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Check Your Six

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DANVILLE In military jargon, “watch my six” means “watch my back.” Certainly it’s a term that Robert Knetsche, MD, an orthopedic and spine surgeon, is familiar with after 22 years in the U.S. Army. But for him it has a double-meaning, given his current position as the medical director of the Spine Center of Central Kentucky in Danville.

The practice, which opened in August of 2008, offers complete spine care and pain management. Knetsche averages 300 surgeries per year and approximately 800 patients are seen at the Spine Center each month.

“This is really a mom and pop spine surgery center because my wife is the practice manager, and she manages it with the help of our great staff,” Knetsche says. “Our practice is a multi-specialty practice for spine care. I perform spine surgery and do my own injections and other minimally invasive procedures before surgery. We have pain management as well as electro-diagnostics to determine neurologic problems. We do our own bracing; we have procedure suites; and we do our own urinalysis for drugs and other diagnostics.”

It’s a comprehensive array of patient care and services that enables the Spine Center of Central Kentucky to treat a wide patient population with expertise and the most up-to-date procedures. Primarily, Knetsche’s typical patients are adults from 25 to 95 suffering from degenerative conditions.

Knetsche received his medical degree from the Medical University of South Carolina, Charleston in 1994 after he had served four years as a tank commander in the U.S. Army. He then embarked on an 18-year residency, specialty, fellowship, and military service journey. He interned in general surgery at the Dwight D. Eisenhower Army Medical Center; took residency in orthopedic surgery at William Beaumont Army Medical Center in El Paso, Texas, and completed a fellowship in spine surgery at University of Colorado Health Sciences Center in Denver.

In 2003 Knetsche took the position of chief of Spine and Neurologic Surgery Service at Landstuhl Regional Medical Center, Landstuhl, Germany, which was responsible for spine surgical care for all combat theatre casualties from Iraq and Afghanistan, a catchment area of 400,000 people, including all military and government personnel stationed in Europe. He was deployed into combat as chief of Orthopaedic Surgery with the 14th Combat Support Hospital, in Bagram, Afghanistan performing over 400 orthopedic and spine surgeries on soldiers and civilians.

Knetsche’s Army experience prepared him well for treating a wide range of patients and conditions. “We would have 60 people who were blown up show up at our door, every single day,” Knetsche says. “It was a very grueling experience. As you can imagine in Afghanistan, you’re going to see a lot of people with gunshot wounds or dismembered or who are injured from some kind of crazy bomb mechanisms.

“The Army was a lot of work and a lot of brutality, but it was one of the most wonderful training grounds for a surgeon because I got to do things that very few people have done and that hopefully we won’t have to do again. I feel like the Army was a wonderful time. It let me serve my country. I loved doing that.”

Knetsche now specializes in complex spine surgery, such as scoliosis surgeries that can take 10 to 12 hours, and in minimally invasive spine surgeries involving several very small incisions that reduce the levels of blood loss and pain while doing the same work of a traditional open surgery.

Surgery is the last resort for Knetsche, as he reports that only seven percent of the Spine Center patients undergo surgery and has witnessed positive outcomes with non-surgical procedures, including injections, pain management, and physical therapy. Roughly half of the Spine Center’s patients report lumbar back pain with radiation down the leg, indicative of a disc herniation or spinal stenosis. Back pain from facet joint arthritis and neck pain with radiation down the arms are other common patient complaints.

Not All Cases Are Routine

“Occasionally we see spinal tumors,” Knetsche says. “We see multiple myeloma, a cancer syndrome that is fairly unusual but occurs when plasma cells mutate and develop into plasmacytoma. Another presentation we see fairly uncommonly is cervical spondylotic myelopathy, degeneration of the cervical spine to the extent that the spinal cord is being damaged.”

Rare or common, a universal component of each of these back and neurological problems is pain. To ensure that patients at the Spine Center of Central Kentucky are treated as effectively for their pain as for their actual conditions, Knetsche recently welcomed Ellen Flinchum, MD, to the team.

“We wanted to have a specialist in medical management of pain as well as a physiatrist who could help with the physical therapy part,” Knetsche said. “Dr. Flinchum brings both things to us.”

“I tell my patients there are three parts to you getting better,” says Knetsche. “One third is me picking the right surgery for you and doing the right surgery, and it turning out well. One third is your attitude and your compliance with the program… and the final piece is physical therapy. If you don’t have the proper physical therapy, you’ve only done two-thirds of the equation, and in most places 67 percent is a failing grade.”

Flinchum echoes Knetsche’s opinion on a patient’s mind-set and therapy. “A big challenge is getting my patients to buy into the idea that exercise really works,” says Flinchum, whose treatment plans typically include physical exam and psychological evaluation, physical therapy, home exercise programs, injections, braces, and medicine. “It’s not just injections and medicine,” she states.

No Looking Back

As in any medical field, advanced technology, detailed research, and new ideas are bringing about significant change. Knetsche gives his viewpoint on four of the most prominent in spine surgery:

Endoscopic Spine surgery: “One of the advances I’m most excited about is endoscopic spine surgery, where we make incisions of two or three millimeters and use scopes. I do some endoscopic surgeries, and I really see spine surgery moving there in the next 10 to 20 years.

Pain management using spinal cord stimulators: “We put devices on the spinal cord that block pain and let the patients control their pain with a remote control that can turn it up or down. And the stimulators are getting smaller. I envision one day they’ll be the size of a postage stamp.”

Motion preserving technology: “Artificial disc technology in the lower back and the neck solves the problem of nerve damage and nerve compression. With this technology, we can leave about 70 percent of the normal motion of the involved spinal segment. I think it’s going to revolutionize spine surgery.”

Minimally Invasive Laminectomy: “The minimally invasive or endoscopic laminectomy will be the standard in the future for lumbar spinal stenosis. As the population ages, spinal stenosis is becoming more and more prevalent.

A Path for Success

The Spine Center of Central Kentucky recently received a Gold Seal awarded from the Joint Commission for all Spine Surgery including Cervical Surgery, Lumbar Fusion and Laminectomy. “Getting these awards means that we have good outcomes, we have very low complication rates, and that our patients are happy,” says Knetsche.