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BACKGROUND: Most randomized trials have shown similar results with endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR); however, there are studies suggesting less postoperative pain, faster improvement in grip and pinch strength, and earlier return to work with the endoscopic technique. Previously presented work of this study from our institution has shown no difference in these measures, however an initial increase in patient satisfaction with the ECTR was reported. The goal of this study was to prospectively examine subjective and functional outcomes, satisfaction, and complications after both ECTR and OCTR in the opposite hands of the same patient, serving as their own control. METHODS: This was a prospective, randomized study in which patients diagnosed with bilateral carpal tunnel syndrome underwent surgical release. The first carpal tunnel release was performed on the most symptomatic hand—as determined by the patient. The initial operative approach utilized was randomly assigned and then patients obtained the contralateral surgery with the other technique approximately one month later. Demographic data were obtained, and functional outcomes were recorded preoperatively and post-operatively, including pain score, 2-point discrimination, Semmes-Weinstein monofilament testing, thenar strength testing APB, and overall grip strength. The carpal tunnel syndrome-functional status score and carpal tunnel syndrome-symptoms severity score were recorded before surgery and at 2, 4, 8, 12, and 24 weeks postoperatively. Overall satisfaction with each technique was recorded at the conclusion of the study. RESULTS: A total of 30 patients have completed the final visit testing. There were no differences in 2-point discrimination, Semmes-Weinstein monofilament testing, thenar strength, or overall grip strength at any of the postoperative time points. Carpal tunnel syndrome-symptom severity score and carpal tunnel syndrome-functional status scores were not significantly different between groups at any of the evaluations. Subjectively, 24/30 patients did state they preferred the ECTR, mostly citing less pain as their primary reason. Pain scores between the two groups, however did not objectively show a significant difference at any of the postoperative time points. Differences in overall satisfaction, where patients recorded a number from 0 to 100, also lost significance at the end of the study. There were no complications with either technique. CONCLUSIONS: This study did not find a benefit to the use of one technique over the other for patients with carpal tunnel syndrome requiring surgical release. Both the OCTR and ECTR are well tolerated with no differences in functional outcomes, symptom severity, or complications. An initial trend towards greater satisfaction with ECTR, at the conclusion of the study, did not remain as there was no significant difference found in the comparison of final patient satisfaction scores between the OCTR and ECTR techniques. With the added cost and equipment associated with ECTR and conversely the ability to perform OCTR with patients wide-awake and outside of the operating room, this study demonstrates that post-operative outcomes may not be the main factor utilized in choice of technique for carpal tunnel release.