Motion-Preserving Lumbar Surgery
An FDA-approved alternative to lumbar fusion — decompression with mechanical facet replacement that keeps your spine moving.
TOPS — Total Posterior Spine System — is an implantable mechanical device that replaces the facet joints at a single lumbar level after decompression surgery. It received FDA approval in 2023 for the treatment of lumbar spinal stenosis with grade I degenerative spondylolisthesis, making it the first posterior motion-preservation device to clear this regulatory bar in the United States.
The device attaches to the posterior elements of two adjacent vertebrae and functions as a mechanical joint — allowing controlled flexion, extension, lateral bending, and rotation while preventing the excessive motion that causes pain and instability. The result is a spine that is decompressed and stable and still moving.
The TOPS System is the only FDA-approved posterior motion-preservation device for lumbar stenosis with spondylolisthesis. Prior to this approval, patients with instability at a stenotic level had one surgical option: fusion. TOPS provides a second option that preserves segmental motion and avoids bone graft healing.
When a spinal segment is fused, all motion at that level is permanently eliminated. The vertebrae above and below must then compensate — absorbing forces the fused segment once shared. Over time, this accelerated mechanical load can cause the adjacent discs and facet joints to degenerate faster than they otherwise would, a condition called adjacent segment disease (ASD).
TOPS addresses this by preserving controlled motion at the treated level, distributing mechanical forces more naturally across the lumbar spine. There is also no bone graft required — eliminating donor site pain, healing time, and the small risk of non-union (pseudarthrosis) that comes with any fusion procedure.
The FDA approval specifies a precise patient profile. You are likely a candidate if you have:
Appropriate for TOPS
Not Appropriate for TOPS
Not sure if you qualify? The evaluation is straightforward — MRI, standing X-rays, and a clinical exam. Many patients who've been told they "need fusion" haven't yet been assessed for motion-preserving alternatives.
Physical therapy, NSAIDs, epidural steroid injections, and activity modification. Surgery is considered only after these measures have been adequately tried.
MRI to confirm single-level stenosis with spondylolisthesis. Standing dynamic X-rays to assess slip grade and segmental mobility. Bone density evaluation if osteoporosis is suspected. Review of prior imaging and treatment history.
A posterior midline incision exposes the affected level. Laminectomy and facetectomy decompress the neural elements. The TOPS device is then anchored to the pedicles and posterior elements of the two vertebrae, providing immediate mechanical stability and restoring the function of the removed facet joints.
Most patients go home the same day or after an overnight stay. Walking begins immediately. There is no fusion-healing protocol — the device is mechanically stable from day one.
Physical therapy typically begins two to four weeks post-operatively. Programs focus on core strengthening, posture, and progressive range-of-motion restoration rather than the protective restrictions typical after fusion.
The pivotal FDA trial data, along with subsequent European experience, shows outcomes comparable to fusion for pain relief and functional improvement — with the added benefit of preserved motion and faster recovery.
Individual outcomes vary. Results depend on age, baseline function, imaging findings, and overall health. The data cited are from the FDA pivotal IDE trial; real-world results may differ.
The TOPS (Total Posterior Spine) System is an FDA-approved mechanical device that replaces the facet joints at one lumbar level after decompression surgery. Unlike fusion, which permanently joins two vertebrae and eliminates motion at that segment, TOPS preserves controlled range of motion — flexion, extension, rotation, and lateral bending — within a safe mechanical boundary. This means you get the same pain relief from decompression while keeping movement at the treated level.
TOPS is FDA-approved for adults with single-level lumbar spinal stenosis between L2 and L5, accompanied by grade I degenerative spondylolisthesis (up to 25% vertebral slip), who have failed at least six months of conservative treatment. You must have intact bone quality at the target level and not have significant osteoporosis, severe disc collapse, or multi-level disease. Your surgeon will review your MRI and standing X-rays to confirm you meet the criteria.
Clinical data supports the motion-preservation claim. In the pivotal FDA trial, patients treated with TOPS maintained measurable segmental range of motion at two years, while fusion patients showed near-zero motion at the treated level. The device constrains but does not eliminate movement — it functions as a mechanical facet joint replacement. Whether preserved motion translates into long-term functional superiority over fusion continues to be studied, but the mechanical evidence is clear.
Recovery is generally faster than fusion because there is no bone graft healing required. Most patients return to desk work within one to two weeks, light physical activity by four to six weeks, and full activity by three months. Walking is encouraged from day one. Physical therapy typically begins two to four weeks post-operatively and focuses on core strengthening and motion restoration rather than the protective restrictions used after fusion.
Preserving motion at the treated level reduces the mechanical stress transferred to adjacent discs and facet joints compared with fusion. Whether TOPS provides the same degree of adjacent-level protection as anterior lumbar disc replacement is an open research question, but biomechanical studies show lower adjacent-level loading with TOPS than with fusion. Long-term five- and ten-year clinical follow-up data will clarify this further as the device accumulates real-world experience.
TOPS received FDA approval in 2023, and insurance coverage is still evolving. Medicare and many private insurers are actively reviewing coverage policies. Some patients may need prior authorization or a peer-to-peer review between your surgeon and the insurer's medical director. Our team will verify your specific benefits before scheduling and can assist with the authorization process. Financing options are available for patients without coverage.
If the TOPS device requires removal due to implant issues or inadequate pain relief, the level can be converted to a standard lumbar fusion (TLIF or PLIF). The posterior approach used for TOPS is the same approach used for posterior fusion, so revision surgery follows a familiar pathway. Device failure rates in the pivotal trial were low, and the conversion-to-fusion option provides a reliable safety net.
Already Told You Need Fusion?
Many patients with single-level lumbar stenosis and spondylolisthesis qualify for TOPS — but most haven't been assessed. A second opinion takes one visit and can change your surgical path entirely.
Single-level stenosis with instability doesn't automatically mean fusion. One consultation can clarify your options.
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