Journal of Hand Surgery Global Online 5 (2023) 595e600

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Journal of Hand Surgery Global Online

journal homepage: www.JHSGO.org

Original Research

Carpal Tunnel Release With Ultrasound Guidance: Intermediate-Term

Clinical Outcomes and Magnetic Resonance Imaging Findings
Grace E. Nicholas, MSc, * Jen Galloway, RN, BSN, y Jennifer Hawley, RT(R), RDMS, RVT, y
Joseph C. McGinley, MD, PhD *, y
*
Department of Radiology, University of Washington School of Medicine, Seattle, WA
y
The McGinley Clinic, Casper, WY

a r t i c l e i n f o

Article history: Purpose: The purpose of this study was to report intermediate-term outcomes following carpal tunnel
Received for publication April 29, 2023 release using ultrasound guidance and wide-awake local anesthesia no tourniquet, including a subset of
Accepted in revised form May 6, 2023 patients with preoperative and postoperative magnetic resonance imaging (MRI).
Available online June 7, 2023
Methods: In this observational study, patients with carpal tunnel syndrome were treated with carpal
tunnel release using ultrasound guidance and wide-awake local anesthesia no tourniquet in a procedure
Key words: room at a single center. Main outcomes were complications; return to activity and work at 2 weeks;
Carpal tunnel syndrome
Quick Disabilities of the Arm, Shoulder, and Hand and Boston Carpal Tunnel Questionnaire scores
Carpal tunnel release
CTR-US
through 6 months; and postoperative morphological changes of the transverse carpal ligament, median
Magnetic resonance imaging nerve, and carpal tunnel evaluated using MRI.
WALANT Results: No complications were reported among 65 patients (68% women, 96 wrists). By 2 weeks, 97% of
patients returned to normal activity and 100% returned to work. Statistically significant improvements in
Boston Carpal Tunnel Questionnaire symptom severity scale, Boston Carpal Tunnel Questionnaire
functional status scale, and Quick Disabilities of the Arm, Shoulder, and Hand scores occurred by the 2-
week follow-up interval and persisted at 6 months (all P < .001). Pre- and postoperative MRI scans were
available for 13 patients (17 wrists) at the 3-month mean follow-up. Complete transverse carpal ligament
transection was documented in all wrists. Key MRI findings included a 22% increase in carpal tunnel
cross-sectional area at the hamate (P < .001), a 52% increase in median nerve cross-sectional area at the
hamate (P < .001), an 18% reduction in median nerve signal intensity (P ¼ .002), a 38% reduction in the
flattening ratio of the median nerve at the hamate (P < .001), a 33% reduction in the flattening ratio of the
median nerve at the pisiform (P < .001), a 20% reduction in the flattening ratio of the carpal tunnel at the
hamate (P < .001), and a palmar shift of the median nerve relative to the hamate in all cases.
Conclusions: Carpal tunnel release using ultrasound guidance using wide-awake local anesthesia no
tourniquet in a procedure room setting was safe, effective, and resulted in morphological changes that
were consistent with carpal tunnel decompression as demonstrated by MRI.
Type of study/level of evidence: Therapeutic IV.

Copyright © 2023, THE AUTHORS. Published by Elsevier Inc. on behalf of The American Society for Surgery of the Hand.
This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Carpal tunnel syndrome (CTS) is the most common entrapment

Declaration of interests: J.C.M. reports consultancy with Sonex Health, Inc
unrelated to the current manuscript and is Founder and CEO of McGinley Education
Innovations, LLC, which owns, produces, and sells the McGinley Augmented Reality
for Ultrasound System. No benefits in any form have been received or will be
received by the other authors related directly to this article.
Corresponding author: Joseph C. McGinley, MD, PhD, The McGinley Clinic, 234
E 1st St., Ste 242, Casper, WY 82601.
E-mail address: mcginley@mcginleyclinic.com (J.C. McGinley).
neuropathy1,2 and is associated with high social and economic
costs.2 Initial treatment typically includes activity modification,
physical therapy, splinting, nonsteroidal anti-inflammatory drugs,
or corticosteroid injections.3 For patients with severe or refractory
symptoms, surgical release of the transverse carpal ligament (TCL)
may be indicated.
Although multiple studies have reported a successful symp-
tomatic relief for patients following traditional open, mini-open,
and endoscopic carpal tunnel release (CTR), techniques continue

https://doi.org/10.1016/j.jhsg.2023.05.002
2589-5141/Copyright © 2023, THE AUTHORS. Published by Elsevier Inc. on behalf of The American Society for Surgery of the Hand. This is an open access article under the
CC BY license (http://creativecommons.org/licenses/by/4.0/).
596 G.E. Nicholas et al. / Journal of Hand Surgery Global Online 5 (2023) 595e600
to evolve with a focus on reducing surgical morbidity and accel-
erating recovery.4e7 More recently, CTR with ultrasound guidance
(CTR-US) has been proposed as a technique with a limited incision
size that maintains satisfactory visualization.3,8e10 CTR-US tech-
niques generally use a minimally invasive approach (incision <5
mm) to transect the TCL while using real-time ultrasound guidance
to continuously monitor critical anatomy during the procedure.8e10
Multiple studies have reported statistically significant and
clinically meaningful improvements in patient-reported outcomes
following CTR-US.3,8e15 Despite these encouraging clinical results,
the morphological changes within the carpal tunnel following CTR-
US have not been fully characterized. Previous research has used
magnetic resonance imaging (MRI) to document morphological
changes consistent with carpal tunnel decompression (eg, TCL
transection, increased carpal tunnel dimensions, and reduced me-
dian nerve compression) following open and endoscopic carpal
tunnel release (ECTR).16e20 However, only one study has used MRI
to evaluate posteCTR-US changes in the carpal tunnel.21 Although
the authors documented complete TCL transection and reduced
median nerve compression, they did not report additional impor-
tant morphological indicators of carpal tunnel decompression such
as an increased carpal tunnel cross-sectional area and reduced
median nerve edema.16e21 Consequently, the purpose of this study
was to report intermediate-term outcomes following CTR-US and
WALANT, including a subset of patients with pre- and posteCTR-US
MRI scan including the assessment of the TCL, median nerve, and
carpal tunnel dimensions.
Materials and Methods
This study was reviewed and approved by the Wyoming Med-
ical Center institutional review board.
Participants
This was a retrospective observational study of prospectively
collected data from patients with CTS treated with CTR-US and
WALANT in a procedure room at a single center between July 2019
and October 2021. Eligible patients had moderate to severe CTS
confirmed by history, physical examination findings, and electro-
diagnostic testing, and they underwent baseline MRI.
Procedures
All procedures were performed by the same physician (who had
13 years of experience in ultrasound-guided procedures) and a
single assistant in a procedure room setting using a WALANT
technique.22 Through a small incision (4e5 mm) and using ultra-
sound guidance with augmented reality for ultrasound (McGinley
Education Innovations, LLC), the TCL was transected using a
commercially available device (UltraGuideCTR, Sonex Health, Inc)
designed to facilitate CTR-US by creating space in the carpal tunnel
followed by TCL transection using a retrograde knife.
Key procedural steps have been previously published.3,12,15 A
preprocedural ultrasound was performed using a high-frequency
17MHz linear transducer (Acuson Freestyle, Siemens USA) to
mark the borders of the transverse and longitudinal safe zones as
well as the incision site in the distal forearm. The forearm was
prepared and draped in the usual sterile fashion. Using a sterile
ultrasound cover and sterile gel, relevant anatomical landmarks
were again identified, including but not limited to the median
nerve, thenar motor branch/recurrent motor branch of the median
nerve, palmar cutaneous branch of the median nerve, median and
ulnar digital nerves and any communications, ulnar vessels and
superficial palmar arch, and distal TCL. The safe zones were re-
scanned to ensure acceptable anatomy and sonographic
visualization.
A #15 scalpel blade was used to create a 4e5 mm incision at the
proximal wrist crease, penetrating the antebrachial fascia. A sterile
stainless-steel dilator was then passed into the transverse safe zone
using direct ultrasound guidance to further free the synovial tissue
from the ligament and facilitate device insertion. Direct ultrasound
guidance was then used to pass the cutting device into the carpal
tunnel and position it within the transverse and longitudinal safe
zones. Following ultrasound confirmation of the appropriate device
positioning distal to the TCL and with respect to the surrounding
neurovascular structures, balloons were deployed to create space in
the carpal tunnel, and the position of the device was re-assessed.
Following a satisfactory re-assessment, the cutting knife was acti-
vated from its recessed position, and the TCL was transected in a
retrograde manner using direct ultrasound guidance and up to
three passes. The cutting knife was then placed in its proximal
recessed position, the balloons were deflated, and the TCL was
probed using the stainless-steel dilator to ensure complete liga-
ment transection and release of the median nerve from the liga-
ment and adjacent synovial tissues. Wounds were closed with
sterile adhesive strips; none of the procedures required sutures.
Following closure, wounds were dressed in sterile gauze and sterile
film, followed by a compression wrap. Patients were instructed to
avoid driving and strenuous activity for the remainder of the day
and were advised to use nonsteroidal anti-inflammatories or
acetaminophen and ice for pain and edema control. Opioids were
not prescribed for pain control. Patients were instructed to wear a
wrist brace at night for 10 days and were provided with recom-
mended post-CTR stretches and exercises beginning on post-
operative day 2 and completed as tolerated. Patients were allowed
to return to activities and work as tolerated, starting the day after
the procedure. Postprocedure follow-up occurred in the clinic 3
weeks after surgery.
Outcomes
Before surgery, patients provided basic demographic informa-
tion including age, sex, employment status, and job description
(desk-based, repetitive light manual, or heavy manual). Return to
activity (normal activities outside of work) and return to work
statuses were collected at 2 weeks after surgery. Before and after
surgery at 2 weeks, 1 month, 3 months, and 6 months, patients
were asked to complete the Quick Disabilities of the Arm, Shoulder,
and Hand (QuickDASH) questionnaire and the Boston Carpal
Questionnaire symptom severity scale (BCTQ-SSS) and functional
status scale (BCTQ-FSS). The QuickDASH is an 11-question survey
that assesses upper limb physical symptoms and function of pa-
tients on a scale of 1 (asymptomatic/no difficulty) to 5 (extreme/
unable to perform). A score is generated from 0 to 100, with higher
scores reflecting more symptoms/disability.23 The BCTQ is a
commonly used patient-reported outcome measure for CTS.24 The
BCTQ-SSS has 11 questions and uses a five-point rating scale, and
the BCTQ-FSS has eight items that are rated for a degree of difficulty
on a five-point scale. Each scale generates a final score ranging from
1 to 5, with a higher score indicating a greater disability. The BCTQ
has undergone extensive testing for validity, reliability, and
responsiveness.25 Questionnaires at 1, 3, and 6 months were
administered online predominantly or by phone or an email at
patient request. Reminder phone calls were placed to patients who
did not complete their questionnaires in a timely manner.
 G.E. Nicholas et al. / Journal of Hand Surgery Global Online 5 (2023) 595e600
Table 1
Changes in Patient-Reported Outcomes Following CTR-US*
Outcome 2 Wk
BCTQ-SSS 1.26 (1.46, 1.07)
BCTQ-FSS 0.68 (0.90, 0.46)
QuickDASH 21.2 (26.7, 15.8)
ANOVA, analysis of variance.
*
Values reported as mean change (95% confidence interval) from pretreatment calculated from linear mixed-model ANOVA with Bonferroni correction.
Magnetic resonance imaging studies
All patients were offered preoperative and postoperative MRI.
Not all patients were able to have MRI scans. Only patients with
both pre- and posteCTR-US MRI scans are included in this study. All
postoperative MRI measurements were measured blinded to the
preoperative MRI data. Following postoperative MRI analyses, the
preoperative MRI parameters were measured and comparisons
were assessed. All measurements were performed by the primary
author and verified by the interventional radiologist who per-
formed all procedures for this study. T1- and T2-weighted axial,
coronal, and sagittal high-resolution sequences along with volu-
metric acquisitions using a Siemens 1.5T and 3.0T scanner were
collected. Imaging analysis followed previously published guide-
lines for measuring morphological changes involved in CTS.16e21
The TCL status was reported as intact or transected. The TCL was
considered to be transected if there was a discontinuity and sepa-
ration throughout the proximaledistal length of the carpal tunnel
on the postoperative MRI. A palmar shift of the median nerve at the
level of the hook of hamate was defined as the postoperative
change in the distance between the palmar aspect of the carpals
and the center of the median nerve. The flattening ratio of the
median nerve was measured at the level of the hook of the hamate
and the level of the pisiform and was defined as the ratio of the long
cross-sectional diameter to the short cross-sectional diameter, with
a larger ratio representing a flatter median nerve. The flattening
ratio of the carpal tunnel was similarly measured at the level of the
hook of the hamate. Median nerve signal intensity was measured to
assess changes in median nerve edema. Finally, the cross-sectional
areas of the carpal tunnel and median nerve were both outlined
digitally and measured at the level of the hamate using Terarecon
3-dimensional software (Terarecon, Inc).
Statistical analysis
Based on multiple repeated measurements of BCTQ-SSS, BCQ-
FSS, and QuickDASH in individual participants, we used a linear
mixed model with Bonferroni correction that incorporates all
available data from patients with a pretreatment and at least one
posttreatment observation. Data at each follow-up interval were
referenced to the pretreatment data and modeled as fixed effects,
with a random effect specified at the procedure level. Follow-up
data were reported as the mean and 95% confidence interval.
Changes in MRI parameters were analyzed with a paired samples t-
test for continuous data and a Wilcoxon signed-rank test for paired
categorical data. Two-sided P values of less than .05 were consid-
ered statistically significant.
Results
A total of 65 patients (96 wrists) were treated consecutively
with CTR-US in this study. All procedures were completed suc-
cessfully using local anesthesia. No procedures were discontinued
because of pain or poor visualization. Procedures were typically
completed using two to three passes to cut the TCL. No
597
1 Mo 3 Mo 6 Mo
1.30 (1.52, 1.08) 1.53 (1.75, 1.31) 1.58 (1.83, 1.33)
0.86 (1.11, 0.61) 1.06 (1.32, 0.80) 1.08 (1.39, 0.78)
24.5 (30.8, 18.3) 28.2 (35.1, 21.4) 30.4 (37.7, 23.1)
complications occurred intraoperatively or during follow-up.
Among the 65 patients (68% women), 34 (52%) had a unilateral
procedure, 19 (29%) had simultaneous bilateral procedures, and 12
(18%) had staged bilateral procedures. The CTR-US procedure was
performed on the dominant hand in 52 (80%) patients. Among the
41 (63%) employed patients, 20 (49%) reported desk-based duties,
13 (32%) reported repetitive light manual duties, and eight (20%)
reported heavy manual duties.
Among the 60 (92%) patients with available time to return to
normal activity data, 58 (97%) reported returning to normal activ-
ities by 2 weeks. Among the 38 (93%) employed patients with
available time to return to work data, 38 (100%) reported returning
to work by 2 weeks, with 34 returning to full work duties and four
returning to limited duties.
Patient-reported outcome data were available in 65 (100%) pa-
tients between 2 weeks and 1 month after surgery and in 39 (60%)
patients between 3 and 6 months after surgery. Statistically sig-
nificant improvements in BCTQ-SSS, BCTQ-FSS, and QuickDASH
scores occurred by the 2-week follow-up interval and persisted at 6
months postprocedure (P < .001 for each outcome at each follow-
up interval) (Table 1 and Figs. 1 and 2). The improvements excee-
ded the previously published minimal clinically important differ-
ence values of 15 points for QuickDASH,26 1.17 points for BCTQ-
SSS,27 and 0.74 points for BCTQ-FSS27 at each follow-up interval,
with the exception of BCTQ-FSS at 2 weeks.
MRI scans were available on 13 patients/17 wrists at a mean of 3
months following surgery (range, 1e7 months). The 3-month
clinical outcomes of patients who returned for an MRI were com-
parable with those who did not (BCTQ-SSS: 1.5 ± 0.4 vs 1.3 ± 0.3;
BCTQ-FSS: 1.1 ± 0.2 vs 1.3 ± 0.3; QuickDASH: 7 ± 8 vs 10 ± 10),
suggesting that the MRI findings are representative of the entire
sample. MRI parameters are summarized in Table 2. Complete
transection of the TCL was documented in all 17 wrists. Key post-
operative MRI findings including a 22% increase in the cross-
sectional area (CSA) of the carpal tunnel at the hamate (P < .001),
a 52% increase in the median nerve CSA at the hamate (P < .001), an
18% reduction in the median nerve signal intensity (P ¼ .002), a 38%
reduction in the flattening ratio of the median nerve at the hamate
(P < .001), a 33% reduction in the flattening ratio of the median
nerve at the pisiform (P < .001), a 20% reduction in the flattening
ratio of the carpal tunnel at the hamate (P < .001), and a palmar
shift of the median nerve relative to the hamate were appreciated
in all cases. These observed changes are consistent with the
decompression of the carpal tunnel, reduction in median nerve
compression in the tunnel (especially distally at the hamate), and
reduction in intraneural edema.16e21 Representative preoperative
and postoperative MRI images are provided in Figures 3 and 4.
Discussion
The purpose of this study was to report intermediate-term
outcomes following CTR-US using WALANT, including expanded
posteCTR-US morphological data and a subset of patients with
preoperative and postoperative MRI. Our results demonstrated that
CTR-US using WALANT in a procedure room setting was safe,
598 G.E. Nicholas et al. / Journal of Hand Surgery Global Online 5 (2023) 595e600

Figure 1. Change in BCTQ-SSS and BCTQ-FSS score over 6 months following CTR-US. Plotted data are mean and 95% confidence interval. Asterisk denotes P < .001 for change
compared to baseline using a Bonferroni-adjusted linear mixed model.

Figure 2. Change in QuickDASH score over 6 months following CTR-US. Plotted data are mean and 95% confidence interval. Asterisk denotes P < .001 for change compared to
baseline using a Bonferroni-adjusted linear mixed model.

effective, and showed clinical improvements in validated patient-
reported outcomes as early as 2 weeks after surgery, which were
maintained throughout the 6-month follow-up period. These re-
sults of rapid improvement are similar to those reported in previ-
ous studies using US-guided techniques and similarly less-invasive
CTR techniques such as ECTR.3,8,10,12,15,28,29
Several studies have reported clinical outcomes following
CTR-US using QuickDASH and BCTQ,3,8,10,12e15 but a few have
reported return to work and return to normal activity out-
comes.3,30,31 These results are important because they demon-
strate a major goal of minimally invasive CTR techniques, like
CTR-US, of reducing recovery time, thereby lessening the
burden of work absenteeism. In the current study, 97% of pa-
tients returned to normal activity by 2 weeks and all patients
had returned to work. These results with respect to return to
work are faster than those reported for open CTR and similar to
those reported for ECTR.3,27,29e33 Although these data are
promising, we consider them preliminary because of the rela-
tively small number of patients.
Detailed MRI analysis demonstrated morphological changes
consistent with successful carpal tunnel decompression in all cases.
A few studies have used ultrasound to evaluate morphological
changes following CTR-US,34,35 but only Petrover et al21 has used
MRI to quantify these changes. In that study, 129 patients who
underwent CTR-US received baseline preoperative and post-
operative MRI at 1 month. The results showed a complete tran-
section of the TCL and nerve decompression in all cases. The
metrics used to demonstrate nerve decompression were CSA of the
median nerve and changes in nerve position, both measured at
the level of the hamate.21 Results of our MRI analysis agree with the
findings of Petrover et al,11 as both investigations reported a com-
plete transection of the TCL in 100% of the cases, a significant in-
crease in median nerve CSA, and a palmar shift of the median nerve.
Our investigation expands this work by documenting increased
carpal tunnel dimensions, reduced flattening ratios of the median
nerve and carpal tunnel (ie, reduced flattening), and reduced me-
dian nerve T2 signal intensities. The results of these expanded
metrics are all consistent with postoperative decompression
following CTR-US and are consistent with previous data reported
for morphological changes of carpal tunnel and its contents using
MRI following endoscopic CTR and open CTR.16e20 Previous work
has used signal intensity of the median nerve expressed as the ratio
to the hypothenar muscles to avoid variations in signal encoun-
tered with surface coils.17,19 For the purpose of this investigation, T2
 G.E. Nicholas et al. / Journal of Hand Surgery Global Online 5 (2023) 595e600 599

Table 2
Changes in MRI Parameters Following CTR-US

MRI Parameter Pre* Post*,y Change (%) Change (Absolute) 95% CI (Absolute) P Value

Carpal tunnel, hamate level

Width (mm) 22.0 ± 1.7 21.9 ± 2.6 0% 0.1 1.1, 0.9 .82
Height (mm) 11.3 ± 1.5 14.1 ± 2.0 24% 2.7 1.9, 3.6 <.001
CSA (mm2) 215 ± 39 263 ± 44 22% 48 34, 62 <.001
Flattening ratioz 1.96 ± 0.25 1.57 ± 0.23 20% 0.39 0.55, 0.23 <.001
Median nerve, hamate level
Long diameter (mm) 6.73 ± 1.95 5.71 ± 2.01 15% 1.02 1.77, 0.28 .01
Short diameter (mm) 2.25 ± 0.70 3.01 ± 0.95 34% 0.76 0.35, 1.17 .001
CSA (mm2)x 10.1 ± 6.7 15.4 ± 8.4 52% 5.3 3.8, 6.8 <.001
Flattening ratioz 3.17 ± 0.98 1.96 ± 0.56 38% 1.21 1.68, 0.75 <.001
Volar distance (mm) 9.22 ± 1.43 11.08 ± 2.10 20% 1.86 1.11, 2.61 <.001
Signal intensity 912 ± 288 749 ± 265 18% 163 253, 72 .002
Median nerve, pisiform level
Short diameter (mm) 2.84 ± 0.98 3.46 ± 1.10 22% 0.62 0.18, 1.06 .008
Long diameter (mm) 8.10 ± 1.64 6.96 ± 1.76 14% 1.13 2.1, 0.17 .02
Flattening ratioz 3.13 ± 1.06 2.10 ± 0.54 33% 1.03 1.46, 0.6 <.001
Volar distance (mm) 11.8 ± 2.7 13.3 ± 2.9 13% 1.5 0.9, 2.1 <.001
Median nerve positionk
Dorsal to line 6% (1/17) 0% (0/0) <.001
Crosses line 94% (16/17) 6% (1/17)
Palmar to line 0% (0/0) 94% (16/17)

CI, confidence interval; CSA, cross-sectional area.

*
Values reported as mean ± SD or percent (n/N).
y
MRI performed at mean 3 months (range, 1e7 months) after CTR-US.
z
Flattening ratio was defined as the ratio of the long cross-sectional diameter to the short-cross-sectional diameter, with the larger ratio representing a flatter median
nerve.
x
Increase in the median nerve CSA is expected at the hamate following successful decompression.
k
Center of the median nerve was compared to a line drawn from the hook of the hamate to the ridge of the trapezium. All nerves demonstrated a palmar shift at the time of
posteCTR-US MRI.

Figure 3. A Preoperative T2 weighted axial MRI at the hamate (H) level shows the
cross-sectional area of median nerve (white outline) with the transverse carpal liga-
ment intact (arrow). B 3-months postoperative T2 weighted axial image at the hamate
level shows an increase in the cross-sectional area of median nerve (white outline) and
a gap in the transected transverse carpal ligament (white line). Dashed line and arrow
in images A and B show a palmar shift of median nerve reported as the difference in
postoperative distance measured from the palmer aspect of the carpals (dashed line)
and the center of the median nerve (dashed arrow).
Figure 4. A Preoperative T2 weighted axial MRI at the hamate (H) level shows the
cross-sectional area of carpal tunnel (yellow shading). B 4-months postoperative T2
weighted axial image at the hamate level shows an increase in the cross-sectional area
of the carpal tunnel (yellow shading).
signal intensity of the median nerve was measured by placing a
region of interest over the nerve at the level of the hamate and
reporting as a single value. Results showed an 18% decrease in
median nerve signal intensity after surgery. Whether this is a
clinically significant value remains unclear without other
600 G.E. Nicholas et al. / Journal of Hand Surgery Global Online 5 (2023) 595e600
comparable works with set a precedent. However, we hypothesize
that this decrease is consistent with some degree of reduction in
intraneural edema.17,19
Major strengths of this study are the use of validated
patient-reported outcomes (BCTQ and QuickDASH), reporting
return to normal activities and work status at 2 weeks, and the
inclusion of morphological MRI data measured in blinded
fashion for a subset of patients post CTR-US. The novel MRI
data presented herein are consistent with carpal tunnel
decompression and validate the ability of CTR-US to result in
favorable morphological changes similar to those reported
following open and ECTR.16e20 The primary limitations of this
study include the retrospective review of prospectively
collected data, the relatively small number of patients with
3e6-month clinical follow-up, and the inability to perform
pre- and postoperative MRI scans on all patients. Although the
clinical results in this study were favorable and commensurate
with previously published intermediate-term outcomes for
open and ECTR, additional research examining larger numbers
of patients with longer follow-up will further define the role of
CTR-US in the surgical treatment of patients with CTS.10,29,33
Although only 13 patients (17 wrists) were able or willing to
have a postoperative MRI scan, the clinical outcomes of these
patients were similar to those in the remainder of the group
who did not have postoperative MRI scans, suggesting that the
reported MRI results are representative of the entire sample of
patients. Furthermore, the number of patients with pre- and
postoperative MRI scans in the current study is commensurate
with recently published studies using MRI to study morpho-
logical changes following CTR.16,20
In conclusion, CTR-US using WALANT in a procedure room setting
was safe, effective, and resulted in morphological changes consistent
with carpal tunnel decompression as demonstrated by MRI.
Acknowledgments
The authors thank Larry Miller, PhD, PStat for statistical analysis
and critical review. The funding source provided financial support
for statistical analysis, but was not involved in study design; in the
interpretation of data; in the writing of the report; and in the de-
cision to submit the article for publication.
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