There is insufficient evidence to make a recommendation for or against the cost effectiveness of ■ medical treatment alone vs ■ vertebral augmentation vs ■ thermal ablation, radiofrequency ablation, or cryoablation with or without augmentation vs ■ operative fusion/fixation Grade of Recommendation: I

In a prospective randomized control trial study, Fritzell et al1 analyzed and compared the cost-effectiveness between BKP and standard medical treatment in patients with acute/subacute VCF due to osteoporosis. The authors concluded that “it was not possible to demonstrate that BKP was cost-effective compared with standard medical treatment in patients treated for an acute/subacute vertebral fracture due to osteoporosis. However, sensitivity analysis indicated a certain degree of uncertainty, which needs to be considered.” This paper provides Level II evidence that based upon a willingness to pay of US $50,000 cost/QALY gained, BKP was not shown to be cost effective, however the sensitivity analyses suggest significant uncertainty. In a retrospective comparative study, Svedbom et al2 estimated the cost effectiveness of BKP to NSM and PVP in patients who were hospitalized with acute osteoporotic vertebral compression fractures. The authors concluded that “BKP may be a cost-effective strategy for the treatment of patients hospitalized with acute OVCF in the UK compared to NSM and PVP.” The work group downgraded this potential Level I paper due to poor estimates. This paper provides Level II evidence that the BKP may be cost-effective compared to PVP and NMS for hospitalized patients with OCVF, but significant variability exists. In a retrospective comparative study, Takahashi et al3 evaluated the cost effectiveness of balloon kyphoplasty of patients with acute/subacute osteoporotic vertebral fractures in Japan. The authors concluded that “this study demonstrated that BKP is a cost-effective treatment option for OVF in Japan. However, the effect might be blunted in patients aged > 80 years.” The work group downgraded this potential Level II paper due to analysis based on modeling, and based on limited alternatives and costs. Multiway sensitivity analyses were not performed. This paper provides Level III evidence that BKP is cost-effective in this modeling study, particularly for people under 80 years in Japan. References 1. Fritzell P, Ohlin A, Borgström F. Cost-effectiveness of balloon kyphoplasty versus standard medical treatment in patients with osteoporotic vertebral compression fracture: a Swedish multicenter randomized controlled trial with 2-year follow-up. Spine (Phila Pa 1976). 2011;36(26):2243-2251. doi:10.1097/BRS.0b013e3182322d0f 2. Svedbom A, Alvares L, Cooper C, Marsh D, Ström O. Balloon kyphoplasty compared to vertebroplasty and nonsurgical management in patients hospitalised with acute osteoporotic vertebral compression fracture: a UK cost-effectiveness analysis. Osteoporos Int. 2013;24(1):355-367. doi:10.1007/s00198-012-2102-y 3. Takahashi S, Hoshino M, Yasuda H, et al. Cost-effectiveness of Balloon Kyphoplasty for Patients With Acute/Subacute Osteoporotic Vertebral Fractures in the Super-Aging Japanese Society. Spine (Phila Pa 1976). 2019;44(5):E298-E305. doi:10.1097/BRS.0000000000002829