What is the treatment for a young to middle-aged adult with a history of alcohol abuse diagnosed with Saturday night palsy (radial neuropathy)?

Saturday Night Palsy (Radial Neuropathy) Treatment

Immediate Management

For a young to middle-aged adult with alcohol-related Saturday night palsy, observation with supportive care is the primary treatment, as spontaneous recovery occurs in the vast majority of cases within 6 months. 1

Treatment Algorithm

Acute Phase (First 72 Hours)

• No specific pharmacologic intervention is required for uncomplicated compressive radial neuropathy 1
• Address alcohol withdrawal syndrome if present, using benzodiazepines (lorazepam or oxazepam preferred in those with potential hepatic dysfunction from chronic alcohol use) 2
• Provide wrist splint in neutral or slight extension position to prevent contractures and facilitate hand function during recovery 1

Corticosteroid Consideration

• Consider a 2-month course of corticosteroids only if there is evidence of severe axonal injury or conduction block on electrodiagnostic testing 1
• This recommendation is based on limited case report evidence showing benefit in severe compression cases 1
• The evidence for steroids in compressive radial neuropathy is substantially weaker than for Bell's palsy, where high-quality RCTs support their use 2

Diagnostic Workup

Obtain electrodiagnostic studies (EMG/NCS) within 2-3 weeks to:

• Confirm radial nerve involvement and localize the lesion to the spiral groove 1, 3
• Distinguish neuropraxia (best prognosis) from axonotmesis or neurotmesis 1
• Identify conduction block, which indicates compression as the mechanism 1
• Rule out alternative diagnoses such as lead toxicity (plumbism) in patients with occupational exposure 4

Monitoring and Follow-Up

• Expect spontaneous recovery within 6 months for typical compressive neuropathy 1
• Serial clinical examinations every 4-6 weeks to document progressive improvement in wrist extension, finger extension, and thumb extension 1, 4
• If no improvement occurs by 3 months or if weakness progresses, obtain MRI of the upper arm to exclude structural lesions (neuroma, mass) 3

Surgical Intervention

• Reserve surgical exploration for cases with no recovery after 6 months or evidence of structural lesion on imaging 3
• One case report documented successful neuroma excision with end-to-end nerve repair in a patient with acute-on-chronic presentation 3

Critical Pitfalls to Avoid

• Do not assume all wrist drop is benign compression neuropathy - bilateral involvement, progressive weakness, or associated systemic symptoms warrant investigation for lead toxicity, acute porphyria, or other systemic causes 4
• Screen for rhabdomyolysis and acute kidney injury in patients with prolonged immobilization and alcohol intoxication, as severe compression can progress to crush syndrome with potentially fatal consequences 5
• Check creatine kinase, serum creatinine, and urine myoglobin if there is concern for muscle breakdown 5
• Address underlying alcohol dependence - consider referral for alcohol treatment programs, as recurrence risk is high without addressing the root cause 2

Alcohol Dependence Management

• Assess severity of alcohol use disorder and provide appropriate counseling 2
• Acamprosate is safe in patients without cirrhosis and may prevent relapse 2
• Avoid naltrexone and disulfiram due to potential hepatotoxicity, especially if there is underlying alcoholic liver disease 2
• Baclofen shows promise for maintaining abstinence and has been studied in patients with liver disease 2