Nine hundred fourty one patients with carpal tunnel syndrome (CTS) were randomized to receive initial surgical decompression (n=470) or initial corticosteroid injection (n=471); further interventions were allowed in both arms as needed. The primary outcome was recovery at 18 months (CTS-6 <8). Secondary outcomes included time to recovery, serial CTS-6, upper-limb function (QuickDASH), palmar pain and pain-related limitation, global perception of recovery, satisfaction, additional treatments, and adverse events. Outcomes were assessed through 18 months at prespecified intervals. Overall, the results of the study revealed that 61% in the surgery group versus 45% in the injection group recovered, and median time to recovery was shorter with surgery (9.0 vs 18.0 months). Patients starting with surgery also had better 18-month QuickDASH, global recovery, and satisfaction, while palmar pain was more frequent early after surgery but comparable by later follow-up. These findings suggest that initial surgery confers earlier and higher long-term recovery than starting with injection.