One hundred twenty-three patients with Carpal Tunnel Syndrome (CTS) were randomized (unbalanced 3:1) to endoscopic carpal tunnel release (ECTR) (n=91) or open carpal tunnel release (OCTR)(n=32). The primary outcomes were CTS Symptom Severity Scale scores and nerve/vascular complications assessed by a blinded evaluator. Secondary outcomes included McGill Pain Questionnaire scores, grip and pinch strength, sensory threshold, time to return to work, and long-term satisfaction/re-operation. Outcomes were measured at baseline, 1, 6, and 12 weeks, with long-term contact at a mean of 3.2 years. Overall, the results revealed no between-group differences in primary outcomes at any time and no nerve/vascular complications in either group; ECTR showed transient advantages in grip and pain at 1 and 6 weeks that dissipated by 12 weeks. In conclusion, ECTR and OCTR yielded similar benefits, with ECTR’s early recovery not translating into earlier return to work and accompanied by a higher re-operation rate (5% vs 0%).