Wide Awake vs Sedation in Carpal Tunnel Surgery: A Mixed-Methods Study on Patient Decision Making and Pain Perceptions

Background: Wide-awake local anesthesia no tourniquet (WALANT) and operating room–based anesthesia with sedation are both commonly used for carpal tunnel release (CTR), with similar clinical outcomes and satisfaction. However, the psychological and experiential factors that influence patients’ anesthesia choice remain poorly characterized. This study aimed to evaluate cognitive, emotional, and experiential drivers of anesthesia selection for CTR using a mixed-methods approach. Methods: 30 patients undergoing primary CTR were enrolled: 15 selected WALANT and 15 selected operating room-based anesthesia with sedation. Participants completed validated preoperative measures assessing pain severity, pain catastrophizing, pain sensitivity, pain self-efficacy, and PROMIS-29 domains. Semi-structured interviews were conducted preoperatively and postoperatively to explore expectations, decision-making processes, and reflections on the surgical experience. Quantitative outcomes were compared between groups, and qualitative data were analyzed using constant comparative methodology. Results: There were no significant differences between groups in demographics, PROMIS-29 domains, or pain-related behavior domains. Qualitative analysis revealed distinct decision-making patterns. Patients choosing WALANT emphasized autonomy and desire for control and awareness during surgery, while patients selecting sedation described avoidance-oriented motivations and preference for relinquishing control. Locus of control behaviors were identified as a central differentiating construct between groups, independent of measured pain-related factors. Conclusions: Anesthesia choice for CTR may be driven by patient preferences related to control, awareness, and agency rather than by differences in pain perception or anxiety. Incorporating concepts of locus of control into preoperative counseling may improve alignment between anesthesia strategy and patient values.