.com/contents/surgery-for-carpal-tunnel-syndrome?search=carpal turnel syndrome surgert&source=search_result&selectedTitl… 13/16

8/14/22, 11:33 PM Surgery for carpal tunnel syndrome - UpToDate

40. Cellocco P, Rossi C, Bizzarri F, et al. Mini-open blind procedure versus limited open
technique for carpal tunnel release: a 30-month follow-up study. J Hand Surg Am 2005;
30:493.

41. Lee DH, Masear VR, Meyer RD, et al. Endoscopic carpal tunnel release: a cadaveric study.
J Hand Surg Am 1992; 17:1003.

42. Rowland EB, Kleinert JM. Endoscopic carpal-tunnel release in cadavera. An investigation
of the results of twelve surgeons with this training model. J Bone Joint Surg Am 1994;
76:266.

43. Katz JN, Fossel KK, Simmons BP, et al. Symptoms, functional status, and neuromuscular
impairment following carpal tunnel release. J Hand Surg Am 1995; 20:549.

44. Netscher D, Steadman AK, Thornby J, Cohen V. Temporal changes in grip and pinch
strength after open carpal tunnel release and the effect of ligament reconstruction. J
Hand Surg Am 1998; 23:48.

45. Katz JN, Keller RB, Simmons BP, et al. Maine Carpal Tunnel Study: outcomes of operative
and nonoperative therapy for carpal tunnel syndrome in a community-based cohort. J
Hand Surg Am 1998; 23:697.

46. Vasiliadis HS, Georgoulas P, Shrier I, et al. Endoscopic release for carpal tunnel
syndrome. Cochrane Database Syst Rev 2014; :CD008265.

47. Zuo D, Zhou Z, Wang H, et al. Endoscopic versus open carpal tunnel release for idiopathic
carpal tunnel syndrome: a meta-analysis of randomized controlled trials. J Orthop Surg
Res 2015; 10:12.

48. Saw NL, Jones S, Shepstone L, et al. Early outcome and cost-effectiveness of endoscopic
versus open carpal tunnel release: a randomized prospective trial. J Hand Surg Br 2003;
28:444.

49. Agee JM, McCarroll HR Jr, Tortosa RD, et al. Endoscopic release of the carpal tunnel: a
randomized prospective multicenter study. J Hand Surg Am 1992; 17:987.

50. Jacobsen MB, Rahme H. A prospective, randomized study with an independent observer
comparing open carpal tunnel release with endoscopic carpal tunnel release. J Hand
Surg Br 1996; 21:202.

https://www.uptodate.com/contents/surgery-for-carpal-tunnel-syndrome?search=carpal turnel syndrome surgert&source=search_result&selectedTitl… 14/16

8/14/22, 11:33 PM Surgery for carpal tunnel syndrome - UpToDate

51. Macdermid JC, Richards RS, Roth JH, et al. Endoscopic versus open carpal tunnel release:
a randomized trial. J Hand Surg Am 2003; 28:475.

52. Atroshi I, Larsson GU, Ornstein E, et al. Outcomes of endoscopic surgery compared with
open surgery for carpal tunnel syndrome among employed patients: randomised
controlled trial. BMJ 2006; 332:1473.

53. Kang HJ, Koh IH, Lee TJ, Choi YR. Endoscopic carpal tunnel release is preferred over mini-
open despite similar outcome: a randomized trial. Clin Orthop Relat Res 2013; 471:1548.

54. Wong KC, Hung LK, Ho PC, Wong JM. Carpal tunnel release. A prospective, randomised
study of endoscopic versus limited-open methods. J Bone Joint Surg Br 2003; 85:863.

55. Brown RK, Peimer CA. Changes in digital flexor tendon mechanics after endoscopic and
open carpal tunnel releases in cadaver wrists. J Hand Surg Am 2000; 25:112.

56. Atroshi I, Hofer M, Larsson GU, Ranstam J. Extended Follow-up of a Randomized Clinical
Trial of Open vs Endoscopic Release Surgery for Carpal Tunnel Syndrome. JAMA 2015;
314:1399.

57. Kamel SI, Freid B, Pomeranz C, et al. Minimally Invasive Ultrasound-Guided Carpal Tunnel
Release Improves Long-Term Clinical Outcomes in Carpal Tunnel Syndrome. AJR Am J
Roentgenol 2021; 217:460.

58. Petrover D, Silvera J, De Baere T, et al. Percutaneous Ultrasound-Guided Carpal Tunnel

Release: Study Upon Clinical Efficacy and Safety. Cardiovasc Intervent Radiol 2017;
40:568.

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