• Spine

I read the results of the Cost Effectiveness and Efficacy of Kyphoplasty and Vertebroplasty Trial (CEEP) by Evans et al published in JNIS as well as Dr Beall’s response with interest and vigor.1 ,2 Evans et al should be lauded for further expanding the body of high quality evidence related to percutaneous vertebral augmentation. They provided valid, although sometimes overstated, scientific points regarding the functional equivalence of balloon kyphoplasty and vertebroplasty. Dr Beall raised some valid, at times overstated, criticisms regarding the CEEP study. There were also some aspects of the study that were, surprisingly to me, not questioned by Dr Beall.

As a first step, let me describe my clinical perspectives on the two procedures. I perform both balloon kyphoplasty and vertebroplasty and do not harbor strong beliefs that one procedure works better than the other under all or most circumstances. Referring physician and patient preference, vertebral size and level, patient discomfort and anxiety, patient comorbidities, and anesthesia risk factors all drive my decision as to which procedure I will perform on a given patient.

Dr Beall reasonably questioned whether the statistical power of the study to evaluate the hypothesis that pain and functional status measured by the Roland Morris Disability Questionnaire was adequate. While I agree with Dr Beall that the study was underpowered to detect a small difference in outcome, the authors acknowledged this limitation. The actual data show only very minimal and insignificant differences at all time points. If a much larger population had been sampled—as Dr Beall suggests was necessary—the data collected suggest that any potential statistically significant difference favoring one procedure would only show a very small …