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Carpal tunnel release

Surgeon-side topic for carpal tunnel release. Backed by 427 articles from the corpus, retrieved via combined MeSH + title-text matching.

Overview

Carpal tunnel release is a highly effective intervention, with 97% of patients experiencing complete or partial relief [17]. Significant improvements in symptom severity and hand function are expected in the general population regardless of age, medical comorbidities, or workers' compensation status [9]. Patients with end-stage disease do not demonstrate worse long-term patient-reported outcomes compared with the general population [4], though full recovery typically requires nearly 6 months [2]. Early release is indicated for patients presenting with autonomic findings to improve outcomes, as ignoring this component may lead to persistent symptoms and surgical failure [3].

While endoscopic release offers faster recovery during the first two postoperative weeks and earlier pain relief compared with open release, no substantive difference in overall benefit has been demonstrated between the two techniques [10, 20]. Patient age of 65 years or older predicts less favourable short-term outcomes following endoscopic release, suggesting this approach may not be justified as a routine procedure in the elderly [16]. Conversely, patients with perilunate injuries who do not undergo initial release have a greater than 50% risk of requiring the procedure during follow-up [1].

The procedure is rarely repeated or revised, and none of the 24 repeat releases in one study provided benefit [11]. Despite the safety and efficacy of the surgery, wide variation exists in recommended timescales for return to work, suggesting patients may receive conflicting advice [6]. Furthermore, routine preoperative electrodiagnostic studies are associated with surgical delays and increased costs, warranting further evaluation regarding their utility relative to patient preferences [7].

Anatomy & Pathophysiology

Ligamentous and Fascial Anatomy

The flexor retinaculum comprises the distal deep fascia of the forearm proximally, the transverse carpal ligament (TCL), and the aponeurosis between the thenar and hypothenar muscles [22]. Successful release requires division of all these components, as TCL fibers can extend distally farther than expected [22]. The palmar cutaneous branch of the median nerve lies deep to the thenar crease and radial to the palmaris longus, traversing the interval between the palmaris longus and flexor carpi radialis tendons [22, 54]. Injury to this branch, particularly if an incision crosses flexor creases at a right angle, frequently causes a painful neuroma requiring later excision [22]. To avoid this injury, the incision should be placed approximately 6 mm ulnar to the thenar crease, positioning it in the watershed area between the median and ulnar palmar cutaneous nerves [35, 54]. The superficial palmar arterial arch is located 5 to 8 mm distal to the distal margin of the TCL [22].

Pathophysiology and Etiology

Carpal tunnel syndrome pathogenesis involves a decrease in tunnel size or an increase in canal contents. Bony abnormalities of the carpal bones, acromegaly, and wrist flexion or extension reduce tunnel size [23]. Increased contents result from forearm and wrist fractures, dislocations, subluxations, posttraumatic arthritis, musculotendinous variants, aberrant muscles, local tumors, persistent medial artery, hypertrophic synovium, or hematoma [23]. Neuropathic conditions include diabetes mellitus, alcoholism, double-crush syndrome, and industrial solvent exposure [23]. Inflammatory conditions encompass rheumatoid arthritis, gout, nonspecific tenosynovitis, and infection [23]. Fluid balance alterations associated with the syndrome include pregnancy, menopause, eclampsia, thyroid disorders (especially hypothyroidism), renal failure, long-term hemodialysis, Raynaud disease, obesity, lupus erythematosus, scleroderma, amyloidosis, and Paget disease [23]. External factors such as vibration and direct pressure also contribute [23]. Obesity, diabetes, use of hand-held vibratory tools, and repeated forceful wrist movements are specific causes of impaired median nerve function [46]. Anatomical anomalies within the tunnel may include connections between the flexor pollicis longus and index flexor digitorum profundus tendons, anomalous flexor digitorum superficialis, palmaris longus, hypothenar, and lumbrical muscle bellies, and median and ulnar nerve branches [22].

Clinical Presentation and Diagnosis

Nocturnal paresthesias in the radial three digits are nearly pathognomonic for carpal tunnel syndrome [53]. Paresthesias characteristically occur during fixed wrist activities such as reading, driving, or using a computer keyboard or mouse [53]. Advanced compression leads to weakness and atrophy of the abductor pollicis brevis and opponens pollicis muscles [53]. The wrist-flexion test is the most sensitive provocative diagnostic test, while the nerve-percussion test is the most specific [61]. Electrodiagnostic studies stage compression severity and assist in anticipating recovery time [53]. Ultrasound measurements of the median nerve at the distal wrist crease correlate with electrodiagnostic severity [64]. When the median nerve diameter exceeds 10 mm² at the pisiform, ultrasound sensitivity is over 97% [23]. High-resolution ultrasonography has a 73% sensitivity for diagnosing the syndrome in patients with negative electrodiagnostic studies if a cutoff of 9.4 mm² is used at the carpal tunnel inlet [23]. Diagnosis should rely on clinical acumen and physical examination, reserving ancillary tests for unclear presentations [23]. MRI is not routine, though diffusion tensor imaging shows promise [23].

Kinematics and Biomechanics

The largest median nerve excursion in the arm and wrist occurs with terminal wrist extension [44]. Transverse nerve movement is most marked with forearm supination, irrespective of other kinetic chain changes [45]. Splints immobilizing the wrist in a functional extension position do not minimize carpal tunnel pressure [48]. The relative motion pattern of finger flexors, subsynovial connective tissue, and the median nerve before and after release is unaffected by flexor retinaculum division [50]. The MANU® soft hand brace provides symptomatic and functional benefits by increasing the tunnel's transverse diameter and thinning the flexor retinaculum [57].

Prognosis and Recovery

Reinnervation for decreased conduction velocity and increased latency occurs within a few months following decompression, whereas axonal regeneration takes significantly longer [35]. Patients with mild or moderate compression typically regain painless sensation in the median nerve distribution [35]. Reinnervation of the thenar muscles occurs, though motor function may not fully return in severe cases [35]. Full wrist range of motion is expected post-decompression [35]. Patients with long-standing symptoms, severe thenar atrophy, and dense sensory loss may not achieve complete sensory or motor recovery [53]. Rarely, severe cases with thenar atrophy experience a postoperative flare of pain, stiffness, and swelling due to reinnervation hypersensitivity [35]. Pillar pain is likely microneuroma related [35].

Proximal Compression and Differential Diagnosis

Proximal median nerve compression may occur under the ligament of Struthers in patients with a supracondylar process [52]. The most common site of proximal compression is the forearm at the pronator level [52]. Pronator syndrome compression sites include the intersection of the deep and superficial heads of the pronator teres, the lacertus fibrosis, and the tendinous leading edge of the flexor digitorum superficialis arch [52]. Accessory muscles acting as compressive structures include the accessory head of the flexor pollicis longus (Gantzer muscle), palmaris profundus, and flexor carpi radialis [52]. The pronator teres entrapment point is located 3 to 7.5 cm distal to the humeral epicondylar line, while the fibrous arch of the flexor digitorum superficialis is located 6.5 cm distal in its most proximal position [52]. Forearm compression can cause sensory disturbance in the median distribution or motor dysfunction of anterior interosseous and median nerve muscles [52]. Anterior interosseous nerve syndrome presents with a shoulder or arm pain prodrome in nearly all cases, manifesting as acute flaccid paralysis of the flexor pollicis longus with or without palsy of the flexor digitorum profundus-index and/or pronator quadratus [52]. Spontaneous recovery occurs in most, but complete functional recovery is not assured [52]. Over 60% of a 246-patient cohort had residual weakness or sensory symptoms after 3 or more years [52]. Recent literature suggests intrinsic constrictions of the anterior interosseous nerve fascicle at or above the elbow may be part of the pathophysiology [52].

Complications and Recurrence

The recurrence rate after primary carpal tunnel release is approximately 2%, with overall complications and failures estimated at 3% to 19% [33]. Unrelieved symptoms lead to repeat operation in 12% of patients [33]. Reoperation findings include incomplete TCL release, re-formation of the flexor retinaculum, tunnel scarring, median or palmar cutaneous neuroma, palmar cutaneous nerve entrapment, recurrent granulomatous or inflammatory tenosynovitis, and hypertrophic skin scarring [33]. Recurrence is more common in patients with diabetes [33]. Incomplete release and median nerve scarring are common intraoperative findings in recurrent cases [33]. Poor prognostic factors include normal preoperative electrodiagnostic studies, workers' compensation claims, ulnar nerve symptoms, persistent symptoms, and multiple prior surgeries [33]. Higher preoperative pain, pain medication use, and workers' compensation predict higher postoperative pain [33]. Temporary relief from corticosteroid injection is a good prognostic sign for reoperation [33]. The reformed TCL is indistinguishable from the native ligament [33]. Management of recurrence requires neural adhesion lysis and early nerve gliding exercises; synovial or hypothenar fat pad flaps are rarely necessary [33].

Acute and Secondary Etiologies

Both compartment syndrome and acute carpal tunnel syndrome can develop after distal forearm fractures [55]. The hallmark of acute carpal tunnel syndrome is pain out of proportion to clinical findings [55]. Timely decompression allows a return to normal sensation and function in acute cases secondary to gout flares [36]. Proximal-row carpectomy is reserved for wrists with osteoarthrosis or symptomatic instability in cases of median-nerve neuropathy associated with chronic anterior dislocation of the lunate [62].

Classification

Indications and Timing: Early carpal tunnel release is indicated in patients presenting with autonomic findings to avoid persistent symptoms and unsuccessful surgery [3]. More than 50% of patients who did not undergo carpal tunnel release at the initial surgery for perilunate injuries required a release within the follow-up period [1].

Outcomes and Prognosis: Significant improvements in symptom severity and hand function may be expected after open carpal tunnel release in the general population regardless of age, medical comorbidities, or workers' compensation status [9]. However, workers' compensation patients undergoing carpal tunnel release fare poorly as compared with non-workers' compensation patients in nearly every metric [18]. Patients with end-stage carpal tunnel syndrome do not have worse long-term patient-reported outcomes after carpal tunnel release compared with the general population [4]. Patients did not report full recovery until an average of nearly 6 months after carpal tunnel release [2].

Diagnostic Utility: The utility of routine preoperative electrodiagnostic studies before carpal tunnel release is uncertain, and their use is associated with delays to surgery and increased costs [7]. The outcome of surgical release of the carpal tunnel seems to be predictable only on the basis of neurophysiological data, and not subjective clinical data [21]. Symptoms experienced outside of the median nerve distribution had a high likelihood of resolution after open carpal tunnel release, with over 85% of symptoms in each of the anatomic zones studied resolving [8].

Procedural Efficacy and Imaging: There is wide variation in recommended timescales for return to work and other functional activities after carpal tunnel release among UK hand surgeons and hand therapists [6]. No substantive difference in benefit was shown between endoscopic and open carpal tunnel release [20]. Carpal tunnel release is a highly effective procedure, though aspects such as recurrence and existing electromyographic data remain poorly understood [5]. MRI of patients 3 months after successful endoscopic carpal tunnel release does not demonstrate a discrete gap or separation in the flexor retinaculum overlying the median nerve but may be useful for evaluating median nerve morphology [15].

Revision and Recurrence: Carpal tunnel release is a surgery that is almost never repeated or revised, and it is possible that none of the 24 repeat releases provided benefit [11]. Management of failed carpal tunnel release may require revision surgery, which includes redo release of the transversal carpal ligament, external neurolysis and flaps [27].

Other Considerations: The evidence base highlights that while the procedure is generally effective, specific subgroups (e.g., workers' compensation) demonstrate distinct outcome trajectories, and diagnostic reliance should prioritize neurophysiological data over subjective clinical presentation.

Clinical Presentation

Carpal tunnel syndrome is the most common compression neuropathy of the upper extremity, with a mean age at diagnosis of 50 years [37]. It occurs nearly four times more frequently in women than men, with prevalence by age 65 reaching approximately 5.1% in women and 1.3% in men [37]. Risk factors include obesity, pregnancy, hypothyroidism, diabetes mellitus, and menopause [37]. The American Academy of Orthopaedic Surgeons (AAOS) guidelines identify body mass index (BMI) and high hand repetition rate as factors with strong evidence of increased risk [37].

Classically, the condition presents with nocturnal paresthesias in a median nerve distribution that gradually worsen, leading to sensory loss and thenar muscle atrophy late in the disease course [37]. Many patients report hand pain and symptoms not directly referable to the median nerve, yet over 85% of symptoms in each anatomic zone studied resolve after release [8]. Symptoms experienced outside the median nerve distribution also have a high likelihood of resolution [8]. Significant improvements in symptom severity and hand function may be expected regardless of age, medical comorbidities, or workers' compensation status [9].

Physical examination may reveal thenar atrophy and abductor pollicis brevis weakness [37]. A positive Tinel sign at the wrist aids diagnosis with specificity ranging from 55% to 100% [37]. Development of symptoms after a provocative Phalen maneuver aids diagnosis with specificity ranging from 54% to 98% [37].

Neurophysiological testing remains a useful diagnostic tool, as nerve conduction studies assess focal demyelination via delayed conduction velocities of the median nerve at the wrist [37]. Needle electromyography is an optional adjunct used to differentiate carpal tunnel syndrome from other causes and to document muscle atrophy and fibrillations for severity identification and prognostication [37]. However, nerve conduction studies can be omitted in cases with typical symptoms, as results are no better after testing [25]. Patients with normal preoperative electrodiagnostic studies have reported significantly worse results than those without these findings [33]. The outcome of surgical release appears predictable only on the basis of neurophysiological data, not subjective clinical data [21]. Higher preoperative cross-sectional area of the median nerve, signifying worse severity, showed almost no correlation with better outcomes after surgery [40].

Ultrasonography allows rapid diagnosis by identifying enlarged, hypoechoic median nerve fascicles proximal to the carpal tunnel [37]. MRI and/or ultrasonography should be considered in patients with new, persistent, or recurrent symptoms after surgery to delineate etiology [37]. MRI three months after successful endoscopic release does not demonstrate a discrete gap in the flexor retinaculum but may be useful for evaluating median nerve morphology [15].

Etiologies for carpal tunnel syndrome include alterations in fluid balance (pregnancy, menopause, eclampsia, thyroid disorders, renal failure, hemodialysis, Raynaud disease, obesity, lupus erythematosus, scleroderma, amyloidosis, Paget disease), neuropathic conditions (diabetes mellitus, alcoholism, double-crush syndrome, industrial solvent exposure), inflammatory conditions (rheumatoid arthritis, gout, nonspecific tenosynovitis, infection), and external forces (vibration, direct pressure) [23]. Decreased tunnel size may result from bony abnormalities, acromegaly, or wrist flexion/extension [23]. Increased canal contents may result from fractures, dislocations, subluxations, posttraumatic arthritis, musculotendinous variants, aberrant muscles, local tumors, persistent medial artery, hypertrophic synovium, or hematoma [23].

In patients with severe carpal tunnel syndrome, symptomatic improvement following release can occur [24]. Early release in patients with autonomic findings is indicated and may improve outcomes, as ignoring the autonomic component may lead to persistent symptoms and unsuccessful surgery [3]. Patients with end-stage carpal tunnel syndrome do not have worse long-term patient-reported outcomes compared with the general population [4]. For patients with a thrombosed persistent median artery, surgical excision of the thrombosed segment and carpal tunnel release led to rapid symptom resolution and return to sport without restrictions [14]. In cases where a mass is not palpable, release of the transverse carpal ligament alone is sufficient for complete resolution in carpal tunnel syndrome secondary to an accessory flexor digitorum superficialis muscle belly [26].

Recovery timelines vary; patients did not report full recovery until an average of nearly 6 months after release [2]. Endoscopic release provides faster recovery for the first 2 postoperative weeks with faster pain relief and functional improvement [10]. Patient age 65 years or older predicts less favorable short-term outcomes, and endoscopic release may not be justified as a routine procedure in this group [16]. However, elderly patients with electrophysiologically severe presentation demonstrate favorable recovery after release, supporting that age alone should not preclude surgical treatment [19].

Complications and failures are estimated at 3% to 19%, with a recurrence rate of approximately 2% [33]. Unrelieved symptoms may lead to repeat operation in 12% of patients [33]. Findings 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 skin scarring [33]. Incomplete release of the flexor retinaculum and scarring of the median nerve were common intraoperative findings in recurrent cases [33]. Recurrent syndrome was demonstrated more often in patients with diabetes [33]. Persistent symptoms and more than one prior syndrome had higher odds of not changing or worsening postoperative pain [33]. Higher preoperative pain, use of pain medication, and workers' compensation were significant predictors of higher postoperative average pain [33]. Patients who filed for compensation and those with ulnar nerve symptoms reported significantly worse results than those without these findings [33].

In patients with perilunate injuries, more than 50% who did not undergo carpal tunnel release at initial surgery required a release within the follow-up period [1]. Given the uncertain utility of routine electrodiagnostic studies and their association with delays and increased costs, further evaluation regarding patient preferences and value of care is warranted [7]. Careful clinical assessment, neurophysiological testing, and examination of vibrotactile sense are required before release should be considered in vibration-exposed male workers [39]. There is wide variation in recommended timescales for return to work and functional activities, suggesting patients receive conflicting advice [6]. Carpal tunnel release is highly effective, though important aspects including recurrence and existing electromyographic data remain poorly understood [5].

Investigations

Clinical Diagnosis: The diagnosis of carpal tunnel syndrome (CTS) should be based on clinical acumen and physical examination in the vast majority of patients, reserving ancillary tests for those without clear presentations [23]. Classically, CTS presents with nocturnal paresthesias in a median nerve distribution that gradually worsen, leading to sensory loss and thenar muscle atrophy late in the disease course [37]. A positive Tinel sign at the wrist or development of symptoms after a provocative Phalen maneuver can aid diagnosis, with reported specificity varying from 55% to 100% for Tinel sign and 54% to 98% for the Phalen test [37]. Documenting muscle atrophy and fibrillations on needle EMG assists with identifying severity and prognostication, though thenar atrophy and abductor pollicis brevis weakness are often detectable on physical examination alone [37]. The four commonly used tests (abnormal hand diagram, abnormal Semmes-Weinstein, positive Durkan compression, and night pain) do not predict the rate of functional recovery or reemployment after release, nor do they increase diagnostic value [23].

Electrodiagnostic Testing: Nerve conduction studies remain a useful diagnostic tool to assess focal demyelination via delayed conduction velocities of the median nerve at the wrist [37]. Needle electromyography is currently considered an optional adjunct to nerve conduction studies, mostly used to differentiate CTS from other possible causes [37]. The outcome of surgical release seems predictable only on the basis of neurophysiological data, not subjective clinical data [21]. However, nerve conduction studies can be omitted in patients with typical symptoms, as results are no better after testing [25]. Reported false-negative rates of electrodiagnostic testing are 10%, limiting their usefulness for determining treatment [23]. Postoperative electrodiagnostic testing may be helpful in assessing recurrent symptoms [23].

Ultrasonography: Advances in ultrasonography technology allow rapid diagnosis by identifying enlarged, hypoechoic median nerve fascicles proximal to the carpal tunnel [37]. Ultrasound sensitivity for CTS has been reported to be over 97% when the median nerve diameter is greater than 10 mm² at the level of the pisiform [23]. In patients with negative electrodiagnostic studies but a clinical diagnosis of CTS, high-resolution ultrasonography has a sensitivity of 73% if a cutoff of 9.4 mm² at the inlet of the carpal tunnel is used [23]. Carpal tunnel release using ultrasound guidance with wide-awake local anesthesia and no tourniquet was safe, effective, and resulted in morphological changes consistent with decompression as demonstrated by MRI [34]. Controversy remains as to whether ultrasonography evaluation could replace electrophysiology in the diagnosis of CTS [37].

MRI: MRI and/or ultrasonography imaging should be considered in patients with new, persistent, or recurrent symptoms after surgery to delineate the etiology, such as incomplete ligament division or iatrogenic injury [37]. Reports of MRI in CTS are promising, especially with newer techniques like diffusion tensor imaging, but MRI is not routinely used for diagnosis [23]. A major advantage of MRI is its high soft-tissue contrast, which provides detailed images of bones and soft tissues [23]. MRI of patients 3 months after successful endoscopic release does not demonstrate a discrete gap or separation in the flexor retinaculum overlying the median nerve but may be useful for evaluating median nerve morphology [15]. Symptom relief after surgical decompression seems to correlate with reduced nerve swelling at the carpal inlet and reversed nerve flattening inside the carpal tunnel [59].

Other Considerations: The mean age at diagnosis of CTS is 50 years, and the condition is more common in women than men by nearly four times, with a prevalence of approximately 5.1% for women and 1.3% for men by age 65 [37]. Risk factors include obesity, pregnancy, hypothyroidism, diabetes mellitus, and menopause [37]. The AAOS guidelines list BMI and high hand repetition rate as factors with strong evidence of increased risk for development of CTS [37]. Early carpal tunnel release in patients with autonomic findings is indicated and may provide improved outcomes, as ignoring the autonomic component may lead to persistent symptoms and unsuccessful surgery [3]. Carpal tunnel release in patients with diabetes results in poor outcomes in long-term study, though symptomatic improvement can occur in patients with severe CTS [24]. Elderly patients with CTS initially present as electrophysiologically severe but demonstrate favorable recovery after release, supporting that age alone should not preclude surgical treatment [19]. Workers' compensation patients undergoing release fare poorly compared with non-workers' compensation patients in nearly every metric [18]. More than 50% of patients who did not undergo release at initial surgery for perilunate injuries required a release within the follow-up period [1]. Patients did not report full recovery until an average of nearly 6 months after release [2]. Carpal tunnel release is a highly effective procedure, but important aspects remain poorly understood, including recurrence and existing electromyographic data [5]. There is wide variation in recommended timescales for return to work and other functional activities after release, suggesting patients receive different and possibly conflicting advice [6]. Symptoms experienced outside of the median nerve distribution had a high likelihood of resolution after release, with over 85% of symptoms in each of the anatomic zones studied resolving [8]. Endoscopic release provides faster recovery for the first 2 postoperative weeks with faster relief of pain and functional improvement compared to open release [10]. Carpal tunnel release is a surgery that is almost never repeated or revised, and it is possible that none of the 24 repeat releases provided benefit [11]. Surgical excision of the thrombosed segment and carpal tunnel release led to rapid resolution of symptoms and return to sport without restrictions in a patient with a thrombosed persistent median artery [14]. In cases where the mass is not palpable, release of the transverse carpal ligament alone is sufficient with complete resolution of symptoms for CTS secondary to an accessory flexor digitorum superficialis muscle belly [26]. Direct visualization of the carpal tunnel at release allowed complete release to be performed without arterial injury in a case with an aberrant radial artery seen in the carpal tunnel [47].

Treatment

Non-Operative

The clinical course and prognostic factors in conservatively managed carpal tunnel syndrome have been reviewed systematically [13], and a randomized controlled trial was designed to assess the effectiveness of surgery versus conservative therapy for mild to moderate carpal tunnel syndrome but did not report final results or conclusions [30]. Evidence-based treatment decisions for carpal tunnel syndrome have been discussed [13], and prior local corticosteroid injection has been evaluated for its potential to prejudice the outcome of subsequent carpal tunnel decompression [13]. Prognostic indicators for recurrent symptoms after a single corticosteroid injection for carpal tunnel syndrome have been identified [13].

Operative

Indications: Early carpal tunnel release is indicated in patients with autonomic findings to avoid persistent symptoms and unsuccessful surgery [3]. Carpal tunnel release is a highly effective procedure, though aspects such as recurrence and existing electromyographic data remain poorly understood [5]. Patients with end-stage carpal tunnel syndrome do not have worse long-term patient-reported outcomes after carpal tunnel release compared with the general population [4]. The benefit of carpal tunnel release in patients with electrophysiologically moderate and severe disease has been evaluated [13]. Carpal tunnel release in patients with diabetes results in poor outcomes in long-term studies [13]. Patient age 65 years or older is a good predictor of a less favourable short-term outcome after endoscopic carpal tunnel release [16], and endoscopic carpal tunnel release may not be justified as a routine procedure in elderly patients [16]. Surgery versus conservative therapy in carpal tunnel syndrome in people aged 70 years and older has been compared [13]. Workers' compensation (WC) patients undergoing carpal tunnel release fare poorly as compared with non-WC patients in nearly every metric [18]. Outcomes following carpal tunnel release in patients receiving workers' compensation have been reviewed systematically [13].

Surgical Approach / Technique: Endoscopic carpal tunnel release provides faster recovery for the first 2 postoperative weeks with faster relief of pain and functional improvement compared to other methods [10]. Endoscopic carpal tunnel release using the single proximal incision technique is a documented surgical approach [12], and endoscopic release of the carpal tunnel has been evaluated in randomized prospective multicenter studies [12]. Endoscopic carpal tunnel release using the Chow technique has been evaluated over thirteen years of experience [12], and endoscopic release of the carpal ligament using the Chow technique has shown long-term results [12]. The two-portal technique for endoscopic carpal tunnel release is a documented method [12], though transection of the motor branch of the ulnar nerve is a complication of two-portal endoscopic carpal tunnel release [12]. Carpal tunnel release using a short palmar incision and a new knife is a documented technique [12], and minimal-incision open carpal tunnel decompression is a documented technique [12]. Surgical ultrasound-guided carpal tunnel release is a documented technique [13], and carpal tunnel release using ultrasound guidance using wide-awake local anesthesia no tourniquet in a procedure room setting was safe, effective, and resulted in morphological changes consistent with carpal tunnel decompression as demonstrated by MRI [34]. A new supraretinacular endoscopic carpal tunnel release technique was shown to be efficacious in a series of 48 consecutive cases [42], and the modified TCTR procedure has been shown to be a safe and effective technique for carpal tunnel release [43]. Carpal tunnel release using the radial sided approach compared with the two-incision approach has been studied [13], and comparison of longitudinal open incision and two-incision techniques for carpal tunnel release has been performed [13]. Comparison of short wrist transverse open and limited open techniques for carpal tunnel release has been conducted in a randomized controlled trial [13]. Carpal tunnel release using the technique of a 1 cm skin incision at the proximal palmar wrist crease appears effective when utilised within the defined safe zones [41]. A modified thread carpal tunnel release has been studied clinically [13].

Implant Selection: No implant selection is applicable for this procedure.

Alignment / Balancing Strategy: No alignment or balancing strategy is applicable for this procedure.

Pain Management: The use of splintage for pain after carpal tunnel release has been evaluated in randomized controlled trials [12]. Postoperative care includes a light compression dressing and a volar splint, with active use of the hand as soon as possible after surgery [22]. The dressing can usually be removed by the patient at home 2 or 3 days after surgery, permitting gentle washing and showering [22]. Sutures are removed after 10 to 14 days [22], and a splint may be continued for comfort as needed for 14 to 21 days [22]. Reduction in pain associated with open carpal tunnel decompression has been reported [12].

Adjuncts: The routine use of antibiotic prophylaxis in carpal tunnel release surgery is not indicated [29].

Setting of Care: A cost analysis of carpal tunnel release surgery performed wide awake versus under sedation has been conducted [13], and cost implications of varying the surgical technique, surgical setting, and anesthesia for carpal tunnel release surgery have been analyzed [13].

Revision: Carpal tunnel release is a surgery that is almost never repeated or revised, and repeat releases may provide no benefit [11]. Symptoms may return after carpal tunnel surgery [12], and the incidence of recurrence after endoscopic carpal tunnel release has been studied [12]. The long-term outcome of carpal tunnel release is favourable with a rate of recurrence of 2.5% and a rate of persistence of 3.75% [38]. Management of failed carpal tunnel release may require revision surgery, which includes redo release of the transversal carpal ligament, external neurolysis, and flaps [27]. Outcomes of reoperation for carpal tunnel syndrome have been evaluated [12], and predicting the outcome of revision carpal tunnel release has been studied [13]. Reoperation surgery for persistent and recurrent carpal tunnel syndrome and for failed carpal tunnel release has been discussed [13]. Management of recurrent carpal tunnel syndrome with microneurolysis and the hypothenar fat pad flap has been described [12], and pedicled fat flap coverage of the median nerve after failed carpal tunnel decompression is a documented technique [12]. Simple carpal tunnel release without additional coverage of the median nerve seems preferable as it is less invasive and without additional donor site morbidity [28]. Poor outcomes for neural surgery (epineurotomy or neurolysis) for carpal tunnel syndrome compared with carpal tunnel release alone have been reported in meta-analyses [12].

Other Considerations: More than 50% of patients who did not undergo carpal tunnel release at the initial surgery for perilunate injuries required a release within the follow-up period [1]. Patients did not report full recovery until an average of nearly 6 months after carpal tunnel release [2]. There is wide variation in recommended timescales for return to work and other functional activities after carpal tunnel release among UK hand surgeons and therapists [6]. Routine preoperative electrodiagnostic studies (EDS) have uncertain utility, are associated with delays to surgery, and increase costs [7]. Pre-operative electrodiagnostic testing predicts time to resolution of symptoms after carpal tunnel release [13], and electrical studies have been evaluated as a prognostic factor in the surgical treatment of carpal tunnel syndrome [12]. Comparison of ultrasound and electrodiagnostic testing for diagnosis of carpal tunnel syndrome has been performed using a validated clinical tool as the reference standard [13]. Electromyography, ultrasonography, computed tomography, and magnetic resonance imaging have been used in idiopathic carpal tunnel syndrome determined by clinical findings [13]. MRI of patients 3 months after successful endoscopic carpal tunnel release does not demonstrate a discrete gap or separation in the flexor retinaculum overlying the median nerve [15], and MRI may be useful for evaluating median nerve morphology after endoscopic carpal tunnel release [15]. Symptoms experienced outside of the median nerve distribution had a high likelihood of resolution after carpal tunnel release, with over 85% of symptoms in each anatomic zone studied resolving [8]. The value of clinical provocative tests in carpal tunnel syndrome has been assessed regarding the need for electrophysiology and outcome prediction [12]. A new diagnostic test for carpal tunnel syndrome has been proposed [12]. Unusual causes of carpal tunnel syndrome, such as space occupying lesions, have been studied [13]. Raynaud's phenomenon in idiopathic carpal tunnel syndrome may alter in prevalence postoperatively [12]. Carpal tunnel syndrome and work have been studied [13]. Litigation in hand surgery arises most commonly from routine procedures such as carpal tunnel release rather than complex surgical cases [67]. Complications related to carpal tunnel release have been documented [12], and complications of carpal tunnel release have been reviewed [13]. Controversies in carpal tunnel syndrome have been discussed in the literature [12], and recurrent carpal tunnel syndrome has been studied [12]. Surgical techniques to reduce scar discomfort after carpal tunnel surgery have been described [12]. Endoscopic carpal tunnel release has been performed in rheumatoid patients [12], and tenosynovectomy occasionally may be indicated, especially in patients with rheumatoid arthritis [22]. Carpal tunnel release provides long-term relief in patients with hemodialysis-associated carpal tunnel syndrome [13], and risk factors for re-recurrent carpal tunnel syndrome in patients undergoing long-term hemodialysis have been identified [13]. Surgical decompression provides satisfactory outcomes for patients with persistent forearm pain and median nerve symptoms [60]. Predictors of patient-centered outcomes of surgical carpal tunnel release have been identified in a prospective cohort study [13]. Outcomes of open and endoscopic carpal tunnel release have been compared in a meta-analysis [13], and effectiveness and safety of endoscopic versus open carpal tunnel decompression have been evaluated [13]. No substantive difference in benefit was shown between endoscopic and open carpal tunnel release in a randomized trial [20], and endoscopic carpal tunnel release is preferred over mini-open despite similar outcomes in a randomized trial [13]. Results of endoscopic carpal tunnel release relative to surgeon experience with the Agee technique have been evaluated [13]. A randomized comparison of three surgical methods for carpal tunnel release has been conducted [13], and a randomized controlled trial compared Knifelight and open carpal tunnel release [12]. Neurophysiological recovery after open carpal tunnel decompression has been compared between simple decompression and decompression with epineurotomy [12]. Lengthening of the flexor retinaculum versus simple division in carpal tunnel decompression has been compared [12]. Carpal tunnel release outcomes have been studied in prospective series [12]. The incidence of carpal tunnel syndrome requiring surgical decompression has been reviewed over 10.5 years [13]. The clinical practice guideline on carpal tunnel syndrome and workers' compensation has been discussed [13]. Diagnosing carpal tunnel syndrome has been discussed [13].

Anatomical Considerations: The thenar crease takes a variable course, and palmar incisions should be well ulnar to it to avoid the median nerve palmar cutaneous branch [22]. A curved incision ulnar and parallel to the thenar crease is not advisable because the palmar cutaneous branch of the median nerve proximally may be more at risk of injury [22]. The incision should be angled toward the ulnar side of the wrist to avoid cutting the palmar cutaneous sensory branch, which lies in the interval between the palmaris longus and the flexor carpi radialis tendons [22]. When severed, the palmar sensory branch frequently causes a painful neuroma that may later require excision from the scar [22]. If the palmar sensory branch is severed, it should be sectioned more proximally to be covered by the middle finger sublimis muscle rather than repaired [22]. The palmar fascia is split to expose the underlying transverse carpal ligament (TCL), avoiding the median nerve beneath it [22]. Fibers of the TCL can extend distally farther than expected [22]. The flexor retinaculum includes the distal deep fascia of the forearm proximally, the TCL, and the aponeurosis between the thenar and hypothenar muscles [22]. A successful carpal tunnel release usually requires division of all components of the flexor retinaculum [22]. Potential anomalies include connections between the flexor pollicis longus and the index flexor digitorum profundus tendons, anomalous flexor digitorum superficialis, palmaris longus, hypothenar, lumbrical muscle bellies, and median and ulnar nerve branches and interconnections [22]. The superficial palmar arterial arch is 5 to 8 mm distal to the distal margin of the TCL and should be avoided [22].

Complications

Wound complications: The routine use of antibiotic prophylaxis in carpal tunnel release surgery is not indicated [29]. While the complication rate is low when endoscopic carpal tunnel release is performed by a trained surgeon [72], early outcomes with the Arthrex NanoScopic Release System also demonstrate low complication rates and high procedural success [74]. Additionally, the incidence of complications in patients treated with extracorporeal shock wave based neural activity for carpal tunnel syndrome is less, and it has high safety [73].

Nerve palsy: Patients did not report full recovery until an average of nearly 6 months after carpal tunnel release [2]. Surgical excision of a thrombosed segment and carpal tunnel release led to rapid resolution of symptoms and return to sport without restrictions in a professional hockey player [14]. In cases of recurrent or persistent carpal tunnel syndrome, simple carpal tunnel release without additional coverage of the median nerve seems preferable as it is less invasive and without additional donor site morbidity [28].

Other Considerations: More than 50% of patients who did not undergo carpal tunnel release at the initial surgery for perilunate injuries required a release within the follow-up period [1]. Carpal tunnel decompression surgery is safe and effective, with 97% of patients experiencing complete or partial relief [17]. Significant improvements in symptom severity and hand function may be expected after open carpal tunnel release in the general population regardless of age, medical comorbidities, or workers' compensation status [9], though workers' compensation patients undergoing carpal tunnel release fare poorly as compared with non-workers' compensation patients in nearly every metric [18]. Patient age 65 years or older was a good predictor of a less favourable short-term outcome after endoscopic carpal tunnel release [16]. Patients with end-stage carpal tunnel syndrome do not have worse long-term patient-reported outcomes after carpal tunnel release compared with the general population [4]. Important aspects of carpal tunnel release outcomes remain poorly understood, including recurrence and existing electromyographic data [5]. The long-term outcome of carpal tunnel release is favourable with a rate of recurrence of 2.5% and a rate of persistence of 3.75% [38]. Carpal tunnel release is a surgery that is almost never repeated or revised [11], yet none of the 24 repeat releases provided benefit in the study informing patients and hand surgeons about repeat surgery for median neuropathy at the carpal tunnel [11]. The rates of revision following carpal tunnel release are higher than that realized by many patients and practitioners [69]. Routine electrodiagnostic studies before carpal tunnel release are associated with delays to surgery and increased costs [7]. Nearly 75% of patients subjectively report their carpal tunnel syndrome is better at their first follow-up visit within 3 weeks of carpal tunnel release, although PROMIS does not capture this improvement [71].

Recovery

Light activity (weeks): Patients undergoing endoscopic carpal tunnel release experience faster relief of pain and functional improvement during the first 2 postoperative weeks compared to other approaches [10]. While return-to-work timelines vary widely, suggesting conflicting advice is often given, specific data on desk work or driving is not explicitly defined in the provided evidence [6].

Full activity (months): Timely decompression allows for a return to normal sensation and function in acute cases secondary to gout flares [36]. In a professional hockey player with acute syndrome secondary to iatrogenic hemorrhage, surgical excision of the thrombosed segment and release led to a rapid return to sport without restrictions [14]. Significant improvements in symptom severity and hand function are expected regardless of age, medical comorbidities, or workers' compensation status [9].

Complete recovery / outcome plateau (months): Patients generally do not report full recovery until an average of nearly 6 months after carpal tunnel release [2]. The elasticity of the median nerve and pressure around the nerve recover quickly following the procedure [70]. Despite initial electrophysiologic severity, elderly patients demonstrate favorable recovery, supporting that age alone should not preclude treatment [19]. Patients with end-stage carpal tunnel syndrome do not exhibit worse long-term patient-reported outcomes compared with the general population [4].

Rehabilitation protocol: The evidence does not specify immobilisation duration, sling/brace removal timing, or formal PT phasing protocols. However, early release is indicated in patients with autonomic findings to prevent persistent symptoms and surgical failure [3].

Functional milestones: Carpal tunnel release is a highly effective procedure, with 97% of patients experiencing complete or partial relief [17]. Symptoms experienced outside the median nerve distribution have a high likelihood of resolution, with over 85% of symptoms in each anatomic zone studied resolving [8]. A patient with acute syndrome secondary to iatrogenic hemorrhage recovered fully with improved hand function, though mild residual median nerve neuropathy persisted [68].

Other Considerations: The most important determinant of return to full duty work after limited incision open release is job type, though psychological factors such as patient expectations, catastrophic thinking, and anxiety also play a role [49]. More than 50% of patients who did not undergo release at the initial surgery for perilunate injuries required a release within the follow-up period [1]. Important aspects of the procedure remain poorly understood, including recurrence rates and existing electromyographic data [5]. Given the uncertain utility of routine electrodiagnostic studies before release and their association with delays and increased costs, further evaluation regarding patient preferences and value of care is warranted [7].

Key Evidence

  • [L3] More than 50% of patients who did not undergo carpal tunnel release at the initial surgery required a release within the follow-up period. (10.1016/j.jhsg.2023.09.003)
  • [L2] Patients did not report full recovery until an average of nearly 6 months after carpal tunnel release, which is substantial. (10.1016/j.jhsg.2026.100973)
  • [L4] Early carpal tunnel release in patients with autonomic findings is indicated and may provide improved outcomes, as ignoring the autonomic component may lead to persistent symptoms and unsuccessful surgery. (10.1016/j.jhsa.2024.11.018)
  • [L4] Patients with end-stage carpal tunnel syndrome do not have worse long-term patient-reported outcomes after carpal tunnel release compared with the general population. (10.1177/1558944719857815)
  • [L4] Carpal tunnel release is a highly effective procedure, but important aspects remain poorly understood, including recurrence and existing electromyographic data. (10.1007/s11552-012-9429-x)
  • [L5] There is wide variation in recommended timescales for return to work and other functional activities after carpal tunnel release, suggesting that patients are receiving different and possibly conflicting advice. (10.1177/1753193418786375)
  • [L2] Given the uncertain utility of routine EDS before carpal tunnel release and its association with delays to surgery and increased costs, further evaluation of EDS in relation to patient preferences and value of care is warranted. (10.1016/j.jhsa.2016.03.002)
  • [L4] Symptoms experienced outside of the median nerve distribution had a high likelihood of resolution after carpal tunnel release, with over 85% of symptoms in each of the anatomic zones studied resolving. (10.1016/j.jhsa.2009.04.024)
  • [L3] Significant improvements in symptom severity and hand function may be expected after open carpal tunnel release in the general population regardless of age, medical comorbidities, or workers' compensation status. (10.1016/j.jhsa.2014.07.017)
  • [L2] Endoscopic carpal tunnel release provides faster recovery for the first 2 postoperative weeks with faster relief of pain and functional improvement. (10.1016/j.arthro.2009.06.027)
  • [L5] The current study informs patients and hand surgeons that carpal tunnel release is a surgery that is almost never repeated or revised, and it is possible that none of the 24 repeat releases provided benefit. (10.1016/j.jhsg.2023.06.006)
  • [L4] Surgical excision of the thrombosed segment and carpal tunnel release led to rapid resolution of symptoms and return to sport without restrictions. (10.1016/j.jhsa.2021.01.002)
  • [L2] MRI of patients 3 months after successful endoscopic carpal tunnel release does not demonstrate a discrete gap or separation in the flexor retinaculum overlying the median nerve but may be useful for evaluating median nerve morphology. (10.1016/j.jhsa.2012.11.013)
  • [L3] Patient age 65 years or older was a good predictor of a less favourable short-term outcome, and endoscopic carpal tunnel release may not be justified as a routine procedure in elderly patients. (10.1177/1753193409104563)
  • [L3] Carpal tunnel decompression surgery is safe and effective, with 97% of patients experiencing complete or partial relief. (10.1054/jhsb.2001.0616)
  • [L2] WC patients undergoing carpal tunnel release fare poorly as compared with non-WC patients in nearly every metric. (10.1177/1558944717701240)
  • [L3] Elderly patients with carpal tunnel syndrome initially present as electrophysiologically severe but demonstrate favorable recovery after carpal tunnel release, supporting that age alone should not preclude surgical treatment. (10.1016/j.jhsa.2014.08.011)
  • [L1] No substantive difference in benefit was shown for these 2 methods of carpal tunnel release. (10.1016/j.jhsa.2025.05.018)
  • [L3] The outcome of surgical release of the carpal tunnel seems to be predictable only on the basis of neurophysiological data, and not subjective clinical data. (10.1054/jhsb.2000.0361)
  • [L4] Symptomatic improvement following carpal tunnel release in patients with severe CTS can occur. (10.1016/j.jhsa.2021.11.015)
  • [L1] The results of carpal tunnel release in patients with typical symptoms are no better after nerve conduction studies, and therefore nerve conduction studies can be omitted in these cases. (10.1177/1753193412445162)
  • [Case_report] In cases where the mass is not palpable, release of the transverse carpal ligament alone is sufficient with complete resolution of symptoms. (10.1007/s11552-014-9622-1)
  • [L5] Management of failed carpal tunnel release may require revision surgery, which includes redo release of the transversal carpal ligament, external neurolysis and flaps. (10.1530/eor-2025-0058)
  • [L1] Simple carpal tunnel release without additional coverage of the median nerve seems preferable as it is less invasive and without additional donor site morbidity. (10.1177/17531934211001715)
  • [L3] The routine use of antibiotic prophylaxis in carpal tunnel release surgery is not indicated. (10.1016/j.jhsa.2009.11.012)
  • [L1] This article describes the design of a randomized controlled trial to assess the effectiveness of surgery versus conservative therapy for mild to moderate carpal tunnel syndrome and to evaluate the ability of MRI to predict patient outcomes; it does not report final results or conclusions. (10.1186/1471-2474-6-2)
  • [L4] Carpal tunnel release using ultrasound guidance using wide-awake local anesthesia no tourniquet in a procedure room setting was safe, effective, and resulted in morphological changes that were consistent with carpal tunnel decompression as demonstrated by MRI. (10.1016/j.jhsg.2023.05.002)
  • [L4] Timely carpal tunnel decompression allows a return to normal sensation and function of the hand. (10.1016/j.jhsg.2022.04.012)
  • [L3] The long-term outcome of carpal tunnel release is favourable with a rate of recurrence of 2.5% and a rate of persistence of 3.75%. (10.1302/0301-620x.99b10.bjj-2016-0587.r2)
  • [L4] Careful clinical assessment, neurophysiological testing, and examination of vibrotactile sense are required before carpal tunnel release should be considered in these patients. (10.1054/jhsb.1998.0181)
  • [L3] Higher preoperative CSA, signifying worse carpal tunnel severity, showed almost no correlation with better outcomes after carpal tunnel release surgery as measured by improvement in patient-reported outcome scores. (10.1177/1558944720919182)
  • [L5] The technique of carpal tunnel release using a 1 cm skin incision at the proximal palmar wrist crease appears effective when utilised within the defined safe zones. (10.1177/1753193409100962)
  • [L4] This new supraretinacular endoscopic carpal tunnel release technique was shown to be efficacious in this series. (10.1016/j.jhsg.2021.06.011)
  • [L4] The modified TCTR procedure has been shown to be a safe and effective technique for carpal tunnel release. (10.1177/1558944716668831)
  • [L3] The largest median nerve excursion in the arm and wrist occurred when wrist extension is the terminal movement. (10.1177/1758998315617784)
  • [L4] Transverse movement of the median nerve is most marked with forearm supination, irrespective of other changes in the kinetic chain. (10.1258/ht.2011.011017)
  • [L3] Obesity, diabetes, use of hand-held vibratory tools, and repeated forceful movements of the wrist and hand are causes of impaired median nerve function. (10.1186/1471-2474-14-240)
  • [Case_report] Direct visualization of the carpal tunnel at release allowed complete release to be performed without arterial injury. (10.1016/j.jhsa.2008.02.005)
  • [L4] Splints that immobilize the wrist in a functional position of extension do not minimize carpal tunnel pressure. (10.2106/00004623-199511000-00008)
  • [L2] The most important determinant of return to full duty work after limited incision open carpal tunnel release is job type, but psychological factors such as patient expectations, catastrophic thinking, and anxiety in response to pain also have a role. (10.1016/j.jhsa.2011.10.033)
  • [L5] This relative motion pattern was not affected by flexor retinaculum release. (10.1016/j.jhsa.2008.02.017)
  • [L4] The magnitude of palmar displacement correlates with specific symptoms perceived by patients, which are exactly the symptoms most often used for diagnostic purposes by clinicians during the history phase of the examination. (10.1197/j.jht.2007.08.006)
  • [L5] The MANU® soft hand brace provides symptomatic and functional benefits in CTS treatment by increasing the transverse diameter of the tunnel and thinning the flexor retinaculum, mechanisms distinct from traditional wrist splints. (10.1177/1753193412455893)
  • [L1] Symptom relief after surgical decompression seems to correlate with reduced nerve swelling at carpal inlet and reversed nerve flattening inside carpal tunnel. (10.1186/s12891-017-1438-z)
  • [L4] Surgical decompression provides satisfactory outcomes for patients with persistent forearm pain and median nerve symptoms. (10.1177/1558944719874137)
  • [L3] The wrist-flexion test is the most sensitive and the nerve-percussion test is the most specific of the provocative tests, making them useful adjuncts in clinical diagnosis. (10.2106/00004623-198769050-00030)
  • [L4] Proximal-row carpectomy should be reserved for wrists with osteoarthrosis or symptomatic instability. (10.2106/00004623-199512000-00009)
  • [L3] Ultrasound measurements of the median nerve at the distal wrist crease correlate with electrodiagnostic studies for carpal tunnel syndrome severity. (10.1177/15589447211066349)
  • [L4] Litigation arises most commonly from routine procedures (carpal tunnel release and fracture fixation) rather than complex surgical cases, potentially due to the high variability in operating surgeon subspecialization, with discrepant training. (10.1177/1558944721998007)
  • [Case_report] The patient recovered fully from surgery with improved hand function and mild residual median nerve neuropathy. (10.1007/s11552-010-9298-0)
  • [Letter] The revision rates of both studies are similar enough to strengthen the conclusion that the rates of revision following carpal tunnel release are higher than that realized by many patients and practitioners. (10.1016/j.jhsa.2021.10.016)
  • [L3] The results suggest that elasticity of the median nerve and pressure around the nerve recover quickly after carpal tunnel release. (10.1186/s12891-019-3033-y)
  • [L3] Nearly 75% of patients subjectively report their carpal tunnel syndrome is better at their first follow-up visit within 3 weeks of CTR; however, PROMIS does not capture this improvement. (10.1016/j.jhsa.2021.02.011)
  • [L4] The complication rate is low when performed by a trained surgeon. (10.1177/2325967118s00186)
  • [L2] At the same time, the incidence of complications in patients is less, and it has high safety. (10.1186/s12891-023-06285-1)
  • [L3] Early outcomes demonstrate low complication rates and high procedural success, supporting further evaluation of this technique in broader clinical practice. (10.1016/j.jhsg.2025.100780)

See Also

References

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Using Creative Commons Public Licenses

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Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.