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Neubauer TM, Alisangco JB. Surgical vs nonsurgical treatments for carpal tunnel syndrome. afp. 2025;112(1):20-21. Accessed April 2, 2026. https://www.aafp.org/pubs/afp/issues/2025/0700/mbtn-carpal-tunnel-syndrome.html

Study Population: Adults 32 to 53 years of age; 84% women; varying severity of carpal tunnel syndrome; average duration of symptoms between 31 weeks and 3.5 years

Efficacy Endpoints

Primary outcomes: short-term (less than 3 months follow-up) and long-term (greater than 3 months follow-up) clinical improvement; secondary outcomes: symptoms, function, pain, and health-related quality of life; the Boston Carpal Tunnel Questionnaire was used in 8 of 14 studies to quantify symptoms and function

Harm Endpoints

Secondary outcomes: adverse effects (eg, painful neuroma, tender or hypertrophic scar, subluxation of flexor tendons, wound infection, complex regional pain syndrome, sectioning of motor branch of medial nerve) and need for surgery

Narrative

Carpal tunnel syndrome (CTS) is the most prevalent mononeuropathy, occurring in 1% to 5% of the general population. It has a female to male ratio of 3:1.1^, 2 CTS is caused by compression and traction of the median nerve as it passes through the volar side of the wrist under the transverse carpal ligament in the carpal tunnel. Patients report pain, numbness, or paresthesia in the first three digits and radial half of the fourth digit. As severity increases, hand dexterity can decrease due to weakness of the thenar muscles, including the abductor pollicis brevis, flexor pollicis brevis, and opponens pollicis.3 Combining history, examination, and provocative test findings using the CTS-6 tool enhances clinical diagnosis.4 Electrodiagnostic studies of the median nerve can be obtained for moderate to severe disease or diagnostic uncertainty. Treatment is guided by shared decision-making, with consideration of disease severity and symptom duration. Clinical practice guidelines recommend surgical referral for patients with severe symptoms, thenar atrophy, or positive findings on electrodiagnostic testing.5 Mild to moderate CTS should be treated with splinting, injections, occupational therapy, or surgery.4

The 2024 Cochrane review discussed here evaluated the benefits and harms of surgical vs various nonsurgical treatments for CTS in adults.6 The systematic review found 14 randomized controlled trials (RCTs) comparing surgery vs splinting, corticosteroid injection, splinting plus corticosteroid injection, platelet-rich plasma injection, manual therapy, multimodal nonoperative treatment, and unspecified medical treatment and hand support. Studies comparing surgery vs surgery with corticosteroid injections were also included.

There were 1,231 total participants 32 to 53 years of age, of which 84% were women, resulting in 1,293 participating or symptomatic wrists. Symptom severity varied among the studies, and symptom duration ranged from 31 weeks to 3.5 years. The primary outcome of clinical improvement was defined as the patient reporting they were completely satisfied or almost satisfied with clinical response at less than 3 months (short term) and greater than 3 months (long term) of follow-up. Secondary outcomes included symptoms, function, pain, health-related quality of life, adverse effects, and need for surgery or reoperation.

Moderate-certainty evidence showed that surgery resulted in higher clinical improvement at long-term follow-up compared with splinting alone (risk ratio = 2.1; 95% CI, 1.04–4.24; absolute risk difference = 32.2%; number needed to treat = 4; three RCTs; n = 210). Moderate-certainty evidence also demonstrated that initial surgical treatment reduced the risk for further surgeries compared with splinting (risk ratio = 0.03; 95% CI, 0.00–0.21; absolute risk difference = 42.8%; number needed to treat = 3; two RCTs; n = 176).

However, moderate-certainty evidence did not demonstrate improvement in symptoms or function with surgery compared with splinting at long-term follow-up (two RCTs; 195 wrists). Low-certainty evidence demonstrated little to no difference in health-related qualify of life between surgery and splinting at long-term follow-up (one RCT; n = 167). Evidence was uncertain for adverse effects (two RCTs; n = 210), and no studies included pain as an outcome.

Moderate-certainty evidence showed that surgery may have little to no effect on function compared with corticosteroid injection at long-term follow-up (two RCTs; n = 191). Additionally, moderate-certainty evidence showed that surgery probably provides a small, but clinically insignificant, reduction in pain compared with corticosteroid injection at long-term follow-up (one RCT; n = 123). The results were uncertain for surgery compared with corticosteroid injection regarding long-term clinical improvement (three RCTs; n = 187), symptom relief (two RCTs; n = 118), adverse effects (two RCTs; n = 90), and need for further surgery (one RCT; n = 163).

Caveats

A limited number of studies were found directly comparing surgery with each nonsurgical treatment option, reducing the strength of these comparisons. No studies were found comparing surgery with placebo or no treatment, limiting the ability to assess the specific risks and benefits of surgery. Although eight studies examined improvement with a validated tool (Boston Carpal Tunnel Questionnaire), the other six studies used subjective terminology that is unvalidated. Additionally, lack of blinding of participants created a high risk for bias.

Most studies used adequate methods for randomization and allocation concealment; however, five studies did not describe this process. Surgical techniques, disease severity, duration of symptoms, and definition of clinical improvement were also heterogeneous among studies. Despite the variation in surgical techniques, the authors considered the benefits and risks generalizable when pooling long-term results. No analyzed studies included ultrasound-guided injections or injectates other than corticosteroid or platelet-rich plasma. Finally, this review compared outcomes from treatment-naive patients, limiting the applicability to this population and its generalizability to patients who have already been treated with nonsurgical therapies.

The original manuscript was published in Medicine by the Numbers, American Family Physician as part of the partnership between TheNNT.com and AFP.

Author

Thomas M. Neubauer, MD; Jason B. Alisangco, DO
Supervising Editors: Shahriar Zehtabchi, MD

Published/Updated

April 7, 2026