[2][3] Approximately 500,000 surgical procedures are performed each year, and the economic impact of this condition is estimated to exceed $2 billion annually.

In this scenario, CTR should be considered only if physical signs of median nerve dysfunction are present in addition to classical symptoms of CTS.

It forms the roof of the carpal tunnel, and when the surgeon cuts across it (i.e., in a line with the ring finger) it no longer presses down on the nerve inside, relieving the pressure.

[citation needed] Open carpal tunnel release (OCTR) has long been considered the gold-standard surgical treatment for CTS.

This approach allows for direct visualization of the anatomy and possible anatomical variants, which minimizes the risk of damaging critical structures.

It also provides the surgeon with the option of probing the carpal canal for other structures that may be contributing to the compression of the median nerve, including ganglions and tumors.

The release is extended to the superficial palmar arterial arch distally and for a limited distance proximally beneath the wrist flexion creases.

Limited-incision carpal tunnel release techniques similar to endoscopic surgery were developed to decrease palmar discomfort and hasten the return to activities.

The surgical approach involves a small skin incision in the palm followed by release of the distal end of the TCL under direct visualization.

[7] Patients experience reduced post-operative pain as this techniques leaves the palmar fascia intact over the proximal TCL.

[8] Sayed Issa's approach[21] is a carpal tunnel release through a small approach on the distal wrist crease; it is about 1.5 cm; the benefits of this technique are less surgical traumatic and more tender, it takes less time for rehabilitation, so the patient can work next day of operation, and it has very cosmetic and gentle scar in results and outcome.

Some studies comparing open and endoscopic carpal tunnel release found no significant differences in function.

The advantages of the endoscopic technique in grip strength and pain relief are realized within the first 12 weeks and seem to benefit those patients not involved in compensable injuries.

However, problems related to endoscopic carpal tunnel release include (1) a technically demanding procedure; (2) a limited visual field that prevents inspection of other structures; (3) the vulnerability of the median nerve, flexor tendons, and superficial palmar arterial arch; (4) the inability to control bleeding easily; and (5) the limitations imposed by mechanical failure.

[26] In the Agee single-portal technique, a small transverse skin incision is made at the ulnar border of the palamaris longus tendon.

A distally based flap of forearm fascia is elevated to expose the proximal end of the carpal canal.

[citation needed] Supporting this are the results of some of the previously mentioned series that cite no difference in the rate of complications for either method of surgery.

[27][28][29] The sono-guided percutaneous surgical technique approach involves the use of ultrasound visibility by a surgeon in a day clinic setting, under local anesthesia, and without the use of a tourniquet or sedation.

The cross-sectional area (CSA) of the median nerve and the transverse carpal ligament's (TCL) thickness are measured at several anatomically significant points.

A small skin puncture opening is made with a 14-gauge catheter, followed by the introduction of a 1.5mm probe to palpate the TCL and establish the safe zone for release.

The surgical instrument, similar to a bent needle, is then used for the gradual release of the Transverse Carpal Ligament, monitored by sonographic imaging to confirm completeness.

The most common cause of failure is incorrect diagnosis, and this surgery will only mitigate carpal tunnel syndrome, and will not relieve symptoms with alternative causes.

[36][37] A recent Cochrane Review showed that the use of absorbable sutures (stitches that the body dissolves) provide the same outcomes (i.e. scar quality, pain levels, etc.)

Findings reported at reoperation include incomplete release of the transverse carpal ligament, re-formation of the flexor retinaculum, scarring in the carpal tunnel, median or palmar cutaneous neuroma, palmar cutaneous nerve entrapment, recurrent granulomatous or inflammatory tenosynovitis, and hypertrophic scar in the skin.

[44] Risk of nerve injury has been found to be higher in patients undergoing endoscopic CTR compared with open, though most are temporary neurapraxias.

[45] The palmar cutaneous branch of the median nerve may be injured during superficial skin dissection or while releasing the proximal portion of the transverse carpal ligament with scissors or an endoscopic device.