For years, the conversation around lumbar spine surgery has centered on a binary choice: fuse the spine or replace the disc. Joshua Prickett, DO, a neurological and spine surgeon with LewisGale Physicians in Salem, Va., part of HCA Healthcare’s Roanoke-area network, thinks that framing leaves out a growing third option — and he’s betting on it.
Dr. Prickett recently became the first provider in Roanoke to offer the TOPS System, a posterior motion-preserving device made by Premia Spine that the FDA approved in June 2023 with a “superior to fusion” label claim — the first time the agency has granted that designation to a lumbar implant.
“Fusion is not a physiologic solution,” Dr. Prickett said. “I know that both as an osteopathic physician — life is motion — as well as a spine surgeon, having fused lots of patients and then seeing the problems: adjacent segment degeneration, accelerated need for further surgery, difficulty of revision surgeries. If you do that in a young patient, they’re set up for a lifetime of problems and chronic pain issues.”
Filling the gap disc replacement can’t reach
Lumbar disc replacement has existed as a motion-preserving alternative to fusion for years, but Dr. Prickett said it’s rarely a practical option below the L5-S1 level. Reaching L4-L5 or L3-L4 anteriorly typically requires navigating around the aortic and iliac vessel bifurcation — a maneuver few approach surgeons are comfortable making.
“So really, disc replacement at those levels really isn’t an option. It’s really only at L5-S1.”
That’s the gap Dr. Prickett said TOPS is built to fill. The device is indicated for patients with severe spinal stenosis and facet disease — typically accompanied by a grade 1 spondylolisthesis — at L3-L4, L4-L5 or L5-S1. Surgically, the procedure starts out identical to a fusion: a full decompression, bilateral facetectomies and four standard pedicle screws. But instead of removing the disc and locking the segment in place, the TOPS device attaches to the screw heads and allows continued flexion and extension — functioning, in effect, as a facet replacement.
“Previously, you’d be taking out a healthy disc and just taking out huge chunks of a healthy disc to stabilize, because you’ve destabilized them and you’re afraid of the slip progressing,” Dr. Prickett said. “This is an alternative. I do the full decompression, bilateral facetectomies — the nerves are hanging in the breeze — and then you leave the healthy disc there to continue to move and absorb forces, as long as it’s not horribly degenerated already.”
The ideal candidate, he said, tends to be younger, with severe symptomatic stenosis and a disc that still has preserved height. Patients with a fully collapsed disc or bridging osteophytes are still better served by fusion.
Dr. Prickett has performed two TOPS procedures so far, with a third scheduled. “I’m not going to say I’m some national expert,” he said. “But if you’re looking for somebody who’s done two of these, there’s not going to be many people around the country, honestly.”
Reimbursement is the biggest barrier to adoption
Despite the technology’s promise, Dr. Prickett said uptake has been slow. Reimbursement, not surgical complexity, is the main reason.
TOPS currently carries an unlisted Category III CPT code and is assigned zero RVUs. Surgeons can bill for the decompression and osteotomy components of the procedure and for instrumentation, but not for a fusion code — the component that typically drives the bulk of reimbursement for a comparable procedure.
“If I was [paid] on straight productivity, I would basically get paid nothing for the procedure,” Dr. Prickett said. “You’ve got to make this argument to the payers as to how much they’re going to pay you, whether you’re on a collections model or in a private capacity.”
Dr. Prickett said he’s in a position to prioritize the procedure regardless of its reimbursement.
“I’m able to do what I think is right for the patient and not have to necessarily take into account the payer piece of it, which not everybody has that advantage,” he said.
Getting the device approved for use at his HCA facility took roughly a year, working through institutional and regulatory channels, a process he said likely explains why TOPS isn’t yet more widely available across other systems in the Roanoke area.
Where it fits in five to 10 years
Dr. Prickett expects motion-preservation technology, including TOPS, to keep gaining ground the way cervical disc replacement has — slowly, but steadily. He noted that other major device makers are likely developing competing facet-replacement systems, and that Premia Spine, a relatively small company, could eventually be acquired as the category matures.
“I think it’s hopefully going to ramp up,” he said. “As time goes on, I hope five years from now we’re in a better place as far as the number of motion-preserving operations versus the number of fusions. Unfortunately, the financial pressure is going to continue for a lot of practices to fuse.”
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