Clinical UM Guideline

This document addresses surgical decompression of the median nerve performed at the carpal tunnel. This is commonly done as a treatment for carpal tunnel syndrome which occurs when the median nerve becomes compressed within the carpal tunnel, a narrow passageway at the wrist, formed by the carpal bones and the transverse carpal ligament. The carpal tunnel contains the median nerve and the flexor tendons that bend the fingers. Compression of the median nerve within the carpal tunnel can result in pain, numbness, tingling, and weakness in the hand.

Note: For a related topic, see:

• CG-MED-24 Electromyography and Nerve Conduction Studies

Note: For a high-level overview of this document, please see “Summary for Members and Families” below. 

Medically Necessary:

Carpal tunnel decompression surgery (open or endoscopic) is considered medically necessary when the criteria in Section I (Diagnostic criteria) and Section II (Symptom Severity criteria) below are met:

1. Diagnostic Criteria:
   Clinical evaluation confirms the diagnosis of carpal tunnel syndrome by consistent history, physical exam and/or confirmatory electrodiagnostic testing.
   and
2. Degree of Clinical Severity Criteria:
   The symptoms are severe based on one (1) or more of the following:
   1. There is persistent pain, sensory loss, or paresthesia in the median nerve distribution that is refractory to one (1) or more of the following noninvasive conservative treatments:
      1. 6 weeks of hand/wrist immobilization (brace or splint); or
      2. Local steroid injections;
         or
   2. There is progressive pain, sensory loss, or paresthesia in the median nerve distribution with evidence of median nerve denervation or axonal loss confirmed by electrodiagnostic testing.

Not Medically Necessary:

Carpal tunnel decompression surgery (open or endoscopic) is considered not medically necessary when the criteria above have not been met.

The following procedures are considered not medically necessary when performed with a carpal tunnel release procedure:

1. Skin nerve preservation; or
2. Epineurotomy; or
3. Flexor retinaculum lengthening; or
4. Internal neurolysis; or
5. Hydrodissection.

The following surgical techniques are considered not medically necessary for treating carpal tunnel syndrome:

1. Thread carpal tunnel release (TCTR); or
2. Ultrasound-guided percutaneous needle release (PCTR); or
3. Carpal tunnel release using ultrasound guidance and intracarpal tunnel balloon dilation (CTR-US).

This document describes clinical studies and expert recommendations, and explains when surgery to relieve pressure on the median nerve at the wrist, referred to as carpal tunnel surgery or carpal tunnel release, is clinically appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Carpal tunnel syndrome is a condition caused by pressure on a nerve in the wrist called the median nerve. It can lead to pain, tingling, numbness, and weakness in the hand. People with this condition may have trouble doing everyday things like buttoning clothes or holding a steering wheel. Treatment often starts with simple steps like wearing a wrist splint or getting a steroid shot. If these don’t work, surgery called a ‘decompression’ may be an option. Surgery can be done through an open cut with a small camera (endoscope), or with ultrasound imaging guidance. Open and endoscopic methods have been shown to work well. Some newer surgical techniques may appear promising, but haven’t been studied enough to know if they are safe or helpful. Because of this, they are not recommended.

What the Studies Show

Surgery can help when symptoms of carpal tunnel syndrome are severe or don’t improve with basic treatment. The goal is to cut through a tight band in the wrist (called the transverse carpal ligament) to relieve pressure on the nerve. People who have endoscopic surgery often recover faster, have less scarring, and return to work sooner. But this method may carry a slightly higher chance of short-term nerve injuries that usually go away with time.

Newer surgeries like thread carpal tunnel release (TCTR), ultrasound-guided percutaneous needle release (PCTR), and carpal tunnel release with intracarpal tunnel balloon dilation (CTR-US) use less invasive tools and are guided by ultrasound imaging. Early research shows they might work, but these studies are small and have limits. There are concerns that these methods could accidentally harm blood vessels or nerves near the area being treated. Experts agree that more research is needed before these options can be considered safe or effective.

Some added surgical steps, like preserving skin nerves or cutting inside the nerve (internal neurolysis), haven’t been shown to help and may increase risks. Groups like the American Academy of Orthopaedic Surgeons (AAOS) do not recommend these added steps because studies haven’t shown they improve results.

When is Carpal Tunnel Surgery Clinically Appropriate?

Carpal tunnel decompression surgery (open or endoscopic) may be appropriate when a diagnosis of carpal tunnel syndrome has been confirmed and there is has lasting pain, numbness, or tingling that has not improved after use of a splint for 6 weeks, receiving a steroid shot, or worsening symptoms with damage to the median nerve.

When is this not Clinically Appropriate?

Carpal tunnel surgery is not appropriate if the conditions described above are not met.

The following procedures are not appropriate when done during carpal tunnel surgery because they have not been shown to help:

• Skin nerve preservation
• Epineurotomy (cutting into the outer layer of the nerve)
• Flexor retinaculum lengthening
• Internal neurolysis (removing tissue inside the nerve)
• Hydrodissection (injecting fluid to separate tissues)

The following surgery techniques are also not appropriate for carpal tunnel syndrome due to unclear evidence regarding possible unintended problems as a result of their use:

• Thread carpal tunnel release (TCTR)
• Ultrasound-guided percutaneous needle release (PCTR)
• Carpal tunnel release using ultrasound guidance and intracarpal tunnel balloon dilation (CTR-US)

(Return to Description)

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met; for the following procedure codes, or when the code describes a procedure or situation designated in the Clinical Indications section as not medically necessary.

Summary

Carpal tunnel syndrome (CTS) is an entrapment neuropathy caused by compression of the median nerve within the carpal tunnel at the wrist. Increased pressure within the tunnel can impair nerve function and result in numbness, tingling, pain, and weakness in the hand. This can interfere with daily activities such as grasping small objects or driving. Treatment typically includes use of wrist splints, oral analgesics, or corticosteroid injections. Surgery may be recommended to relieve pressure on the nerve if these measures are ineffective.

Open and endoscopic surgeries are well-established approaches demonstrated to result in similar long-term outcomes including symptom relief, strength, and nerve recovery. However, people who undergo endoscopic surgery often return to normal activities more quickly and have fewer problems with pain and scarring. Endoscopic surgery may carry a slightly higher risk of short-term nerve injuries, but these are usually reversible. Overall complication rates and satisfaction levels are similar between the two types of surgery.

Thread Carpal Tunnel Release (TCTR), ultrasound-guided percutaneous needle release (PCTR), and carpal tunnel release using ultrasound guidance and intracarpal tunnel balloon dilation (CTR-US) are newer surgical techniques. These are less invasive and are done using ultrasound to guide the cutting of the ligament that compresses the nerve. Early research on these methods shows that they may be safe and effective, but the number and quality of studies is limited, and the risks posed by these procedures, including accidentally injuring nearby blood vessels or nerves, have not been fully evaluated. Due to the low level of evidence currently available and the potential for significant adverse events, these procedures have not been widely accepted as standard practice.

Discussion

The carpal tunnel is a narrow, rigid passageway of ligament and bones at the base of the hand that houses the median nerve and the flexor tendons that bend the fingers. The median nerve provides feeling to the palm side of the thumb and to most of the fingers. CTS occurs when the median nerve is compressed at the wrist resulting in symptoms, such as recurrent numbness or tingling sensations in the hand and wrist, hand weakness, and recurrent pain of the hand and wrist. These symptoms usually begin gradually with increasing intensity over time, which can interfere with ordinary activities of daily living, such as grasping small objects and driving (National Institute of Neurological Disorders and Stroke [NINDS], 2020).

Risk factors associated with CTS include diabetes mellitus, hypothyroidism, rheumatoid arthritis and other inflammatory arthropathies, obesity, pregnancy, dialysis-dependent kidney disease, and prior wrist trauma or fracture. In many individuals, no specific cause can be identified. Management of underlying conditions may help reduce symptoms but does not preclude consideration of conservative or surgical treatment when clinically indicated.

CTS usually occurs only in adults and is rare in children. Women are three times more likely than men to develop this condition. Additional risk factors for CTS include regular computer work where repetitive awkward positioning and forceful movements of the hands and wrists over prolonged periods are associated with the development of CTS. Assembly line work and work that involves forceful gripping exertion over time are also associated with CTS, as is a past history of wrist fracture in some individuals. Musculoskeletal conditions, such as hand, wrist and elbow tendinopathies, as well as elevated body mass index (BMI), dialysis, and fibromyalgia have also been noted in some studies as risk factors for CTS. 

CTS is primarily diagnosed through clinical history and physical examination. Typical symptoms include numbness and paresthesia in the median nerve distribution (thumb, index, middle, and radial half of the ring finger), often with nocturnal exacerbation, and in advanced cases, thenar weakness or atrophy. The CTS-6 clinical prediction tool is strongly recommended by the 2024 American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guideline as sufficient for diagnosis in most patients (AAOS, 2024). The CTS-6 tool assigns weighted scores to six findings (numbness in the median nerve distribution, nocturnal symptoms, thenar atrophy or weakness, positive Phalen test, loss of two-point discrimination, and positive Tinel sign) and has demonstrated sensitivity of 89-95% and specificity of 80-94%. Electrodiagnostic studies such as nerve conduction velocity (NCV) and electromyography (EMG) complement clinical assessment by providing quantitative data on median nerve conduction slowing and axonal loss, with comparative and segmental techniques achieving sensitivity of 80-90% and specificity exceeding 95%. High-resolution ultrasonography has emerged as a non-invasive adjunct, with a pooled sensitivity of 81% and specificity of 84% for median nerve cross-sectional area measurements at the carpal tunnel inlet. Further evaluation with electrodiagnostic studies or ultrasonography should be considered when the CTS-6 result is negative but clinical suspicion remains high, when quantification of severity is needed, or when alternative diagnoses (for example, cervical radiculopathy, polyneuropathy) must be excluded. Magnetic resonance imaging (MRI) and upper limb neurodynamic testing are not recommended for routine CTS diagnosis (Currie, 2022).

Initial treatment usually involves wearing a splint at night to keep the wrist in proper alignment. Over-the-counter and prescription drugs, including non-steroidal anti-inflammatory drugs (NSAIDs), can reduce painful swelling and corticosteroid injections have also been used to relieve symptoms. Stretching exercises, taking frequent rest breaks, wearing splints to keep wrists straight, and using correct posture and wrist position can help with the symptoms of CTS. For severe cases, carpal tunnel release (CTR) may be recommended. However, some residual numbness or weakness of the involved hand/wrist is common following surgical correction when performed by open approach or endoscopically (NINDS, 2020).

Surgical treatment for CTS is proposed when conservative measures have not improved symptoms. Surgical decompression involves release of the median nerve by cutting the transverse carpal ligament. This can be done either with an open approach or endoscopically. Mini-invasive techniques, including endoscopic and mini-open approaches, have been studied and noted to have higher learning curves for the surgeon. These minimally invasive techniques have shorter functional recovery times compared to classical open surgery and appear to have comparable long-term results. The decision about which surgical technique to use depends on the individual’s and surgeon’s preferences. Additional factors that influence the choice of surgical technique include CTS severity, etiology, and the availability of surgical tools. Results from use of these minimally invasive techniques have been reported as satisfactory in 90% of cases. Nerve recovery depends on the stage of preoperative severity with full recovery of function reported to take about 2-3 months in most cases. These surgical procedures are reported to have a 0.2-0.5% neurovascular complication rate (Chammas, 2014).

The 2024 American Academy of Orthopaedic Surgeons (AAOS) Management of Carpal Tunnel Syndrome Evidence-based Clinical Practice Guideline  make the following recommendations regarding diagnosis:

• Strong evidence suggests that CTS-6 can be used to diagnose carpal tunnel syndrome, in lieu of routine use of Ultrasonography or NCV/EMG.
• Moderate evidence suggests that MRI and Upper Limb Neurodynamic Testing should not be used to diagnose carpal tunnel syndrome.

The AAOS guideline makes the following recommendations regarding surgical repair of CTS:

• Strong evidence suggests that there is no difference in patient reported outcomes between a mini-open carpal tunnel release and an endoscopic carpal tunnel release.

Additional or adjunctive surgical procedures are sometimes performed with carpal tunnel release surgery. The following surgical procedures have no recommendation from the AAOS when performed in conjunction with carpal tunnel release surgery:

• Skin nerve preservation;
• Epineurotomy;
• Flexor retinaculum lengthening;
• Internal neurolysis;
• Tenosynovectomy;
• Ulnar bursa preservation;
• Thread carpal tunnel release (TCTR);
• Ultrasound-guided percutaneous needle release (PCTR);
• Hydrodissection;
• Carpal tunnel release using ultrasound guidance and intracarpal tunnel balloon dilation (CTR-US).

Carpal tunnel decompression surgery has been studied in multiple clinical trials, including systematic reviews of randomized controlled trials (RCTs) that compared outcomes from open and endoscopic techniques. Results have consistently shown similar clinical outcomes from open and endoscopic approaches in relief of symptoms but with better recovery of function and shorter recovery times seen from endoscopic techniques (Chen, 2014; Kang, 2013; Michelotti, 2014; Soltani, 2013; Vasiliadis, 2015).

A 2015 meta-analysis of RCTs by Zuo and colleagues found similar results for safety and efficacy for both endoscopic and conventional open procedures. This analysis included 13 randomized trials which were reported as showing no significant difference in several member-centered outcomes:

The rate of hand pain in the endoscopic group was significantly lower than that in the open group. Endoscopic treatment seemed to cause more reversible postoperative nerve injuries, as compared with open procedures. No statistical differences were observed in the overall complication rate, subjective satisfaction, time to return to work, postoperative grip and pinch strength, and operative time.

In 2020, Li and colleagues conducted a comprehensive systematic review and meta-analysis of 28 studies that compared outcomes for endoscopic vs. open surgical repair of CTS. This study reported the following outcomes:

The endoscopic approach was associated with significantly higher satisfaction rates, greater key pinch strength, earlier return to work times, higher transient nerve injury rates, and a lower incidence of scar-related complications. The permanent nerve injury showed no significant differences between the two groups.

A 2024 systematic review by Rajapandian and colleagues included 11 studies published through October 2023. Comparing endoscopic and open carpal tunnel release, of which 7 were RCTs and 4 were meta-analyses. The authors reviewed studies qualitatively and did not conduct pooled analyses of data. The study found comparable efficacy outcomes relating to symptom relief, grip strength, and digital sensation. The endoscopic approach was associated with lower levels of complications including scar sensitivity, pillar pain, and wound-related complications than the open approach, but required greater technical proficiency and was associated with a higher risk of reversible nerve injury.

Thread Carpal Tunnel Release (TCTR)

TCTR is a minimally invasive method to divide the transverse carpal ligament (TCL) by sawing the ligament with a piece of thread looped percutaneously under ultrasound (US) guidance. This procedure has been proposed as an alternative technique for performing carpal tunnel release for the treatment of CTS. To date, there are a limited number of published studies describing this procedure in the clinical setting. Meaike (2025) reported on the results of a prospective, single-institution RCT involving 11 participants with bilateral CTS. All participants acted as their own controls, receiving mini-open carpal tunnel release on one side and TCTR on the other. With a 12 month follow-up, the authors reported no clinical or statistical differences between the two procedures at multiple postoperative time periods with respect to functional outcome scores, pain, or strength. The small study population, lack of blinding, use of a single center, and other factors limit the generalizability of these findings.

The published evidence has also described interventional challenges including risk for injuring the superficial palmar arterial arch (SPA) if the TCTR needle exits too distally or a risk of incomplete transection of distal TCL if the needle exits too proximally. Other concerns include injury of the common digital branch or the communicating branch between the ulnar nerve and median nerve, called the Berrettini branch, if the needle control accuracy is not improved. Recent trials using cadaveric wrists have demonstrated a more precise approach to protect the superficial palmar aponeurosis (SupPA), Berrettini branch, and common digital nerves but larger trials better designed to show clinical outcomes are needed to support the safety and efficacy of TCTR (Guo, 2017).

Percutaneous Needle Release (PCTR)

Another minimally invasive surgical technique proposed for the treatment of CTS is PCTR, which is very similar to TCTR. PCTR uses US guidance to divide the transverse carpal ligament. Only small cohort trials have been published, to date, most of which are cadaveric trials, in which the safety and efficacy of PCTR to transect the transverse carpal ligament with minimal adjacent tissue damage has been reported. Larger well-designed trials are needed to validate the impact on clinical outcomes, as compared with traditional carpal tunnel release techniques (Burnham, 2017; Burnham, 2021; Dekimpe, 2019).

Intracarpal Tunnel Balloon Dilation with Ultrasound Guidance (CTR-US)

Carpal tunnel release using CTR-US is a minimally invasive technique to treat CTS. A specific surgical device, UltraGuideCTR, received U.S. Food and Drug Administration (FDA) 510(k) marketing clearance in 2019 for this procedure. The device contains a retractable surgical blade and small balloons that are temporarily expanded in the carpal tunnel to create working space before dividing the transverse carpal ligament.

Several prospective and retrospective case series have reported improvements in symptoms and function following CTR-US, including studies with follow-up extending beyond 1 year. However, these studies lack comparison groups and therefore cannot determine whether outcomes are equivalent or superior to established surgical approaches (Aguila, 2024; Bergum, 2022; Cano, 2024; Pistorio, 2024). The highest quality evidence comes from the TUTOR RCT, which compared CTR-US (n=94) with mini-open carpal tunnel release (n=28) (Eberlin, 2024). Both groups demonstrated similar improvement in CTS symptoms and quality of life at 12 months of follow-up, with low and comparable complication rates. Additional studies are warranted to confirm these findings. The study was not blinded, which may lead to performance and expectation bias, and a disproportionate number of participants randomized to mini-open carpal tunnel release withdrew before treatment, increasing risks for bias. Because of these limitations, the lack of long-term clinical data, and no recommendation from the AAOS, traditional open or endoscopic release remain the standard of care.

Carpal tunnel release using ultrasound guidance and intracarpal tunnel balloon dilation (CTR-US): A percutaneous procedure that uses a small wrist incision with real-time ultrasonography and a specialized instrument with a balloon that is inflated inside the wrist to create space before cutting the transverse carpal ligament.

Carpal Tunnel Release (CTR): A surgical procedure that relieves pressure on the median nerve by dividing the transverse carpal ligament.

Carpal Tunnel Syndrome (CTS): An entrapment neuropathy caused by compression of the median nerve within the carpal tunnel at the wrist.

CTS-6 (Carpal Tunnel Syndrome 6-item diagnostic tool): A validated clinical scoring system that incorporates six examination findings and symptoms to estimate the likelihood of carpal tunnel syndrome.

Electromyography (EMG): An electrodiagnostic test that evaluates electrical activity within muscles and can help identify nerve injury.

Endoscopic carpal tunnel decompression: A surgical procedure where the transverse carpal ligament is incised under indirect visualization via endoscopic guidance, in order to decompress the median nerve.

Epineurotomy: Surgical incision of the epineurium, the outer connective tissue covering of a peripheral nerve.

Flexor retinaculum lengthening: A surgical technique that lengthens rather than completely divides the transverse carpal ligament in an attempt to decompress the median nerve while preserving some ligament continuity.

Hydrodissection: An ultrasound-guided injection technique in which fluid is injected around a nerve to separate it from surrounding tissues and potentially reduce nerve entrapment.

Median nerve compression test (Durkan Test): A test for CTS where pressure is applied with the thumbs over the median nerve within the carpal tunnel, located just distal to the wrist crease. The test is positive if the individual responds with numbness and tingling within 30 seconds.

Mini open carpal tunnel release: A variation of open carpal tunnel release performed through a smaller skin incision.

Nerve Conduction Velocity (NCV) - also referred to as Nerve Conduction Study (NCS): An electrodiagnostic test that evaluates the speed and strength of electrical signals traveling through a nerve.

Neurolysis: Surgical dissection of scar tissue or connective tissue within or around a nerve in an attempt to improve nerve mobility or relieve compression.

Open carpal tunnel surgical decompression: A surgical procedure where a small incision is made at the wrist, in order to transect or divide the transverse carpal ligament, decompress the median nerve and widen the carpal tunnel.

Paresthesia: An abnormal sensation such as tingling, burning, or "pins and needles."

Phalen test: A test for CTS where the dorsal surface of the hands is pushed together and held for 30 - 60 seconds. Pain, numbness, or tingling caused by this technique is considered a positive test for CTS.

Pillar pain: Pain localized to the thenar or hypothenar regions of the palm following carpal tunnel release surgery.

Skin nerve preservation: Refers to a surgical technique aimed at preserving the superficial nerve branches that cross the incision site during open carpal tunnel decompression surgery. This is intended to reduce the postoperative scar pain associated with open carpal tunnel surgery.

Symptom severity:

Moderate symptoms: Refers to sensory loss in the median nerve distribution or symptoms (sensory loss or pain) interfere slightly with hand function but the individual is able to perform all activities of daily living (ADLs); nocturnal symptoms may occasionally but not routinely disturb sleep;
Severe symptoms: Refers to weakness in the median nerve distribution or symptoms disrupt one or more ADLs or nocturnal symptoms routinely disrupt sleep.

Tenosynovectomy: Refers to the surgical excision of a tendon sheath.

Thenar atrophy: Visible wasting of the muscles at the base of the thumb caused by chronic median nerve dysfunction.

Thenar weakness: Reduced strength of the thumb muscles supplied by the median nerve.

Thread carpal tunnel release (TCTR): A minimally invasive surgical procedure where a piece of surgical dissecting thread is introduced under ultrasound guidance and used as a dividing element, in order to transect the transverse carpal ligament and decompress the median nerve.

Tinel sign: A test for CTS where light tapping is applied over the median nerve to see if it generates a tingling sensation, which is considered a positive test.

Transverse carpal ligament: A fibrous band of tissue that forms the roof of the carpal tunnel and is divided during carpal tunnel release surgery.

Two point discrimination: A sensory examination that measures the ability to distinguish two closely spaced points touching the skin.

Ulnar bursa preservation: Refers to the surgical preservation of a layer of gliding tissue, which is the parietal layer of the ulnar bursa between the contents of the carpal tunnel and the soft tissues incised during carpal tunnel surgery. This surgical procedure is intended to reduce scar pain, and improve grip strength and function following open carpal tunnel decompression.

Ultrasonography: An imaging technique that uses high-frequency sound waves to visualize soft tissues and nerves.

Ultrasound-guided percutaneous needle release (PCTR): Refers to a percutaneous procedure done under sonographic guidance in order to release the median nerve at the area in the carpal tunnel where compression has occurred causing CTS.

Peer Reviewed Publications:

1. Aguila D, Kirsch M, Kindle B, and Paterson P. Long-term clinical results of carpal tunnel release using ultrasound guidance: a multicenter pragmatic study. J Hand Surg Glob Online. 2024; 6(1):79-84.
2. Ansari NN, Adelmanesh F, Naghdi S, Mousavi S. The relationship between symptoms, clinical tests and nerve conduction study findings in carpal tunnel syndrome. Electromyog Clin Neurophysiol. 2009; 49(1):53-57.
3. Atroshi I, Flondell M, Hofer M, Ranstam J. Methylprednisolone injections for the carpal tunnel syndrome: a randomized, placebo-controlled trial. Ann Intern Med. 2013; 159(5):309-317.
4. Beck JD, Wingert NC, Rutter MR, et al. Clinical outcomes of endoscopic carpal tunnel release in patients 65 and over. J Hand Surg. 2013; 38(8):1524-1529.
5. Bergum RA, and Ciota MR. Office-based carpal tunnel release using ultrasound guidance in a community setting: long-term results. Cureus. 2022; 14(7):e27169.
6. Burnham R, Loh E, Rambaransingh B, et al. A controlled trial evaluating the safety and effectiveness of ultrasound-guided looped thread carpal tunnel release. Hand (NY). 2021; 16(1):73.
7. 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(7):457-463.
8. Calandruccio JH, Thompson NB. Carpal tunnel syndrome: making evidence-based treatment decisions. Orthopedic Clinics of North America 2018; 49(2):223-229.
9. Cano LC, Leiby BM, Shum LC, et al. Clinical results of carpal tunnel release using ultrasound guidance in over 100 patients at two to six years. Journal of Hand Surgery Global Online. 2024; 6(3):354-359.
10. Chammas M. Carpal tunnel syndrome. Chir Main. 2014; 33(2):75-94.
11. Chen L, Duan X, Huang X, et al. Effectiveness and safety of endoscopic versus open carpal tunnel decompression. Rev Arch Orthop Trau Surg. 2014; 134(4):585-593.
12. Currie KB, Tadisina KK, Mackinnon SE. Common hand conditions: a review. JAMA. 2022; 327(24):2434-2445.
13. Dekimpe C, Andreani O, Camuzard O, et al. Ultrasound-guided percutaneous release of the carpal tunnel: comparison of the learning curves of a senior versus a junior operator. A cadaveric study. Skeletal Radiol. 2019; 48(11):1803-1809.
14. Eberlin KR, Amis BP, Berkbigler TP, et al. Final 1-year results of the TUTOR randomized trial comparing carpal tunnel release with ultrasound guidance to mini-open technique. Plast Reconstr Surg Glob Open. 2024; 12(3):e5665.
15. Faour-Martín O, Martín-Ferrero MA, Castrillo AV, et al. Long-term effects of preserving or splitting the carpal ligament in carpal tunnel operation. J Plast Surg Hand Surg. 2013; 47(4):263-267.
16. Guo D, Guo D, Guo J, et al. A clinical study of the modified thread carpal tunnel release. Hand (NY). 2017; 12(5):453-460.
17. Huisstede BM, Randsdorp MS, Coert JH, et al. Carpal tunnel syndrome. Part II: effectiveness of surgical treatments--a systematic review. Arch Phys Med Rehab. 2010; 91(7):1005-1024.
18. Huisstede BM, van den Brink J, Randsdorp MS, et al. Effectiveness of surgical and postsurgical interventions for carpal tunnel syndrome- a systematic review. Arch Phys Med Rehabil. 2018; 99(8):1660-1680.e21.
19. Kang HJ, Koh H, 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(5):1548-1554.
20. Li Y, Luo W, Wu G, et al. Open versus endoscopic carpal tunnel release: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2020; 21(1):272.
21. Maggard MA, Harness NG, Chang WT, et al. Indications for performing carpal tunnel surgery: clinical quality measures. Plast Reconstr Surg. 2010; 126(1):169-179.
22. Meaike JJ, Hasley IB, Brault JS, Shin AY. Prospective, randomized, intra-subject controlled trial comparing ultrasound-guided thread and mini-open carpal tunnel release. J Surg Orthop Adv. 2025; 34(1):31-36.
23. Meems M, Spek V, Kop WJ, et al. Mechanical wrist traction as a non-invasive treatment for carpal tunnel syndrome: a randomized controlled trial. Random Controll Trials. 2017; 18(1):464.
24. Michelotti B, Romanowsky D, Hauck RM. Prospective, randomized evaluation of endoscopic versus open carpal tunnel release in bilateral carpal tunnel syndrome: an interim analysis. Ann Plast Surg. 2014; 73(Suppl 2):S157-60.
25. Pistorio AL, Marwin VM, Paterson PD, et al. Office-based carpal tunnel release with ultrasound guidance: 6-month outcomes from the multicenter ROBUST trial. Journal of Hand Surgery Global Online. 2024; 6(3):273-279.
26. Rajapandian R, Moti Wala S, Aledani EM, et al. Endoscopic versus open carpal tunnel release: a systematic review of outcomes and complications. Cureus. 2024; 16(7):e64991.
27. Soltani AM, Allan BJ, Best MJ, et al. A systematic review of the literature on the outcomes of treatment for recurrent and persistent carpal tunnel syndrome. Plast Recon Surg. 2013; 132(1):114-121.
28. Vasiliadis HS, Nikolakopoulou A, Shrier I, et al. Endoscopic and open release similarly safe for the treatment of carpal tunnel syndrome. A systematic review and meta-analysis. PLoS One. 2015; 10(12):e0143683.
29. Werner RA, Andary M. Electrodiagnostic evaluation of carpal tunnel syndrome. Muscle Nerve. 2011; 44(4):597-607.
30. 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.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Orthopedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. Endorsed by the American Society for Surgery of the Hand, American Society of Plastic Surgeons, American College of Radiology, American College of Surgeons, and the American Society of Anesthesiologists. Published May 17, 2024. Available at: https://www.aaos.org/quality/quality-programs/carpal-tunnel-syndrome/?tab=all_guidelines. Accessed on June 15, 2026.
2. National Institute of Neurological Disorders and Stroke (NINDS). Carpal tunnel syndrome. March 2020. Available at: https://www.ninds.nih.gov/sites/default/files/migrate-documents/carpal_tunnel_syndrome_e_march_2020_508c_0.pdf. Accessed on June 15, 2026.
3. Page MJ, Massy-Westropp N, O'Connor D, Pitt V. Splinting for carpal tunnel syndrome. Cochrane Database of Syst Rev. 2012; (7):CD010003.
4. U.S. Food and Drug Administration. 510(k) Premarket Notification Database. Orthopedic Manual Surgical Instrument. No. K192873. Rockville, MD: FDA. December 20, 2019. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf19/K192873.pdf. Accessed on June15, 2026.
5. Vasiliadis HS, Georgoulas P, Shrier I, et al. Endoscopic release for carpal tunnel syndrome. Cochrane Database Syst Rev. 2014; (1):CD008265.

Carpal tunnel decompression
Carpal Tunnel Syndrome
CTS
Endoscopic carpal tunnel surgery
Thread carpal tunnel release
Open carpal tunnel surgery
UltraGuideCTR

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

© CPT Only - American Medical Association