A Prospective Evaluation of Duplex Ultrasound for Thoracic Outlet Syndrome in High-Performance Musicians Playing Bowed String Instruments

Thoracic outlet syndrome (TOS) is a neurovascular condition involving the upper extremity, which is known to occur in individuals who perform chronic repetitive upper extremity activities. We prospectively evaluate the incidence of TOS in high-performance musicians who played bowed string musicians. Sixty-four high-performance string instrument musicians from orchestras and professional musical bands were included in the study. Fifty-two healthy volunteers formed an age-matched control group. Bilateral upper extremity duplex scanning for subclavian vessel compression was performed in all subjects. Provocative maneuvers including Elevated Arm Stress Test (EAST) and Upper Limb Tension Test (ULTT) were performed. Abnormal ultrasound finding is defined by greater than 50% subclavian vessel compression with arm abduction, diminished venous waveforms, or arterial photoplethysmography (PPG) tracing with arm abduction. Bowed string instruments performed by musicians in our study included violin (41%), viola (33%), and cello (27%). Positive EAST or ULTT test in the musician group and control group were 44%, and 3%, respectively (p = 0.03). Abnormal ultrasound scan with vascular compression was detected in 69% of musicians, in contrast to 15% of control subjects (p = 0.03). TOS is a common phenomenon among high-performance bowed string instrumentalists. Musicians who perform bowed string instruments should be aware of this condition and its associated musculoskeletal symptoms.

Long-term outcomes of staged basilic vein transposition for hemodialysis access in children.

INTRODUCTION: Children requiring long-term hemodialysis often face significant challenges due to their young age and small-vessel caliber for arteriovenous (AV) access creation. In this study, we report our experience of staged basilic vein transposition (BVT) in pediatric patients. METHODS: All patients undergoing staged BVT at a tertiary care pediatric hospital from 2003 to 2015 were reviewed. Indications for staged BVT included inadequate cephalic conduit or failed AV fistula using cephalic vein. Pertinent clinical variables were analyzed to determine treatment outcomes. RESULTS: Forty-two children (24 males, 57%) underwent 46 staged BVT during the study period. Median age was 12.8 ± 4.8 years (range 3-18). The mean weight was 47 ± 5.1 kg (range, 13-126 kg), with four children (10%) weighing ≤20 kg. Mean operative times for initial brachiobasilic AV fistula and staged BVT were 39 ± 12 minutes and 66 ± 17 minutes, respectively. Mean follow-up period was 5.4 ± 1.8 years. Functional maturation was achieved in 93% of BVTs. Early fistula thrombosis within 30 days following BVT occurred in four patients (10%). Late BVT thrombosis occurred in 13 patients (31%). Primary patency rates at 2 years and 4 years were 78% and 72%, respectively. Secondary patency rates at 2 years and 4 years were 86% and 82%, respectively. CONCLUSIONS: Staged BVT is a durable and reliable autologous hemodialysis access in children who do not have adequate cephalic venous conduit.

Cancer Seeding Risk from an Epidural Blood Patch in Patients with Leukemia or Lymphoma.

Introduction: Lumber punctures are a common procedure in patients with cancer. However, a potential complication of a lumbar puncture is a postdural puncture headache. The risk of neoplastic seeding to the central nervous system has led to concern over performing epidural blood patches (EBPs) for the treatment of postdural puncture headaches in patients with cancer. The goal of this retrospective study was to evaluate cancer seeding in the central nervous system in patients diagnosed with leukemia or lymphoma. Methods: Institutional electronic records were queried over a 13-year period from 2000 to 2013 for patients with leukemia and/or lymphoma and who received at least one EBP. Demographic and procedural data, cancer treatments, and mortality were all examined. Patient records were reviewed for evidence of new-onset neoplastic central nervous system seeding after an epidural blood patch. Results: A total of 80 patients were identified for review. Eighteen patients had a diagnosis of leukemia, and 62 had lymphoma. Following an EBP, none of the patients experienced new cancer or cancer seeding in the central nervous system following an epidural blood patch at a median follow-up of 3.74 years. Discussion: Though the risks of EBP in the cancer patient population have been hypothesized, no previous studies have assessed the risk of seeding cancer to the central nervous system. Based on our results, an epidural blood patch bears low risk of cancer seeding when used to treat postdural puncture headache that is unresponsive to conservative treatments.

Thoracic outlet syndrome affecting high-performance musicians playing bowed string instruments.

Thoracic outlet syndrome, a condition due to neurovascular compression in the upper shoulder region, can be caused by chronic repetitive activity of the upper extremities. Studies have linked upper extremity musculoskeletal disorders to high-performance musicians who play bowed string instruments such as the violin or viola. We report herein a case series of five elite musicians, including three violinists and two violaists, who developed neurogenic thoracic outlet syndrome following years of intense practice. Successful surgical treatment including first rib resection, scalenectomy, and brachial plexus neurolysis was performed in all patients. All patients were able to resume their musical career following surgical treatment. Our report represents the first description of thoracic outlet syndrome in high-performance bowed string instrumentalists. Clinicians should be aware of thoracic outlet syndrome as a differential diagnosis when treating string instrumentalists with upper extremity musculoskeletal ailments.