Treatment of Saturday Night Palsy (Radial Neuropathy)
Saturday night palsy is treated conservatively with supportive care—no pharmacological intervention is indicated, as steroids have no proven benefit for compressive radial neuropathy. 1, 2
Initial Management Approach
The cornerstone of treatment is watchful waiting with supportive measures, as most cases resolve spontaneously within 6 months. 3
What NOT to Do
- Do not prescribe corticosteroids—unlike Bell's palsy where steroids are highly effective, there is no evidence supporting their use in radial nerve compression injuries 1, 2
- Avoid pharmacological interventions entirely for the nerve injury itself 1
Supportive Care Measures
- Implement passive range of motion exercises to maintain joint mobility and prevent stiffness in the wrist, fingers, and thumb 1
- Begin these exercises immediately to prevent contractures during the recovery period 1
- Note that evidence for active physical therapy is limited, but passive ROM is recommended 1
Addressing the Underlying Cause
If alcohol intoxication was the precipitating factor, address alcohol use disorder aggressively, as recurrence risk is high without treating the root cause. 2
Alcohol Withdrawal Management
- Use benzodiazepines (lorazepam or oxazepam) for alcohol withdrawal syndrome, particularly if hepatic dysfunction from chronic use is suspected 2
- Assess severity of alcohol use disorder and provide counseling 2
Relapse Prevention
- Consider acamprosate to prevent relapse 2
- Avoid naltrexone and disulfiram due to potential hepatotoxicity, especially with underlying alcoholic liver disease 2
- Baclofen may be a promising alternative for maintaining abstinence 2
When to Consider Surgical Intervention
Most cases do not require surgery, but specific red flags warrant urgent evaluation and potential surgical exploration:
Indications for Advanced Imaging and Possible Surgery
- No recovery by 3 months warrants electrodiagnostic testing and consideration of high-resolution nerve ultrasound 4
- Progressive weakness beyond expected timeline suggests alternative diagnosis (neuroma, nerve torsion) 5, 4
- Severe axonal loss on EMG with conductive defect 5
Rare Surgical Scenarios
- Nerve torsion visualized on high-resolution ultrasound requires early surgical intervention with favorable outcomes 4
- Neuroma formation (rare in "spontaneous" cases) requires surgical excision and nerve repair, with complete recovery achievable in 9 months 5
Critical Pitfall to Avoid
Beware of severe, prolonged compression leading to Crush Syndrome—skeletal muscle injury from protracted immobilization causes rhabdomyolysis and potentially fatal acute renal failure. 6 This is not just a simple neuropraxia but a medical emergency requiring:
- Immediate hospitalization
- Aggressive IV hydration
- Monitoring of creatine kinase levels and renal function
- Treatment of hyperkalemia and metabolic acidosis 6
Expected Recovery Timeline
Universal recovery occurs by 6 months in typical compressive neuropraxia cases with the characteristic pattern of wrist, thumb, and finger drop. 3 If recovery has not begun by 3 months, reassess for alternative diagnoses including neuroma, nerve torsion, or metabolic causes (lead toxicity, acute porphyrias). 5, 3, 4