Carpal tunnel surgery, also called carpal tunnel release surgery (CTR) and carpal tunnel decompression surgery, is surgery in which the transverse carpal ligament is cut. It is a surgical treatment for Carpal Tunnel Syndrome (CTS) and is recommended in cases of constant numbness (not just intermittent), muscle weakness or atrophy, and when the night splint does not control the more intermittent symptoms of carpal tunnel pain. general, less severe cases can be followed for months or years, but severe cases are symptomatically unrelenting and may lead to surgical treatment  Long-term results of carpal tunnel release: a critical review of the literature  Approximately 500,000 surgeries are performed annually and the economic impact of this condition is estimated to be more than $2 billion per year .
2 Surgical Techniques
2.1 Open surgery
2.1.1 Post-operative care
2.2 Limited release of open carpal tunnel
2.2.1 Carpal tunnel release by mini-transverse approach (CTRMTA)
2.3 Endoscopic carpal tunnel release
2.4 Carpal tunnel release from wire
4 Risks and Complications
5 carpal tunnel plastic with balloon
The procedure is used as a treatment for carpal tunnel syndrome and according to the treatment guidelines of the American Academy of Orthopedic Surgeons (AAOS), early surgery is an option when there is clinical evidence of median nerve denervation or the patient chooses to proceed directly to surgical therapy .  Management decisions are based on several factors, including the etiology and chronicity of CTS, the severity of symptoms, and individual patient choices. Non-surgical treatment measures are appropriate in the initial treatment of most idiopathic cases of CTS. Splints and corticosteroid injections can be prescribed and have shown benefits. Steroid injections can provide relief if the symptoms are short-lived. If no improvement is seen following steroid injection, carpal tunnel release may not be as effective. Surgical treatment is indicated in acute cases of CTS from trauma or infection, in chronic cases with denervation of the abductor pollicis brevis muscle or a pronounced sensory loss, and in cases unresponsive to conservative management.
Before pursuing CTR, confirmation of the diagnosis of carpal tunnel syndrome is recommended, given that the symptoms of median nerve entrapment can overlap with other disorders including: cervical radiculopathy, thoracic outlet syndrome, and pronator syndrome. Beyond physical exam testing, confirmatory electrodiagnostic studies are recommended for all patients being considered for surgery. Nerve conduction studies are reported to be 90% sensitive and 60% specific for the diagnosis of carpal tunnel syndrome. These studies provide the surgeon with a patient baseline and can rule out other syndromes that present similarly. Specifically, a distal motor latency of more than 4.5 ms and a sensory latency of more than 3.5 ms are considered abnormal. Of note, these electrodiagnostic studies can yield normal results despite symptomatic median nerve compression. In this scenario, CTR should be considered only if physical signs of median nerve dysfunction are present in addition to classical symptoms of CTS.
Scars from carpal tunnel release surgery. Two different techniques were used. The left scar is 6 weeks old, the right scar is 2 weeks old. Also note the muscular atrophy of the thenar eminence in the left hand, a common sign of advanced CTS.
The goal of any carpal tunnel release surgery is to divide the transverse carpal ligament and the distal aspect of the volar ante brachial fascia, thereby decompressing the median nerve and providing relief. The transverse carpal ligament is a wide ligament that runs across the hand, from the scaphoid bone to the hamate bone and pisiform. 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.[unreliable medical source?]
The two major types of surgery are open carpal tunnel release and endoscopic carpal tunnel release. Open carpal tunnel release can be performed through a standard incision or a limited incision. Endoscopic carpal tunnel release, which can be performed through a single or double portal. Most surgeons historically have performed the open procedure, widely considered to be the gold standard. However, since the 1990s, a growing number of surgeons now offer endoscopic carpal tunnel release. Existing research does not show significant differences in outcomes of one kind of surgery versus the other, so patients can choose a surgeon they like and the surgeon also will practice the technique they like.
Historically, carpal tunnel release was performed under general anesthesia with a tourniquet, however the worldwide trend is now for ‘wide awake hand surgery’: with no tourniquet, no general or regional anesthesia and no sedation; which also enables carpal tunnel release to be performed under local anesthesia as a one stop procedure.
After carpal tunnel surgery, the long term use of a splint on the wrist should not be used for relief. Splints do not improve grip strength, lateral pinch strength, or bowstringing. While splints may protect people working with their hands, using a splint does not change complication rates or patient satisfaction. Using splints can cause problems including adhesion and lack of flexibility.
Carpal tunnel surgery is usually performed by a hand surgeon, orthopaedic surgeon, or plastic surgeon.
The traditional open carpal tunnel surgery
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, include ganglions and tumors. The technique involves placement of a longitudinal incision at the base of the hand. There are a few ways to determine where the incision can be placed. One option is to make an incision above the carpal tunnel where it coincides with the 3rd hand weave space. The other option is to bring the ring finger down and where the cut is . The length of the skin incision varies but is usually less than 4 cm. The subcutaneous tissue, superficial palmar fascia, and palmar brevis muscle (if present) are also incised along the incision, exposing the TCL . The median nerve is exposed by the longitudinal incision of the transverse carpal ligament  . The release is extended to the arc of the superficial palmar artery distally and over a limited distance proximally below the wrist crease . For best results, the TCL should be fully released avoiding damage to vital structures. The flexor tendons can be retracted to examine the bottom of the canal for damage. Scar tenderness, pillar pain, weakness, and delays in return to work can occasionally be seen following an OCTR.
The open release technique has been compared to other treatments.
A light compression dressing and a volar splint may be applied. The hand is actively used as soon as possible after surgery, but the dependent position is avoided. Usually the dressing can be removed by the patient at home 2 or 3 days after the surgery, and then gentle washing and showering of the hand is permitted. Gradual resumption of normal hand use is encouraged. If non-absornable sutures are used, they are removed after 10 to 14 days. A splint may be continued for comfort as needed for 14 to 21 days.
Limited open carpal tunnel release
Limited-incision carpal tunnel release techniques similar to endoscopic surgery were developed to decrease palmar discomfort and hasten the return to activities. It allows for adequate exposure to avoid complications and keeps the incision out of the painful portion of the palm. The surgical approach involves a small skin incision in the palm followed by release of the distal end of the TCL under direct visualization. Patients experience reduced post-operative pain as this techniques leaves the palmar fascia intact over the proximal TCL.
Carpal tunnel release through mini-transverse approach (CTRMTA)
Sayed Issa’s approach 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. A skin incision is made and the surgeon will dissect through fat and the superficial palmar fascia. Once the superficial palmar fascia has been released the transverse carpal ligament will be exposed. The lateral carpal ligament is cut longitudinally and released. 
Endoscopic release of carpal tunnel
Main article: Endoscopic release of carpal tunnel
Carpal tunnel surgery endoscopic techniques include one or two small incisions (each) that look underneath the lateral carpal ligament using tools such as synovial lifts, probes, knives, and endoscopes. Includes (less than 0.5 inches). 23] [Unreliable medical source? ] Endoscopy does not divide the subcutaneous tissue or palm fascia as much as the laparotomy.  Proponents of endoscopic carpal tunnel surgery have shown that the “spine” of the ulna is less scarred and less painful, rapid and complete.