Are you a Candidate for TOPS?
Clinical Perspectives · Lumbar Spine · Naples FL
Are you a candidate for
TOPS?
TOPS is an FDA Breakthrough Device that treats lumbar spinal stenosis and Grade I spondylolisthesis without fusion — but the disc has to be healthy. Some patients asking about TOPS are actually candidates for an even smaller, no-implant operation. Which path fits depends on where your pain is coming from.
What TOPS is —
and what problem it solves
The standard surgical answer to lumbar spinal stenosis with Grade I spondylolisthesis has been decompression plus fusion — remove the bone and tissue compressing the nerve, then lock the vertebral segment with pedicle screws and rods to stabilise the slip. Fusion works. But it eliminates motion at the treated level permanently, transfers mechanical load to the adjacent levels, and carries the recovery timeline of any instrumented fusion.
TOPS — the Total Posterior Spine System, developed by Premia Spine — received FDA Breakthrough Device designation and completed its FDA-pivotal IDE trial with a result that is difficult to ignore: 77% overall success for TOPS versus 24% for fusion at 2 years. The TOPS implant is placed after decompression through the same posterior approach used for fusion. Pedicle screws are placed. But instead of connecting rods that lock the segment, the TOPS implant connects those screws with a mechanical device that controls and limits motion without eliminating it. The spondylolisthesis is stabilised. The nerve is decompressed. Motion is preserved.
The result is a procedure that addresses the same anatomical problem as fusion — stenosis with instability — while preserving functional motion at the treated level and avoiding the adjacent segment stress that accumulated fusion constructs generate over time.
For the full clinical overview and to download the official Premia Spine patient brochure, see the TOPS patient pamphlet in our patient library.
The single most important candidacy criterion —
the disc must be healthy
TOPS stabilises the posterior column. It does not address the disc. That distinction is the most important candidacy criterion in the entire evaluation.
If the disc at the operative level is significantly degenerated — collapsed, desiccated, with endplate changes — the disc itself is a pain generator. TOPS decompresses the nerve and stabilises the posterior elements, but it does not remove or replace the disc. A patient with a severely degenerated disc who undergoes TOPS will have the nerve decompression they need but will still have a degenerating disc contributing to their axial back pain. In those patients, an interbody fusion construct — which replaces the disc space with a cage and bone graft — addresses both the instability and the disc.
What makes someone a candidate for TOPS —
the full criteria
Lumbar spinal stenosis at L3–L4 or L4–L5The FDA-approved indication for TOPS is lumbar stenosis at one level, L3–L4 or L4–L5. Stenosis produces the leg symptoms — neurogenic claudication, radiculopathy — that TOPS addresses through decompression.
Grade I degenerative spondylolisthesis at the operative levelThe spondylolisthesis produces the instability component — the vertebral body above has slipped forward on the one below, generating both stenosis and dynamic instability. Grade I (up to 25% slip) is the target. Higher-grade spondylolisthesis generally requires a more extensive fusion construct.
A healthy, tall disc at the operative levelThis is the essential requirement. The disc must be preserved — adequate height, maintained hydration on MRI, no significant endplate pathology. A degenerated disc at the operative level shifts the recommendation to a fusion approach that addresses the disc space directly.
Both back pain and leg painTOPS is the right operation when the patient has both components: leg symptoms from nerve compression, and back pain from the instability of the spondylolisthesis. The TOPS implant addresses both by decompressing the nerve and stabilising the unstable segment. Patients with predominantly leg symptoms and minimal back pain may be candidates for a smaller operation entirely — see below.
Failure of conservative managementAs with any elective spine procedure, TOPS follows an adequate trial of non-operative treatment: physical therapy, anti-inflammatory medication, and epidural steroid injections where appropriate. Surgery is considered when conservative measures have been exhausted and the symptoms significantly limit function or quality of life.
The question many patients don’t think to ask —
do you actually need an implant at all?
I see this regularly. A patient arrives having read about TOPS and asks whether they are a candidate. They have lumbar stenosis, they have a spondylolisthesis on their MRI, and they have concluded that they need TOPS — or fusion. What they have not considered is a third option that involves no implant at all.
The critical question is: where is the pain coming from?
Spondylolisthesis on an MRI does not mean the spondylolisthesis is causing pain. Many patients have a Grade I slip that is stable — it has been there for years, it does not move dynamically on flexion-extension films, and it is not generating back pain. What is generating their symptoms is the stenosis: the narrowing that is compressing the nerve and producing leg pain, neurogenic claudication, or radiculopathy.
If the spondylolisthesis is stable on dynamic films and the patient’s complaint is predominantly leg pain without significant axial back pain, MIS laminectomy decompresses the nerve without touching the posterior instrumentation or the disc. Recovery is faster than any implant procedure. There is no hardware to integrate. The operation is limited to what is actually causing the symptoms.
TOPS is the right answer when both components are present: leg symptoms from stenosis and back pain from the instability of the spondylolisthesis. When only the leg component is driving the presentation, the operation should match the problem.
Three operations, three different anatomical problems —
which one fits yours
Stenosis + Grade I spondylolisthesis + healthy disc + both back and leg pain. Decompression and posterior stabilisation without fusion. Motion preserved.
Stenosis + stable spondylolisthesis + predominantly leg pain, minimal back pain. No hardware, no fusion. Smallest footprint. Fastest recovery.
Stenosis + spondylolisthesis + degenerated disc, high-grade slip, dynamic instability, or multi-level disease. Addresses the disc space directly. Appropriate when the disc itself is a pain generator or structural integrity requires it.
The comparison at a glance
| Factor | TOPS System | MIS Laminectomy | Lumbar Fusion (TLIF / PLIF / ALIF / LLIF / XLIF) |
|---|---|---|---|
| Decompression | ✓ Yes | ✓ Yes | ✓ Yes |
| Stabilises spondylolisthesis | ✓ Yes — motion-preserving | × No (stable slip only) | ✓ Yes — permanently |
| Segmental motion | ✓ Preserved & controlled | ✓ Preserved | × Eliminated permanently |
| Addresses disc | × No — disc must be healthy | × No | ✓ Yes — disc replaced with cage |
| Implant / hardware | TOPS implant + pedicle screws | None | Cage + pedicle screws + rods |
| Best for | Back + leg pain, healthy disc, Grade I spondy | Leg pain only, stable spondy or no spondy | Degenerated disc, high-grade spondy, instability |
| FDA trial outcome (2 yr) | 77% overall success | — | 24% overall success (TOPS IDE comparator) |
What the evaluation involves
1. MRI of the lumbar spine. The disc at the operative level is assessed on T2-weighted sagittal and axial sequences. Signal intensity, disc height, and endplate morphology determine whether the disc is a preserved, non-pain-generating structure (TOPS candidate) or a degenerated disc contributing to axial pain (fusion candidate).
2. Flexion-extension lateral X-rays under load. Dynamic films determine whether the spondylolisthesis is mobile — increasing in slip angle from flexion to extension — or stable. A stable slip that does not move on dynamic films in a patient with predominantly leg symptoms supports MIS laminectomy. A dynamic slip generating back pain supports TOPS. A high-grade or highly mobile slip supports fusion.
3. Pain pattern clarification. The history and examination establish where the pain is coming from. Back-dominant pain with leg symptoms = instability + stenosis = TOPS territory. Leg-dominant pain with a stable slip = stenosis = MIS laminectomy territory. Disc-mediated axial pain with a degenerated disc = fusion territory. This distinction is clinical as much as radiographic, and it drives the operation selection as much as the imaging does.
Find out if TOPS — or something smaller — fits your anatomy.
A second opinion consultation will determine whether your anatomy and pain pattern support TOPS, MIS laminectomy, or fusion — and exactly why. Dr. Katsevman reviews all imaging personally. Telemedicine available statewide. Upload your MRI and standing X-rays before the consultation so the appointment goes directly to your anatomy and your options.
Submit your lumbar MRI and flexion-extension X-rays via the secure imaging portal. Dr. Katsevman reviews all imaging in advance so the consultation focuses on your anatomy and your options — not on reading films cold.
References — PubMed-verified
- Becker S, Tuschel A, Ogon M, et al. TOPS IDE trial: total posterior arthroplasty versus fusion for lumbar spinal stenosis with spondylolisthesis — 2-year outcomes. Spine. Referenced in Premia Spine FDA submission data; see Premia Spine clinical data.
