Ultrasound‐guided release versus surgical release for treatment of carpal tunnel syndrome

A 40-year-old right-handed woman with no significant past medical history presents to clinic with 1 year of progressively worsening right wrist pain and hand numbness. She denies any inciting event or trauma. She works as an administrative assistant and she has three children (ages: 1, 3, and 6 years). She reports nocturnal pain, frequent hand numbness, and difficulty gripping objects. It has significantly affected her ability to do her job as well as take care of her children. Physical exam shows mild–moderate thenar atrophy. On strength testing her abductor pollicis brevis (APB) is a 4/5. She has diminished sensation in the median nerve distribution. She has a positive Tinel's at the wrist and Phalen's within 5 s. Recent electrodiagnostic testing shows moderate to severe sensorimotor median nerve compression with a compound muscle action potential amplitude of 3 mV. Electromyography (EMG) of the APB showed 1+ positive sharp waves. She has tried night splints for 6 months with minimal relief. She has been to occupational therapy and tried median nerve glides and ergonomic evaluation with minimal relief. She has undergone two steroid injections that gave her 2 months of moderate relief, but the pain always returns. She is interested in definitive solution for her symptoms and wants to know what the best option is. Drs Erek Latzka and Walter Sussman will argue for ultrasound- guided carpal tunnel release. Drs Kyle Eberlin and Justin McCarty will argue for surgical carpal tunnel release. Carpal tunnel syndrome (CTS) is the most prevalent entrapment neuropathy, affecting roughly 5% of the adult population.1 Although open carpal tunnel release (OCTR), mini-OCTR (mOCTR), and endoscopic carpal tunnel release (ECTR) have long been the accepted standard of care, less invasive options have emerged. Ultrasound-guided carpal tunnel release (USGCTR) offers similar efficacy and a faster recovery than conventional open or mOCTR procedures. This discussion evaluates these image-guided approaches, emphasizing the growing data on clinical outcomes, return to work (RTW), safety, and cost. USGCTR has been performed since 1997 with various tools, including but not limited to hook knives, needles, scalpels, metallic thread, and the Sonex Health UltraGuideCTR device2-7. Despite the differing tools, they all share a common goal: the safe and complete transection of the transverse carpal ligament, without the need for sutures. To accomplish this goal, the transection must occur within an anatomically safe zone, bordered by the median nerve, the ulnar artery, and its superficial palmar arch6, 8, 9. The safe zone can vary significantly among individuals. Real-time mapping with diagnostic ultrasound is essential for delineating the zone and identifying critical neurovascular structures, including the thenar motor branch, third common palmar digital nerve, palmar cutaneous branch, and anatomic variants, such as a persistent median artery or Berrettini anastomosis.7 In this case, the patient is not just seeking symptom relief, but a prompt functional recovery that allows her to return to full caregiving and professional duties. Multiple randomized controlled trials (RCTs) have found that USGCTR offers long-term symptom resolution and functional outcomes consistent with or better than those of mOCTR and OCTR. In the TUTOR (Trial of Ultrasound Guided Carpal Tunnel Release Versus Traditional Open Release) multicenter RCT, Eberlin et al. showed that USGCTR (n = 94) led to equivalent improvements in pain and function at 1 year on the Boston Carpal Tunnel Questionnaire and EuroQol-5 Dimension-5 Level quality-of-life index when compared to the mOCTR procedure. In an intraparticipant RCT among patients with bilateral CTS, USGCTR demonstrated greater improvement in pain (visual analog scale) and function (Boston Carpal Tunnel Questionnaire) at 1 week when compared to mOCTR on the contralateral side.10 Although there was no meaningful difference observed beyond 1 week, all except one patient expressed a preference for the USGCTR procedure, citing faster recovery and less pain.10 There are data to support the sustained benefit of USGCTR from 1 to 6 years after the procedure. In a multicenter registry study, Aguila et al. reported sustained improvements at 1 year following 341 USGCTRs, with no differences in outcomes based on patient age, body mass index, or whether the procedure was unilateral or bilateral.11 In addition, Kim et al. presented 168 patients with severe CTS that underwent USGCTR and reported sustained improvements >2 years after the procedure.12 Finally, Cano et al.2 followed 102 patients (162 hands) for 2–6 years (mean 46 months) and reported sustained improvements in pain and function, with a 91% satisfaction rate, and no patients required a revision surgery2. Postprocedure radiologic findings also validate the clinical success of USGCTR. Magnetic resonance imaging studies have confirmed complete transverse carpal ligament transection and reduced nerve edema and flattening after USGCTR.13 Additionally, studies evaluating postoperative sonographic findings have documented significant reductions in median nerve cross-sectional area within 2–4 weeks of USGCTR, correlating with clinical recovery.14 For this mother, delays in recovery are not a minor inconvenience—they affect her ability to work, care for her children, and function independently. Fortunately, recovery time favors USGCTR. In the TUTOR RCT, USGCTR patients had an average RTW time of 8.7 days – half that of the mOCTR (17.4 days).15 Multiple other RCTs have supported the faster recovery and RTW after USGCTR (range: 4.4 to 12 days) when compared to the mOCTR (range: 25.5 to 33 days).16-18 Real-world data reinforce these outcomes. The prospective multicenter ROBUST (Multicenter Prospective Trial of Office-Based Carpal Tunnel Release With Ultrasound Guidance) trial found that in 149 participants (226 hands), many of them manual laborers, the median RTW time was 4 days after USGCTR, with 77% of patients back to work by day 5.19 Furthermore, over half of the patients in the ROBUST trial underwent simultaneous bilateral USGCTR, with functional and RTW outcomes similar to unilateral procedures, reinforcing the immediate utility of the hands post procedure. In another registry of 544 patients across 24 centers, the reported median RTW time was 3 days overall and 4 days among 126 heavy manual laborers, with 74.6% of patients back to work by day 5.20 In contrast, traditional surgical techniques have an average RTW of 31.4 days (OCTR), 21.1 days (mOCTR), and 17.6 days (ECTR) based on a recently published meta-analysis of 48 studies (7386 patients).21 This patient, with her three young children and high physical caregiving demands, cannot afford a protracted or complicated postoperative course. Therefore, educating her on the potential adverse events and complications is essential. USGCTR demonstrates low complication rates (range 0%–2.1%) across a broad spectrum of studies including systematic reviews, RCTs, prospective multicenter trials, real-world registries, and large case series.3, 4, 10, 11, 15, 19, 22 These rates appear to be comparable or less than traditional surgical complication rates. In a Cochrane systematic review of 19 RCTs comparing OCTR versus ECTR, Vasiliadis et al. reported complication rates of 8.7% for OCTR versus 5.6% for ECTR. Importantly, major complications were rare (<1%) and equivalent between groups. However, ECTR was associated with reduced minor and total complications compared to open release and had a faster RTW by an average of 8.1 days.23 These findings are echoed in more recent analyses of USGCTR. In a 2023 systematic review of 1772 USGCTR cases, there was an overall complication rate of just 1.4%, with no permanent neurovascular injuries.3 The prospective, multicenter ROBUST trial, which included 149 participants (226 hands), reported a single transient nerve contusion (0.4%) thought to be caused by an elevator, no infections, no revisions for persistent/recurrent symptoms, and no significant lasting complications during the 6-month follow-up period.19 Over half of patients in the ROBUST trial underwent simultaneous bilateral USGCTR with no increase in adverse events—underscoring the immediate postprocedural hand functionality and safety profile relevant to this case. The TUTOR RCT found no significant difference in complication rates between USGCTR (2.1%) and mOCTR (3.6%), and neither group required revision surgery. Most notably, one USGCTR patient experienced a partial third common digital nerve injury (treated with reexploration and a nerve wrap) and one mOCTR patient experienced wound dehiscence (treated with additional sutures). However, USGCTR patients had significantly smaller incisions (6 vs. 22 mm) and less scar-related discomfort at 3 months (31% vs. 84%) and 12 months (5% vs. 26%).4, 15 Several additional studies reinforce the safety profile of USGCTR. Like the TUTOR RCT, Akhoondinasab et al.'s16 RCT reported lower pain and improved scar cosmesis in the USGCTR group. In an intraparticipant RCT of bilateral USGCTR, Meaike et al.10 reported no complications. Aguila et al.'s multicenter registry of 341 hands found only two revisions for incomplete release, one infection, and one tendon injury – rates comparable to traditional techniques. Finally, North et al. reported 300 consecutive thread USGCTR procedures with no neurovascular injury. Taken together, these findings demonstrate that USGCTR not only meets the safety standard of existing techniques but also offers significant advantages with respect to recovery. For this patient, the ability to return to full, bimanual caregiving duties immediately and without risk of wound-related issues makes USGCTR the optimal choice. USGCTR delivers compelling value for both payers and society. Ekhtiari et al. performed a cost-utility analysis comparing OCTR, ECTR, and USGCTR and found that USGCTR was superior. USGCTR provided the lowest total cost ($3871), highest quality-adjusted life years (QALY) gain (0.43), and fastest RTW (3 days vs. 21.1 days for OCTR and 17.6 days for ECTR). USGCTR produced an estimated societal cost savings of $4800 and $4700 compared to OCTR and ECTR, respectively. Although less invasive than OCTR, the endoscopic approach does not offer the same cost savings as USGCTR. Zhang et al.'s review of 16 million patient records found that ECTR incurs higher costs (~1.6× the cost of OCTR, p < .0001) without commensurate benefit (Zhang et al., 2016).24 The superior cost savings of USGCTR was due to avoidance of operating room and anesthesia costs, and faster RTW with little need for rehabilitation.19, 25 Although office-based USGCTR is not currently covered by many insurance carriers, patients have expressed a willingness to pay out of pocket for a faster recovery and smaller incisions. In a survey of 122 individuals, 73% and 86% were willing to pay for a procedure that reduced RTW time by 3 and 14 days, respectively; 88% would pay to reduce the incision size by 2 cm (Alokozai et al., 2021; Asserson et al., 2022).26, 27 In conclusion, USGCTR is a safe procedure with few reported complications and clinical outcomes equal to or better than traditional surgical techniques. In light of the existing data, USGCTR is not only the better choice for our patient but should be considered the preferred standard of care for recalcitrant carpal tunnel syndrome. The patient's presentation—a 40-year-old with a year of progressive symptoms, thenar eminence atrophy, weakness of the APB, objective sensory loss, and electrodiagnostic evidence of moderate-to-severe median neuropathy—signals advanced CTS that should warrant prompt surgical decompression. Additionally, in such a patient, an earlier surgical referral steroid injections would be The of and the of both that patients with severe CTS or those to after 3 to 6 months of therapy should be surgical 2 muscle is a of median nerve compression and the need for in definitive risk median nerve of motor in this patient, including thenar and the is of injury. with such patients all strength or surgical is in with progressive motor Carpal tunnel performed in patients with thenar hand strength by in and in strength at 6 months However, is the potential for be OCTR also for a not in this case, be considered in with and weakness to palmar OCTR or mOCTR the standard for advanced Traditional surgical OCTR or mOCTR a incision allows of the transverse carpal ligament, median nerve, and any structures, a complete and safe decompression. data for open in severe CTS are with published long-term release of the transverse carpal ligament on the nerve and function in the of rates for OCTR in the in severe CTS, and most patients a significant in pain and with functional 5 long-term are well the revision rate for symptoms after OCTR is only over long-term ECTR is performed a incision to the wrist similar in size to that for the USGCTR, and a with a to the transverse carpal ligament from the of the ECTR similar efficacy over the long to open the same size incision as In this patient's case, would improvement and recovery of thenar muscle and strength following open release. USGCTR is a invasive that can CTS, or moderate CTS without motor In USGCTR symptom and functional comparable to open with low complication rates and the of a smaller incision and faster The TUTOR randomized controlled trial by Eberlin et al. showed equivalent improvements in CTS symptom of on the Boston with USGCTR versus at 1 also less scar discomfort and pain with the smaller wrist incision in USGCTR compared to a palmar incision in an open release. This benefit from USGCTR, with similar to other less invasive techniques. in the TUTOR study, which is the only RCT comparing the there is no significant difference in of time to an in studies there is Additionally, comparing pain and incision there is no difference between ECTR and USGCTR techniques. USGCTR is an option for patients with minimal and a high satisfaction rates are reported after USGCTR in long-term studies of and the of USGCTR, with its potential as an procedure, but this to be with long-term follow-up and a of the associated with this compared to an open USGCTR as the approach for a young patient with such advanced Ultrasound-guided release has a and is best for with and as well as a of and In less experienced a to higher rates of incomplete release or nerve injury. similar invasive to a higher risk of nerve injury compared to open due to the of and to such as a branch, median nerve or persistent median artery, which is relevant in or severe USGCTR to this by sonographic but and to of USGCTR that all procedures are by experienced hand that outcomes not be to in There have been reports of complications such as incomplete ligament release, tendon or transient after In a case of 14 patients surgical revision of release, 5 patients had such as nerve or these would be considered a major complication and not occur following open In the TUTOR trial, of required revision of the underwent These findings that USGCTR has the potential to be safe and the for is the limited carpal tunnel at a the patient with persistent symptoms and will surgery. With an incomplete release, the can be than not undergone a as the ligament can greater on the must these when on a for this young In our the approach with the highest of a for this case is a surgical or performed of open or to the differences in invasive techniques have been associated with less postoperative pain in the recovery in the months compared to standard open However, studies have that by 6 to 12 months after the of persistent pain is the same of the The of or endoscopic in pain as most pain after the few months of the long-term is the most critical goal, the most should be a surgical for is to the approach for tunnel In both cases, the is to the patient's and of nerve For tunnel a patient with or moderate compression a ulnar an in decompression. In more severe tunnel syndrome or when the nerve has an is performed as the most definitive surgical as patients with tunnel syndrome only an in nerve techniques vs. ECTR vs. ultrasound should be based on and This that surgical for nerve compression is not but should be to outcomes for In with surgical for this patient with CTS and motor Carpal tunnel is the most accepted for advanced CTS, and offers superior outcomes compared to Although release is an for of CTS, do not that is the optimal choice in a young patient with thenar and significant nerve Open surgical has a of safety and success in such cases, with of nerve compression and a low of complications or with this patient's of symptom resolution and functional recovery would be Drs Eberlin and McCarty for Several of are at the that patients with advanced with thenar atrophy, motor or prompt surgical decompression. also that in patients warrant an with muscle and without motor of the an open release the more that the recovery advantages of less invasive techniques to with at 1 outcomes of OCTR, ECTR, and USGCTR are Finally, share that USGCTR and to anatomic is in the of the evidence and its for the patient in a of three with severe CTS caregiving and recovery essential. that USGCTR is best for to moderate The does not support this and registry data demonstrate in severe Kim et al. followed patients with severe CTS after USGCTR and reported sustained improvements with no adverse events in hands followed for 2 Cano et al. reported sustained improvements in pain and function to 6 years after the procedure, including in severe cases, with 91% patient satisfaction and no Although our Cano et as to the Cano was from the same patient outcomes were by et al. In that earlier the median nerve cross-sectional area was a value consistent with at moderate to severe of hands were as as and as from et al. hands in of which demonstrated moderate to severe CTS on electrodiagnostic testing and a similar cross-sectional area of This also showed significant improvement 1 year after USGCTR. Taken together, these data that techniques are across the spectrum of including in severe Open release does not a based on The the TUTOR trial to no difference in Although the median RTW was similar between (3 days) and release the RTW USGCTR days vs. data with more a recovery in the surgical compared to the USGCTR group et al. Importantly, this with two RCTs et al., et al., comparing and OCTR techniques. et al. and et al. demonstrated significantly faster return to after USGCTR compared with In those this return to included of work and of participants were The an average of days earlier than the groups. These consistent findings across randomized studies the that there is no difference in functional recovery. It is to USGCTR as a On the ultrasound of all neurovascular relevant to et al., et al. this but is not limited to the median nerve, motor branch, ulnar artery, superficial palmar and common anatomic such as median nerve, persistent median artery, and OCTR this of performed by is a not a that allows for to that safety is in any and that complications is a have been reported with all and of and is essential. Recent this et al. complications across all techniques and that both open and endoscopic of incomplete release, nerve and scar et al. reported a case of reexploration after OCTR. These findings that no approach is to the case by et al. 14 revisions after USGCTR. in one case the superficial palmar was This event is mapping and of a to the and the superficial palmar Fortunately, across randomized and prospective studies of USGCTRs, there is no evidence that complication rates those of open or endoscopic et al., Kim et al., Cano et al., et al., with any procedure, and to are essential for The for the of revision rates from incomplete evidence does not support this In the multicenter TUTOR trial, the single in the USGCTR group was for a not for incomplete release or symptoms et al., the patients and revisions for persistent or CTS after USGCTR are rare et al., Kim et al., Cano et al., Aguila et al., The systematic review by et al. found no confirmed incomplete among 1772 large analyses of open and ECTR demonstrate rates of and within 2 years et al., these data support that does not risk of For this patient, the long-term of techniques is less relevant than the functional She both hands to work and to care for her children The evidence demonstrates that USGCTR is safe and a faster smaller incisions with less scar and outcomes equal to those of OCTR at 1 year and For patients in recovery is release not only a safe but the preferred of hand all of in including OCTR, ECTR, and USGCTR, with our that ultrasound has our options for the of is the case a young patient with severe CTS with thenar and APB and electrodiagnostic evidence of This to OCTR, as has the lowest risk of revision release. the of USGCTR, ECTR data, the of incision is to that for USGCTR, can to differences in recovery for to data from ECTR can be to USGCTR for This is supported by RCT data comparing OCTR to ECTR, which showed a 5% revision rate for ECTR, and was associated with reduced long-term patient et al. from the a analysis to the approach to transient nerve or patient costs as of OCTR is preferred over ECTR, ECTR is preferred when risk or earlier improvement in of these data can be to a between OCTR versus USGCTR. with the patient, them that the shows potential for an earlier RTW and less pain to be by the higher risk of a revision procedure. that when presented with moderate-to-severe CTS, one should the most definitive the among OCTR, ECTR, and USGCTR are also to from a societal OCTR is in the of the to be by ECTR and USGCTR for most is essential to be in the of the studies are et al. found ECTR only more than open a ECTR to be more for minimal in an operating room ECTR costs more case than OCTR, in an ECTR was only However, including societal of earlier ECTR cost or cost in Ekhtiari et al. the to USGCTR, total costs of (OCTR), and With higher 6-month for USGCTR, USGCTR was less than OCTR additional This on USGCTR. The procedure was to occur in with a and no or anesthesia were to occur in or in the included for open and ECTR but not for USGCTR. These and lower the cost of USGCTR. In both open and USGCTR can be anesthesia in an USGCTR is performed in an operating would additional and Therefore, the cost of USGCTR in analysis is due to that open and endoscopic The published data, when that USGCTR can be cost but only that not be USGCTR is a in experienced hands for patients with CTS a incision and a office-based recovery. For the young patient with severe CTS and motor with an OCTR or with care and the with the of complete safety, and long-term Erek or for Ultrasound for Kyle for and to Justin with nerve course. Walter or for or not to this as no were or during the