Hristo Shipkov

Background: Cervical dystonia (CD) is a chronic neurological disorder characterized by involuntary neck muscle contractions, leading to abnormal head postures, pain, and functional impairment. Botulinum toxin type A (BoNT-A) remains the treatment of choice, but its efficacy is highly dependent on injection accuracy. Various techniques, including palpation-guided, ultrasound-guided, and electromyography-guided (EMG), have been developed to optimize delivery, each with distinct advantages and limitations. Methods: A systematic search of PubMed and Scopus was conducted up until 30 December 2024, using defined keywords related to BoNT-A, CD, and injection techniques. Studies were included if they reported clinical outcomes of BoNT-A injection methods in adult CD patients. Data on efficacy, safety, accuracy, and muscle targeting were extracted and synthesized. Results: Seven studies comprising 239 patients were included: two randomized controlled trials, one retrospective study, one cohort study, one systematic review, one literature review, and one cadaveric study. The most common CD subtype was torticollis/torticaput (49.79%). Frequently targeted muscles included the trapezius (56.9%), levator scapulae (51.7%), and splenius capitis (48.3%). Ultrasound guidance consistently demonstrated superior injection accuracy and reduced adverse effects due to real-time anatomical visualization. EMG-guided techniques showed advantages in identifying dystonic muscles, especially when anatomy was unclear. In contrast, palpation-guided injections were less accurate and suitable only for superficial muscles. Dosing varied by product, with mean doses of 117–118 units for onabotulinumtoxinA and incobotulinumtoxinA, and 405 units for abobotulinumtoxinA. Adverse events were generally mild, including local discomfort, dysphagia, and transient muscle weakness. Conclusions: Ultrasound- and EMG-guided injections enhance the precision, safety, and efficacy of BoNT-A therapy for CD compared to anatomy-guided techniques. While ultrasound guidance improves anatomical accuracy, EMG remains valuable for functionally identifying dystonic muscles. Integration of both may offer optimal outcomes. However, further high-quality, standardized trials are needed to definitively establish best practices.

Dear Sirs, We read with great interest the article of Shinohara et al . “Benefits of using omental pedicle flap over muscle flap for closure of open window thoracotomy “in which they compare the muscle and omentum flaps (1). The authors compare the omentum pedicle flap with the loco-regional muscle flaps for the treatment of empyema. They conclude that the omentum is superior in reducing local recurrence and shortening postoperative hospital stay after open-window thoracostomy (OWT) closure with mortality, morbidity and success rates remaining the same in both groups (1).