Adjunctive Techniques
Moderate evidence supports that there is no benefit to routine inclusion of the following adjunctive techniques: epineurotomy, neurolysis, flexor tenosynovectomy, and lengthening/reconstruction of the flexor retinaculum (transverse carpal ligament).

Rationale
Epineurotomy: There are two high quality studies (Leinberry 1997and Crnkovic 2012) and one moderate quality study (Blair 1996) that evaluated carpal tunnel release alone versus the addition of epineurotomy of the median nerve. The Leinberry (1997) evaluated patients at 11.8 months after surgery. There was no significant difference found in clinical evaluation (Boston Questionnaire, APB strength, Phalen’s, Tinel’s, or two-point discrimination) or in symptom recurrence. Crnkovic (2012) studied nerve volume measured by MRI as an index of nerve recovery. Patients were evaluated at 3 and 6 months after surgery and no significant differences was noted at either time point. There were also no differences found for the symptoms of pain between the groups. Blair (1996) found no differences in post-operative two-point discrimination, pain, or ability to complete activities of daily living at a minimum of two years following surgery. There were also no differences electrodiagnostic parameters.
 
Neurolysis: There was one high quality study (Mackinnon 1991) and one moderate quality study (Lowry 1988) which evaluated the addition of neurolysis of the median nerve to a standard carpal tunnel release. The Mackinnon study focused on internal neurolysis and found no differences in thenar atrophy, muscle strength, pressure threshold, vibration threshold and static two-point discrimination at 12 months after surgery. No difference was noted in pinch or grip strength. The Lowry study evaluated the NCS findings at 3 months after surgery and did not find a difference in nerve conduction velocity or distal motor and sensory latency. Neither study found a difference in symptom relief or recurrence.
 
Flexor Tenosynovectomy: There was one high quality study (Shum 2002) evaluating flexor tenosynovectomy as an adjunct to carpal tunnel release. There was no difference in surgical site infection, scar sensitivity, wrist motion, finger motion, or Boston Carpal Tunnel Questionnaire at 12 months following surgery.
 
Flexor Retinaculum Reconstruction/Lengthening: There was one high quality study (Dias 2004) that evaluated flexor retinaculum lengthening/reconstruction. Six months following surgery there were no differences in grip strength, Jebsen Taylor score, Phalen test, pinch strength, Boston Carpal Tunnel Questionnaire score or symptom recurrence. 
 

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