Saturday Night Palsy

What is a Saturday Night Palsy?

Saturday Night Palsy

Saturday night palsy, a compressive neuropathy of the radial nerve, is caused by an object or surface pressing directly onto the upper medial arm or axilla for an extended length of time.

The posterior segment of the brachial nerve plexus gives rise to the C5 to T1 nerve roots, which make up the radial nerve. Before wrapping down the medial aspect of the humerus and resting in a spiral groove, it runs deep to the axillary artery and then passes inferiorly to the teres minor. A nerve palsy caused by compression of the radial nerve affects motor and sensory function.

"Saturday night palsy" is the name given to the relationship between Saturday night partying and the ensuing drowsiness which can result in an extended period of immobility and nerve compression. This compression leads to Radial nerve palsy that impairs sensory and motor function. Additionally, Saturday night palsy has also been referred to as "honeymoon palsy".

Causes of Saturday Night Palsy

It is possible that drunken individuals become incapable of reflexively readjusting their sleeping positions. A person falling asleep with their arm hanging over a chair or other hard surface is the classic scenario, which compresses the axilla. Similarly, one has "honeymoon palsy" if they fall asleep on someone else's arm and then compress their nerve.

It is crucial to keep in mind that Saturday night palsy can arise from abnormal positioning or use of the limbs that can compress by a similar mechanism, even though these are the more well-known presentations. Examples of this include using crutches incorrectly, wearing tight apparel or accessories, bood cuff, and more.

Epidemiology

It has been estimated that the prevalence of Saturday night palsy is 1.42 per 100,000 women and 2.97 per 100,000 men.

It is the fourth most prevalent mononeuropathy in the United States and is highly prevalent worldwide.

Because of the age-neutral mechanism of the injury, it has been seen in patients of all ages.

History

Patients often describe how excessive alcohol consumption precedes abnormal sleeping positions, which in turn causes their symptoms.

Patients may describe another mechanism by which the upper medial arm or axilla would have been unnaturally compressed if alcohol consumption is absent.

Patients may not recognize this information as the trigger event, so they may withhold it unless asked.

Symptoms of Saturday Night Palsy

It may take a few days after the first injury for symptoms to appear, which could cause a delayed presentation.

Patients may report experiencing pain, tingling, numbness, weakness, or any combination of these symptoms.

A physical examination may show a typical wrist drop due to the preservation of flexor muscle function supplied by other nerves in the hand and arm and the loss of extensor muscle function controlled by the radial nerve branches. This prevents extension of the fingers and wrist at the metacarpophalangeal joints. It becomes challenging to open the hand and grasp objects when the thumb's ability to extend is also lost.

Because the ulnar nerve controls the proximal and distal interphalangeal joints, patients can still extend their fingers at this level. This is something that healthcare providers should be aware of.

Patients may also lose the radial nerve innervation that controls the triceps reflex.

The posterior forearm, posterior hand, and posterolateral aspect of the lateral three and a half digits are frequently affected by sensory deficiencies that first affect the posterior or lateral upper arm.

Diagnosis

Physical Examination

Since Saturday night palsy is primarily diagnosed and evaluated clinically, many patients with a clear medical history and physical examination might not require further diagnostic testing.

However, additional diagnostic techniques might be helpful in evaluating possible side effects and causes in addition to estimating prognosis.

Electromyography and nerve conduction studies can localize lesions anatomically and help separate peripheral neuropathies, brachial plexopathies, and cervical radiculopathies.

A low-risk, low-cost technique that can help visualize the nerve and identify areas of disruption or damage is ultrasound. Additionally, in certain cases, it can be very helpful in expediting early surgical intervention by detecting obvious disruption of the nerve.

In addition to identifying the affected muscles, magnetic resonance imaging (MRI) can provide fine detail that ultrasound is unable to provide. In addition, it can detect tissue masses and screen for neurological conditions and other disease processes.

Bony tumors, fractures, and dislocations that may be the cause of nerve damage can all be found with X-ray imaging.

Treatment of Saturday Night Palsy

Physical rehabilitation is the main focus of Saturday night palsy; a soft wrist splint keeps the wrist extended during treatment. However, during rehabilitation, it is essential to permit passive range of motion of the affected extremity, which can be achieved with a dynamic splint.

The previous measures can be supplemented with supportive care, which includes steroid injections, systemic corticosteroids, NSAIDs, and rest.

One of the latest therapeutic approaches is localized injections administered via ultrasound to speed up healing. Surgery is only recommended in cases of severe damage to the radial nerve or when an intrinsic process, such as a mass, bone, spur, or cyst, is the cause of the compression.

Physiotherapy Treatment

• Strenthening Exercises of Wrist Muscles
• Exercises for numbness and tingling in the hands.
• TENS, or transcutaneous nerve stimulation, is used to treat neuropathic pain locally.
• Electrical Stimulation (SF or IG) as per RD Test

Differential Diagnosis

One common cause of radial nerve injury is a traumatic fracture of the humerus. Severe blunt trauma, crush injuries, puncture wounds, and stab wounds are other frequent causes.

In patients with physical exam findings consistent with the possibility of a radial nerve injury, anterior glenohumeral shoulder dislocation should be taken into consideration. This condition is rare.

Iatrogenic injury can arise from any surgery or injection involving anatomy related to the radial nerve's path.

Internal compression from cysts, masses, tumors, muscle hypertrophy, and fibrinous tissue can result in nerve palsy.

Neurologic diseases or repetitive overuse can cause isolated palsies. Acute ischemic strokes have also been reported in some patients who initially presented with isolated symptoms.

Prognosis

The extent of the injury, which is established by the force and duration of compression, determines the prognosis for Saturday night palsy.

Neuropraxia, a temporary conduction block that prevents nerve degeneration, is caused by mild damage. A partial recovery is nearly always the outcome of this kind of injury.

Axonotmesis, which is characterized by Wallerian degeneration and axonal damage with partial or delayed recovery, is caused by moderate damage.

Neurotmesis, characterized by complete axon degradation and Schwann cell death, is the result of severe injury and has a low chance of full recovery. Almost invariably, patients with this degree of injury will need surgery.

Only using electromyography to assess the extent of damage can be challenging, and predicting the prognosis early on can be challenging as well.

Even mild cases require at least 2-4 months, and often longer, to recover from.

Complications

Ignoring to take into account a wide range of possible diagnoses may result in issues, like failing to identify a serious illness or disease. Since the course of treatment for radial nerve deficits varies widely from case to case, it is imperative to identify the underlying cause.

The primary complication of true compressive Saturday night palsy is that it may not heal, which might require further investigation through surgery.

Following that, a number of surgical options are available, such as nerve grafting, nerve transfers, tendon or muscle transfers, and other methods. Similar to the majority of surgical operations, a range of complications pertaining to intraoperative problems and post-operative infections are possible.

Moreover, long-term disability can be difficult to achieve, and partial recovery is typical in these situations. Even though consistent, long-term physical therapy is required to restore some functionality, it can be extremely demanding.

Neglecting to take into account a wide range of possible diagnoses may result in issues, like failing to identify a serious illness or disease. Since the course of treatment for radial nerve deficits varies widely from case to case, it is essential to identify the underlying cause.

The primary complication of true compressive Saturday night palsy is that it may not heal, which might require further investigation through surgery.

Following that, a number of surgical options are available, such as nerve grafting, nerve transfers, tendon or muscle transfers, and other methods. Similar to the majority of surgical operations, a range of complications related to intraoperative problems and post-operative infections are possible.

Moreover, long-term disability can be difficult to achieve, and partial recovery is typical in these situations. Even though consistent, long-term physical therapy is required to restore some functionality, it can be very taxing.

Multidisciplinary Team (MDT) Approach

For the treatment of patients with Saturday night palsy, a team-based approach works best.

A patient with Saturday night palsy should be evaluated thoroughly by the initial healthcare provider to rule out other possible causes of a neurological deficit that has just started.

To schedule an electromyogram and other diagnostic or therapeutic procedures, a neurologist should also be appropriately referred.

Physical therapy needs to be suggested as well.

Instruction on supportive measures needs to be given to patients.

In cases where early surgical intervention is considered necessary, a specific timeline should be established to facilitate appropriate surgical follow-up.

Patients should, in any case, be given reasonable expectations about the recovery process, which may not be as easy or convenient as they had intended.