"Saturday night palsy" - other side of the coin

Ano: 2023 | Volume: 61 | Número: Não se aplica

Autores: Vitorino Modesto dos Santos, Taciana Arruda Modesto Sugai

Palavras-chave: COVID-19, NEUROPHYSIOLOGY, SATURDAY NIGHT PALSY, VACCINE

Resumo Inglês:

“Saturday night palsy” (SNP) is a scarcely described entity, that classically involves compression of the radial nerve during deep sleep over the arm following alcohol or drug abuse, anesthetic act, local trauma, as well as vaccine or COVID-19 infection.1-8 The term SNP is due to the common association of Saturday night carousing, followed by a prolonged immobilization during which the nerve compression can take place.1 “Honeymoon palsy” is another ancient designation, referring to the case of an individual falling asleep over the arm of another and causing a compression of the radial nerve.1 Traumas caused by falls, cold weapons or firearms, and traffic accidents are included; besides, compressive clothing, usage of crutches or prolonged blood pressure cuff, and the prone positioning and lateral decubitus of COVID-19 patients can cause SNP.1-8 Radial nerve torsion, fascicular entwinement, saturnism, or beriberi can cause wrist drop.2 The wrist drop of mononeuritis multiplex is related to immunological, paraneoplastic, or infectious mechanisms resulting in damage to the axon, with abnormal nerve conduction.2 Symptoms may appear several days after the original factor, including numbness, weakness, tingling, and pain; the typical wrist drop results from the loss of extensor muscle function by the radial nerve, while the function of flexor muscles are preserved; the loss of ability to extend the thumb impairs to open the hand and grasping objects.1-3,6 Typical manifestations are inability to extend the elbow, wrist, hand, and fingers; with outcomes depending on causative factors, but more often there is complete restitution.1-8 This condition is prevalent in the whole world, affecting 2.97 per 100,000 men and 1.42 per 100,000 women, and being the fourth most common mononeuropathy in the USA.1,2 The nerve lesions may include: neuropraxia (preserved nerve continuity, with transient dysfunction; axonotmesis (interruption of the axon and of the myelin, with preserved perineurium and epineurium; or the neurotmesis (the complete nerve disconnection).1,4,7,8 Clinical hypothesis of SNP may be confirmed by electromyography with a slowing conduction in motor and sensory fibers, which usually persists during up to eight weeks, and the better management results are related to an interprofessional team approach.1-8 Imaging studies by X-ray, ultrasound, and magnetic resonance imaging contribute to identify areas of nerve damage or disruption, and to hasten early surgical intervention.1-4 The treatment depends on the specific cause, and main focus is physical rehabilitation; and even a mild case often resolves at the earliest in 2-4 months, and often much longer.1,2 Near 70% of SNP are described to be resolved only with the conservative management.2 In the scenery of SAR-COV-2 pandemic, peripheral nerve injuries related to severe COVID-19, and radial neuropathy after COVID-19 mRNA vaccine are cited.3-6,8 The intensive care unit acquired weakness has been a complication of severe COVID-19, and is clinically manifested by myopathy, polyneuropathy, or a combination of them.3 The prone positioning is indicated for 12 to 16 h daily in mechanically ventilated adults with COVID-19 and refractory hypoxemia, but can increase peripheral nerve traumas.3 Franz CK et al. (2022) described 66 peripheral nerve injuries (PNI) in 34 patients with severe COVID-19 combined with a re-analysis of 117 nerve injuries in 58 reported cases.3 By order of frequency, the nerves ulnar, fibular, sciatic, median, and brachial plexus were the most vulnerable 2 • Brasília Med. VOLUME 61; ANO 2023: 2-3 CARTA sites to mechanical loading, and should merit priority for protection.3 These sites are well-known to be vulnerable to compression and/or traction and the PNIs contribute to long term disabilities between 14.5 to 16% survivors of severe COVID-19.3 The authors also emphasized the role of a wearable, wireless pressure sensor to provide real time monitoring at the elbow, because the ulnar neuropathy at the elbow is the single most common nerve compression site in the hospitalized survivors of severe COVID-19.3 Li NY et al. (2022) did a multicenter retrospective study about cases of COVID-19 with acute respiratory distress syndrome (ARDS), and requiring the mechanical ventilation.5