What is the treatment for Saturday night palsy (radial neuropathy)?

Saturday Night Palsy (Radial Neuropathy) Treatment

Initial Management: Observation is Standard

Saturday night palsy is a self-limiting condition that typically resolves spontaneously within 6 months without intervention, making observation the primary treatment approach. 1, 2

The condition results from compression of the radial nerve against the spiral groove of the humerus, most commonly after prolonged pressure during sleep (often alcohol-related), causing a neuropraxia that universally recovers without surgical intervention. 1, 2

Treatment Algorithm

Acute Phase (First 72 Hours)

• No pharmacological intervention is indicated - Unlike Bell's palsy where corticosteroids are beneficial, there is no evidence supporting steroid use for radial nerve compression injuries 3
• Immediate removal of compressive forces - Ensure no ongoing pressure on the affected nerve 1
• Baseline electrodiagnostic testing - Consider EMG/NCS to document severity and rule out axonal loss, though this is not mandatory for typical presentations 1, 4

Supportive Care (Weeks 1-24)

• Wrist splinting in neutral position - Prevents contractures and maintains hand function during recovery 2
• Passive range of motion exercises - Maintain joint mobility to prevent stiffness, though evidence for active physical therapy is limited 5
• Occupational therapy referral - For adaptive strategies during recovery period 2

Monitoring Timeline

• Reassess at 4-6 weeks - Most patients show early signs of recovery by this point 1
• Repeat electrodiagnostic testing at 3 months if no improvement - Documents progression and identifies patients needing surgical evaluation 1
• Surgical exploration indicated only if:
  • No clinical improvement by 3-4 months 1
  • Progressive worsening of symptoms 1
  • High-resolution ultrasound or MRI reveals structural lesion (neuroma, nerve torsion) 4

Red Flags Requiring Immediate Surgical Evaluation

• Severe axonal loss on initial EMG - Suggests more than simple compression 1
• Palpable mass along radial nerve course - May indicate neuroma formation 1
• Nerve torsion visualized on high-resolution ultrasound - Rare but requires early surgical intervention 4
• History of preceding weeks of pain/numbness - Suggests chronic process with acute decompensation rather than simple compression 1

Surgical Intervention (Rare)

When structural pathology is identified, surgical options include:

• Neuroma excision with end-to-end nerve repair - For documented neuromas causing compression 1
• Neurolysis - For nerve torsion or constriction 4

Complete recovery typically occurs within 9 months post-operatively when surgery is required. 1

Critical Pitfalls to Avoid

• Do not prescribe corticosteroids - No evidence supports their use in compressive radial neuropathy, unlike facial nerve palsy 3
• Do not delay electrodiagnostic testing beyond 3 months - Patients without improvement need documentation to guide surgical decision-making 1
• Do not miss atypical presentations - Preceding weeks of pain/numbness suggest neuroma rather than simple compression and warrant earlier imaging 1
• Do not confuse with toxic/metabolic causes - Bilateral presentation, absence of compression history, or systemic symptoms suggest lead toxicity or porphyria rather than Saturday night palsy 2

Expected Recovery

• Universal recovery by 6 months for typical compression injuries 2
• Earlier recovery (weeks to months) for mild neuropraxia 1
• 9-month recovery when surgical intervention is required 1