Diagnostic Assessment — Cervical Spine - Central Canal Stenosis
Example 1 of 1 · fictitious patient (Veteran AQ)
Diagnostic Assessment
Cervical Spine - Central Canal Stenosis
BOP Code: 12 of 2023 (Cervical Spondylosis)
RH Code: 11 of 2023 (Cervical Spondylosis)
ADF History
Veteran AQ, date of birth 19 April 1965, Australian Army from 14 February 1983 (Combat Engineer), Royal Australian Air Force from January 1994 (Pilot, fast jet), Australian Army from January 2005 (Pilot, Army aviation, helicopters), medically discharged 30 June 2016. Operational service: Somalia, 12 January 1993 to 21 May 1993 (warlike); Middle East (Iraq), 10 February 2003 to 20 May 2003 (warlike); Afghanistan, 02 March 2006 to 15 July 2006 and 11 February 2008 to 01 July 2008 (warlike), including captivity from 14 June 2008 to 01 July 2008.
Occupational History
Combat engineers build, demolish and repair in the field, lifting and carrying heavy and bulky loads such as cement bags, sandbags, steel pickets and water containers, often on the shoulder or head where equipment is unavailable. Fast jet pilots are exposed to repeated high sustained acceleration with the head turned, and helicopter pilots to prolonged flexed and rotated neck postures under heavy helmets and night-vision goggles.
Aviators on operations also face hard landings, being shot down, injury from fragments and, rarely, capture by hostile forces. Each of these roles places sustained mechanical load on the cervical discs and facet joints.
History
Veteran AQ, a combat engineer who became an RAAF fast jet pilot and then an Army helicopter pilot, was shot down, wounded and held as a prisoner for 17 days on warlike service in Afghanistan in 2008, sustaining cervical fractures, a penetrating disc injury, septic facet arthritis and reactive arthritis. He developed cervical spondylosis with central canal stenosis at C5/6 on 11 March 2013, which worsened to severe stenosis with myelopathy in October 2017.
Timeline
- 14 Jun 2008 — On warlike service in Afghanistan the veteran's helicopter was forced down by ground fire and a fragment entered the left side of his neck. He was captured and held by insurgents for 17 days, during which he was beaten about the neck with rifle butts, held in stress positions and contracted dysentery. He was rescued on 01 July 2008. "captured, beaten, dysentery"
- 12 Aug 2008 — CT at the role 3 hospital on 01 July 2008 had shown a right C5/6 intra-articular facet fracture, a 25 per cent wedge fracture of C6, a fragment track through the C5/6 disc and C6/7 ligamentous instability. MRI on 03 July 2008 showed a traumatic C5/6 disc prolapse. Anterior discectomy and fusion at C6/7 was performed on 15 July 2008. On 12 August 2008 septic arthritis of the right C5/6 facet joint was aspirated, growing Staphylococcus aureus, and intravenous antibiotics began. "facet fracture, C6/7 ACDF"
- 22 Sep 2008 — A rheumatologist diagnosed reactive arthritis after Shigella dysentery, with inflammatory neck and low back pain, HLA-B27 positivity, sacroiliitis and C5/6 facet enhancement on MRI. Sulfasalazine was commenced. BMI was 31.8, and he had been obese at every aircrew medical since 2002. "reactive arthritis, HLA-B27 positive"
- 14 Nov 2012 — Paget's disease of C6 and C7 was diagnosed on bone scan. Acromegaly had been diagnosed on 06 June 2011 and treated by transsphenoidal surgery, and crowned dens calcium pyrophosphate deposition was confirmed in March 2012. CT of the cervical spine on 01 February 2011 had shown healed fractures, a solid C6/7 fusion and a grade 1 C5/6 anterolisthesis, but no osteophytes or disc space narrowing at C5/6. "no spondylotic change C5/6"
- 18 Mar 2013 — The veteran presented with one week of new neck pain and stiffness, occipital headaches and bilateral hand paraesthesia since 11 March 2013. Examination showed reduced neck extension and rotation, brisk upper limb reflexes and a positive Hoffmann sign on the right. MRI was arranged. "neck stiffness, bilateral hand paraesthesia"
- 09 Apr 2013 — MRI showed C5/6 disc degeneration with a broad disc-osteophyte complex, facet and ligamentum flavum hypertrophy and moderate central canal stenosis, AP diameter 8.5 mm, without cord signal change. A spinal surgeon diagnosed cervical spondylosis with central canal stenosis. Surgical review was not available for 14 months. "moderate central stenosis, 8.5 mm"
- 04 Oct 2017 — Repeat MRI for worsening hand clumsiness, gait unsteadiness and falls showed severe C5/6 central canal stenosis with an AP diameter of 6 mm and T2 signal change in the cord. Modified Japanese Orthopaedic Association score was 12. Posterior decompression and fusion from C4 to C6 was performed on 21 November 2017. "severe stenosis, cord signal change"
Symptoms
At onset the veteran had neck pain and stiffness, occipital headaches and intermittent tingling in both hands, with reduced neck extension. Symptoms were worse after flying and computer work.
After the worsening he developed clumsy hands, difficulty with buttons and writing, an unsteady gait with falls and urinary urgency. He now has persisting neck pain and stiffness after decompression, reduced hand dexterity and requires a walking stick outdoors.
Imaging
- 01 Jul 2008 — CT cervical spine: "Right C5/6 facet fracture extending into the joint. Anterior wedge fracture of C6 with 25 per cent height loss. Metallic track through the C5/6 disc. Widening at C6/7 indicating ligamentous injury."
- 03 Jul 2008 — MRI cervical spine: "Traumatic left paracentral C5/6 disc prolapse with foraminal narrowing. Interspinous ligament disruption at C6/7."
- 01 Feb 2011 — CT cervical spine: "Healed C5/6 facet and C6 wedge fractures. Solid C6/7 fusion. Grade 1 anterolisthesis of C5 on C6. No osteophytes or disc space narrowing at C5/6."
- 09 Apr 2013 — MRI cervical spine: "C5/6 disc degeneration with broad disc-osteophyte complex, facet and ligamentum flavum hypertrophy. Moderate central canal stenosis, AP diameter 8.5 mm. No cord signal change."
- 04 Oct 2017 — MRI cervical spine: "Severe C5/6 central canal stenosis, AP diameter 6 mm, with cord compression and intramedullary T2 hyperintensity. Progression of the disc-osteophyte complex since 2013."
Onset Date
The most likely date of onset of this condition is 11 Mar 2013.
At that date the veteran was serving full time as an Army helicopter pilot in Australia, on restricted flying duties after the injuries he sustained in captivity in 2008. From 11 March 2013 he developed new neck pain and stiffness, occipital headaches and tingling in both hands.
This date is appropriate because CT on 01 February 2011 showed no osteophytes or disc space narrowing at C5/6, and he first presented with the symptoms on 18 March 2013, one week after onset, with spondylosis and central canal stenosis confirmed on MRI on 09 April 2013. It falls within continuous full-time service.
For the factors requiring an event at least 6 months before onset (facet infection, intra-articular fracture, fusion, disc prolapse and trauma), the latest qualifying date was 11 Sep 2012; all occurred between June and August 2008. For the trauma factor, the 20 years before onset run from 11 Mar 1993 to 11 Mar 2013 and include the 2008 trauma. For the spinal condition factor, the 6 months before onset run from 11 Sep 2012 to 11 Mar 2013, throughout which the C6 deformity and C5/6 spondylolisthesis were present. For the flying and obesity factors, the 25 years before onset run from 11 Mar 1988 to 11 Mar 2013, containing 1,080 F/A-18 hours (1996 to 2004), 1,350 helicopter hours (2005 to 2012) and obesity from March 2002. For the load-carrying factors, the 10 year period was February 1983 to December 1993, and onset fell within the 25 years after it. Captivity, reactive arthritis, the penetrating disc injury, calcium pyrophosphate deposition, acromegaly and Paget's disease all preceded onset.
For the worsening factors, the period after onset runs from 11 Mar 2013 to the documented worsening on 04 Oct 2017. The 6 months before the worsening run from 04 Apr 2017 to 04 Oct 2017, during which the vertebral deformity and spondylolisthesis persisted. The 20 years before the worsening run from 04 Oct 1997 and include the 2008 trauma. The 25 years before the worsening run from 04 Oct 1992 and include all his flying and his obesity, and the worsening fell within the 25 years following the 1983 to 1993 load-carrying period, which end in December 2018.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is cervical spondylosis with central canal stenosis at C5/6 (ICD-10-AM M48.02), decided under the Statements of Principles concerning cervical spondylosis, Balance of Probabilities No. 12 of 2023 and Reasonable Hypothesis No. 11 of 2023, which recognise spinal stenosis as a commonly associated feature of cervical spondylosis.
Cervical spondylosis is degeneration of the cervical intervertebral discs and the adjacent vertebrae and facet joints, with disc space narrowing and osteophyte formation. Central canal stenosis develops when a disc-osteophyte complex, hypertrophied facet joints and a thickened ligamentum flavum narrow the canal that contains the spinal cord. Moderate stenosis causes neck pain, stiffness and intermittent limb paraesthesia; severe stenosis compresses the cord and causes myelopathy, with clumsy hands, gait disturbance and sphincter symptoms. Injury, fusion of an adjacent level, inflammatory and depositional joint disease and endocrine and metabolic bone disease all accelerate the degeneration.
The diagnosis followed the cervical fractures, penetrating disc injury, infection and fusion of 2008. It began on 11 March 2013, was confirmed on MRI on 09 April 2013 and worsened to severe stenosis with myelopathy in October 2017.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
11 March 2013.
When did the veteran first present to a health / medical provider for this condition?
18 March 2013.
When was the condition confirmed / formally diagnosed?
09 April 2013.
When did the veteran first present to you (or your practice) for this condition?
23 April 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on MRI on 09 April 2013, which showed C5/6 disc degeneration with a disc-osteophyte complex, facet and ligamentum flavum hypertrophy and moderate central canal stenosis with an AP diameter of 8.5 mm. This meets the Statement of Principles definition of cervical spondylosis, and the stenosis is a recognised associated feature.
The clinical picture was consistent: neck pain and stiffness, bilateral hand paraesthesia, brisk reflexes and a positive Hoffmann sign. MRI on 04 October 2017 confirmed progression to severe stenosis with cord signal change, and a spinal surgeon confirmed cervical spondylotic myelopathy.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 11 March 2013, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Somalia in 1993, over Iraq in 2003 and in Afghanistan in 2006 and 2008, including his captivity and the injuries sustained when he was shot down. The Balance of Probabilities instrument applies to his peacetime service, including his load carrying as an engineer and his peacetime flying.
Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Balance of Probabilities — Statement of Principles concerning Cervical Spondylosis, No. 12 of 2023
Causative factors
Factor 9(1): having an inflammatory joint disease from the specified list of inflammatory joint diseases, in the cervical spine before the clinical onset of cervical spondylosis; — MET
- Reactive arthritis followed Shigella dysentery contracted while the veteran was held captive in June 2008. A rheumatologist confirmed it on 22 September 2008 (HLA-B27 positive, raised CRP, bilateral sacroiliitis on MRI) with inflammatory neck pain and enhancement of the C5/6 facet joints on MRI. It involved the cervical spine from 2008, before onset on 11 March 2013.
Factor 9(2): having non-viral infection of the affected joint, resulting in inflammation within that joint, at least 6 months before the clinical onset of cervical spondylosis; — MET
- Aspiration of the right C5/6 facet joint on 12 August 2008 grew Staphylococcus aureus, and the veteran received six weeks of intravenous antibiotics for septic facet arthritis introduced along the fragment track. This non-viral infection with inflammation of the affected joint was more than 4 years before onset on 11 March 2013.
Factor 9(3): having an intra-articular fracture of the spine, at the level of, or adjacent to, the affected joint, at least 6 months before the clinical onset of cervical spondylosis; — MET
- CT on 01 July 2008 showed a fracture of the right C5/6 facet extending into the joint, caused by rifle-butt blows to the neck in captivity. This intra-articular fracture at the affected level was more than 4 years before onset on 11 March 2013.
Factor 9(4): having a spinal condition from the specified list of spinal conditions, affecting the cervical spine for at least the 6 months before the clinical onset of cervical spondylosis; — MET
- The C6 vertebral body healed with a 25 per cent anterior wedge deformity after the 2008 injuries, and a grade 1 degenerative anterolisthesis of C5 on C6 was documented from January 2010. Both affected the cervical spine continuously for the 6 months before onset, from 11 September 2012 to 11 March 2013.
Factor 9(5): having undergone a spinal fusion, immediately above or below the affected joint, at least 6 months before the clinical onset of cervical spondylosis; — MET
- Anterior cervical discectomy and fusion at C6/7 was performed on 15 July 2008 for traumatic ligamentous instability, immediately below the affected C5/6 joint, more than 4 years before onset on 11 March 2013. The fused segment transferred motion and load to C5/6.
Factor 9(6): having a depositional joint disease from the specified list of depositional joint diseases, in the cervical spine before the clinical onset of cervical spondylosis; — MET
- Calcium pyrophosphate dihydrate deposition disease was confirmed on 19 March 2012, when CT showed calcification around the dens (crowned dens) and in the C5/6 facet capsules and knee aspirate showed calcium pyrophosphate crystals. It was present in the cervical spine before onset on 11 March 2013.
Factor 9(7): having trauma to the cervical spine at least 6 months before the clinical onset of cervical spondylosis, and where the trauma to the cervical spine occurred within the 20 years before the clinical onset of cervical spondylosis; — MET
- During captivity from 14 June 2008 to 01 July 2008 the veteran was repeatedly struck on the neck with rifle butts, causing facet and vertebral body fractures, immediate pain and tenderness, and loss of movement that required a hard collar for eight weeks. This trauma was more than 6 months before onset and within the 20 years before it, which run from 11 March 1993 to 11 March 2013.
Factor 9(8): having a penetrating injury to an intervertebral disc before the clinical onset of cervical spondylosis at the level of, or adjacent to, the intervertebral disc injury; — MET
- When the veteran's helicopter was forced down by ground fire on 14 June 2008, a shell fragment entered the left side of his neck and pierced the C5/6 intervertebral disc, as shown by the metallic track on CT on 01 July 2008. This penetrating injury was at the level of the spondylosis and preceded onset on 11 March 2013.
Factor 9(9): having a cervical intervertebral disc prolapse at least 6 months before the clinical onset of cervical spondylosis at the level of the intervertebral disc prolapse; — MET
- MRI on 03 July 2008 showed a traumatic C5/6 disc prolapse with left foraminal narrowing and C6 radicular symptoms. It was more than 4 years before onset on 11 March 2013, at the level of the spondylosis.
Factor 9(10): carrying loads of at least 25 kilograms on the head while upright to a cumulative total of at least 5,000 hours within any 10 year period before the clinical onset of cervical spondylosis, and where the clinical onset of cervical spondylosis occurred within the 25 years following that period; — MET
- As a combat engineer from February 1983 to December 1993, the veteran carried 25 to 40 kilogram bags of cement and full water containers balanced on his head while building in remote communities and on exercises, recorded at about 10 hours a week. This totals more than 5,000 hours within that 10 year period. Onset on 11 March 2013 was within the 25 years following the period, which run to December 2018.
Factor 9(11): flying in high performance aircraft for a cumulative total of at least 1,000 hours within the 25 years before the clinical onset of cervical spondylosis; — MET
- The veteran flew 1,080 hours in F/A-18 aircraft, routinely pulling 6 to 7.5g, between January 1996 and December 2004, within the 25 years before onset, which run from 11 March 1988 to 11 March 2013.
Factor 9(12): piloting a helicopter for a cumulative total of at least 1,000 hours within the 25 years before the clinical onset of cervical spondylosis; — MET
- After transferring to Army aviation in January 2005 the veteran piloted helicopters for 1,350 hours to December 2012, within the 25 years before onset.
Factor 9(13): being obese for at least 10 years within the 25 years before the clinical onset of cervical spondylosis; — MET
- The veteran's BMI was 31 or more at every annual aircrew medical from March 2002 (31.2) to 2013 (33.0), so he was obese for at least 10 years within the 25 years before onset, from 11 March 1988 to 11 March 2013.
Factor 9(14): having acromegaly involving the cervical spine before the clinical onset of cervical spondylosis; — MET
- Acromegaly was diagnosed on 06 June 2011, with an IGF-1 of 3.2 times the upper limit and a 14 mm pituitary macroadenoma. CT of the neck showed vertebral body enlargement and hypertrophic change, confirming involvement of the cervical spine before onset on 11 March 2013.
Factor 9(15): having Paget's disease of bone involving the cervical spine before the clinical onset of cervical spondylosis; — MET
- Paget's disease of bone was diagnosed on 14 November 2012 on a raised alkaline phosphatase (380 U/L) and a bone scan showing increased uptake in C6, C7 and the right hemipelvis, with cortical thickening of C6 on CT. It involved the cervical spine before onset on 11 March 2013.
Worsening factors
Factor 9(16): having an inflammatory joint disease from the specified list of inflammatory joint diseases, in the cervical spine before the clinical worsening of cervical spondylosis; — MET
- Reactive arthritis with cervical involvement, with flares in 2015 and 2016 requiring sulfasalazine, was present before the worsening on 04 October 2017.
Factor 9(17): having non-viral infection of the affected joint, resulting in inflammation within that joint, at least 6 months before the clinical worsening of cervical spondylosis; — MET
- The septic arthritis of the C5/6 facet joint in August 2008 was more than 9 years before the worsening on 04 October 2017.
Factor 9(18): having an intra-articular fracture of the spine, at the level of, or adjacent to, the affected joint, at least 6 months before the clinical worsening of cervical spondylosis; — MET
- The intra-articular C5/6 facet fracture of 2008 was more than 6 months before the worsening on 04 October 2017.
Factor 9(19): having a spinal condition from the specified list of spinal conditions, affecting the cervical spine for at least the 6 months before the clinical worsening of cervical spondylosis; — MET
- The C6 wedge deformity and C5/6 spondylolisthesis, which had progressed to 4 mm by 2017, affected the cervical spine throughout the 6 months before the worsening, from 04 April 2017 to 04 October 2017.
Factor 9(20): having undergone a spinal fusion, immediately above or below the affected joint, at least 6 months before the clinical worsening of cervical spondylosis; — MET
- The C6/7 fusion of July 2008, immediately below the affected joint, was more than 6 months before the worsening on 04 October 2017.
Factor 9(21): having a depositional joint disease from the specified list of depositional joint diseases, in the cervical spine before the clinical worsening of cervical spondylosis; — MET
- Calcium pyrophosphate deposition in the cervical spine persisted and was present before the worsening on 04 October 2017.
Factor 9(22): having trauma to the cervical spine at least 6 months before the clinical worsening of cervical spondylosis, and where the trauma to the cervical spine occurred within the 20 years before the clinical worsening of cervical spondylosis; — MET
- The neck trauma of June 2008 was more than 6 months before the worsening and within the 20 years before it, which run from 04 October 1997 to 04 October 2017.
Factor 9(23): having a penetrating injury to an intervertebral disc before the clinical worsening of cervical spondylosis at the level of, or adjacent to, the intervertebral disc injury; — MET
- The penetrating fragment injury to the C5/6 disc in 2008 preceded the worsening on 04 October 2017, at the same level.
Factor 9(24): having a cervical intervertebral disc prolapse at least 6 months before the clinical worsening of cervical spondylosis at the level of the intervertebral disc prolapse; — MET
- The C5/6 disc prolapse of 2008 was more than 6 months before the worsening, at the same level.
Factor 9(25): carrying loads of at least 25 kilograms on the head while upright to a cumulative total of at least 5,000 hours within any 10 year period before the clinical worsening of cervical spondylosis, and where the clinical worsening of cervical spondylosis occurred within the 25 years following that period; — MET
- The more than 5,000 hours of head-carrying of 25 to 40 kilogram loads between 1983 and 1993 preceded the worsening on 04 October 2017, which occurred within the 25 years following that period.
Factor 9(26): flying in high performance aircraft for a cumulative total of at least 1,000 hours within the 25 years before the clinical worsening of cervical spondylosis; — MET
- The 1,080 F/A-18 hours of 1996 to 2004 fell within the 25 years before the worsening on 04 October 2017.
Factor 9(27): piloting a helicopter for a cumulative total of at least 1,000 hours within the 25 years before the clinical worsening of cervical spondylosis; — MET
- His 1,350 helicopter piloting hours from 2005 to 2012 fell within the 25 years before the worsening.
Factor 9(28): being obese for at least 10 years within the 25 years before the clinical worsening of cervical spondylosis; — MET
- He remained obese (BMI 34.1 in 2017) from 2002 to the worsening, more than 10 years within the 25 years before it.
Factor 9(29): having acromegaly involving the cervical spine before the clinical worsening of cervical spondylosis; — MET
- Acromegaly, incompletely controlled after surgery, continued to involve the cervical spine before the worsening on 04 October 2017.
Factor 9(30): having Paget's disease of bone involving the cervical spine before the clinical worsening of cervical spondylosis; — MET
- Paget's disease involving C6 and C7 persisted, with rising alkaline phosphatase in 2017, before the worsening on 04 October 2017.
Factor 9(31): inability to obtain appropriate clinical management for cervical spondylosis. — MET
- After onset the veteran was referred to a spinal surgeon on 09 April 2013, but the appointment was not available for 14 months, and decompression recommended in June 2014 was deferred for operational and administrative reasons until after the worsening. Myelopathy developed while he waited. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Cervical Spondylosis, No. 11 of 2023
Causative factors
Factor 9(1): being a prisoner of war before the clinical onset of cervical spondylosis; — MET
- The veteran was captured by insurgents after his helicopter was shot down on warlike service in Afghanistan on 14 June 2008, and held as a prisoner for 17 days until his rescue on 01 July 2008. He was beaten, tied in stress positions, deprived of food and contracted dysentery. He was a prisoner of war before onset on 11 March 2013.
Factor 9(2): having an inflammatory joint disease from the specified list of inflammatory joint diseases, in the cervical spine before the clinical onset of cervical spondylosis; — MET
- Reactive arthritis of the cervical spine, confirmed on 22 September 2008, followed Shigella dysentery contracted in captivity on warlike service in Afghanistan in June 2008, and preceded onset on 11 March 2013.
Factor 9(3): having non-viral infection of the affected joint, resulting in inflammation within that joint, at least 6 months before the clinical onset of cervical spondylosis; — MET
- Staphylococcal septic arthritis of the right C5/6 facet joint (12 August 2008) followed the fragment wound sustained on warlike service in Afghanistan, more than 6 months before onset.
Factor 9(4): having an intra-articular fracture of the spine, at the level of, or adjacent to, the affected joint, at least 6 months before the clinical onset of cervical spondylosis; — MET
- The intra-articular right C5/6 facet fracture, shown on CT on 01 July 2008, was inflicted in captivity on warlike service in Afghanistan, more than 6 months before onset.
Factor 9(5): having a spinal condition from the specified list of spinal conditions, affecting the cervical spine for at least the 6 months before the clinical onset of cervical spondylosis; — MET
- The C6 wedge deformity from the 2008 warlike-service injuries and the C5/6 spondylolisthesis present from January 2010 affected the cervical spine throughout the 6 months before onset.
Factor 9(6): having undergone a spinal fusion, immediately above or below the affected joint, at least 6 months before the clinical onset of cervical spondylosis; — MET
- The C6/7 fusion of 15 July 2008, immediately below the affected joint, treated instability caused by injuries sustained in captivity on warlike service, more than 6 months before onset.
Factor 9(7): having a depositional joint disease from the specified list of depositional joint diseases, in the cervical spine before the clinical onset of cervical spondylosis; — MET
- Calcium pyrophosphate dihydrate deposition disease in the cervical spine, confirmed on 19 March 2012, was present before onset. It was associated with the acromegaly and the joint damage from the warlike-service injuries.
Factor 9(8): having trauma to the cervical spine at least 6 months before the clinical onset of cervical spondylosis, and where the trauma to the cervical spine occurred within the 20 years before the clinical onset of cervical spondylosis; — MET
- The rifle-butt blows to the neck in captivity on warlike service in Afghanistan from 14 June 2008 caused fractures and persisting pain and stiffness, more than 6 months before onset and within the 20 years before it.
Factor 9(9): having a penetrating injury to an intervertebral disc before the clinical onset of cervical spondylosis at the level of, or adjacent to, the intervertebral disc injury; — MET
- The shell fragment that pierced the C5/6 disc when his helicopter was shot down on warlike service in Afghanistan on 14 June 2008 preceded onset, at the affected level.
Factor 9(10): having a cervical intervertebral disc prolapse at least 6 months before the clinical onset of cervical spondylosis at the level of the intervertebral disc prolapse; — MET
- The traumatic C5/6 disc prolapse, shown on MRI on 03 July 2008 after the shoot-down and captivity on warlike service, was more than 6 months before onset at the affected level.
Factor 9(11): carrying loads of at least 15 kilograms on the head while upright to a cumulative total of at least 5,000 hours within any 10 year period before the clinical onset of cervical spondylosis; — MET
- The veteran carried loads of 25 to 40 kilograms on his head for more than 5,000 hours as a combat engineer between February 1983 and December 1993, including during warlike service in Somalia from January to May 1993, before onset.
Factor 9(12): carrying a large bulky load of at least 15 kilograms positioned between the neck and shoulder to a cumulative total of at least 5,000 hours within any 10 year period before the clinical onset of cervical spondylosis; — MET
- Between 1983 and 1993 the veteran also carried sandbags, steel pickets and bulky stores of 20 to 30 kilograms on his shoulder against the side of his neck for more than 5,000 hours, including on warlike service in Somalia in 1993.
Factor 9(13): flying in high performance aircraft for a cumulative total of at least 500 hours within the 25 years before the clinical onset of cervical spondylosis; — MET
- He flew 1,080 hours in F/A-18 aircraft between 1996 and 2004, including combat missions on warlike service over Iraq from February to May 2003, within the 25 years before onset.
Factor 9(14): piloting a helicopter for a cumulative total of at least 500 hours within the 25 years before the clinical onset of cervical spondylosis; — MET
- He piloted helicopters for 1,350 hours from 2005 to 2012, including warlike service in Afghanistan in 2006 and 2008, within the 25 years before onset.
Factor 9(15): being obese for at least 10 years before the clinical onset of cervical spondylosis; — MET
- He was obese, with a BMI of 31 to 33, from March 2002 continuously to onset, more than 10 years. The weight gain accelerated after the 2008 injuries from warlike service limited his exercise.
Factor 9(16): having acromegaly involving the cervical spine before the clinical onset of cervical spondylosis; — MET
- Acromegaly involving the cervical spine was confirmed on 06 June 2011 and preceded onset on 11 March 2013.
Factor 9(17): having Paget's disease of bone involving the cervical spine before the clinical onset of cervical spondylosis; — MET
- Paget's disease of bone involving C6 and C7 was diagnosed on 14 November 2012, before onset.
Worsening factors
Factor 9(18): being a prisoner of war before the clinical worsening of cervical spondylosis; — MET
- The veteran was a prisoner of war in Afghanistan from 14 June 2008 to 01 July 2008, before the worsening on 04 October 2017.
Factor 9(19): having an inflammatory joint disease from the specified list of inflammatory joint diseases, in the cervical spine before the clinical worsening of cervical spondylosis; — MET
- Reactive arthritis arising from captivity on warlike service involved the cervical spine before the worsening on 04 October 2017.
Factor 9(20): having non-viral infection of the affected joint, resulting in inflammation within that joint, at least 6 months before the clinical worsening of cervical spondylosis; — MET
- The C5/6 facet joint infection from the warlike-service fragment wound was more than 6 months before the worsening.
Factor 9(21): having an intra-articular fracture of the spine, at the level of, or adjacent to, the affected joint, at least 6 months before the clinical worsening of cervical spondylosis; — MET
- The facet fracture inflicted in captivity on warlike service in 2008 preceded the worsening by more than 9 years.
Factor 9(22): having a spinal condition from the specified list of spinal conditions, affecting the cervical spine for at least the 6 months before the clinical worsening of cervical spondylosis; — MET
- The vertebral deformity and spondylolisthesis arising from the warlike-service injuries persisted through the 6 months before the worsening.
Factor 9(23): having undergone a spinal fusion, immediately above or below the affected joint, at least 6 months before the clinical worsening of cervical spondylosis; — MET
- The C6/7 fusion for the warlike-service injury was more than 6 months before the worsening.
Factor 9(24): having a depositional joint disease from the specified list of depositional joint diseases, in the cervical spine before the clinical worsening of cervical spondylosis; — MET
- Calcium pyrophosphate deposition disease of the cervical spine was present before the worsening.
Factor 9(25): having trauma to the cervical spine at least 6 months before the clinical worsening of cervical spondylosis, and where the trauma to the cervical spine occurred within the 20 years before the clinical worsening of cervical spondylosis; — MET
- The neck trauma in captivity on warlike service in 2008 fell within the 20 years before the worsening and more than 6 months before it.
Factor 9(26): having a penetrating injury to an intervertebral disc before the clinical worsening of cervical spondylosis at the level of, or adjacent to, the intervertebral disc injury; — MET
- The warlike-service fragment injury to the C5/6 disc preceded the worsening at that level.
Factor 9(27): having a cervical intervertebral disc prolapse at least 6 months before the clinical worsening of cervical spondylosis at the level of the intervertebral disc prolapse; — MET
- The C5/6 disc prolapse from warlike service in 2008 was more than 6 months before the worsening.
Factor 9(28): carrying loads of at least 15 kilograms on the head while upright to a cumulative total of at least 5,000 hours within any 10 year period before the clinical worsening of cervical spondylosis; — MET
- The head-carrying of 1983 to 1993, including in Somalia in 1993, exceeded 5,000 hours with loads over 15 kilograms within a 10 year period before the worsening.
Factor 9(29): carrying a large bulky load of at least 15 kilograms positioned between the neck and shoulder to a cumulative total of at least 5,000 hours within any 10 year period before the clinical worsening of cervical spondylosis; — MET
- The more than 5,000 hours of bulky shoulder loads over 15 kilograms between 1983 and 1993 preceded the worsening.
Factor 9(30): flying in high performance aircraft for a cumulative total of at least 500 hours within the 25 years before the clinical worsening of cervical spondylosis; — MET
- The 1,080 F/A-18 hours, including warlike service over Iraq in 2003, fell within the 25 years before the worsening.
Factor 9(31): piloting a helicopter for a cumulative total of at least 500 hours within the 25 years before the clinical worsening of cervical spondylosis; — MET
- The 1,350 helicopter hours, including warlike service in Afghanistan, fell within the 25 years before the worsening.
Factor 9(32): being obese for at least 10 years before the clinical worsening of cervical spondylosis; — MET
- He was obese for more than 10 years, from 2002 to the worsening on 04 October 2017.
Factor 9(33): having acromegaly involving the cervical spine before the clinical worsening of cervical spondylosis; — MET
- Acromegaly involving the cervical spine was present before the worsening.
Factor 9(34): having Paget's disease of bone involving the cervical spine before the clinical worsening of cervical spondylosis; — MET
- Paget's disease of bone involving the cervical spine was present before the worsening.
Factor 9(35): inability to obtain appropriate clinical management for cervical spondylosis. — MET
- Decompression recommended in June 2014 was not obtained before the worsening in October 2017, and myelopathy developed during the delay.
The % contribution of the causes is 100% and significant.
Sequelae
The central canal stenosis is a sequela of the injuries the veteran sustained when shot down and held captive on warlike service in 2008: the C5/6 facet fracture, C6 wedge deformity, penetrating disc injury, septic facet arthritis, reactive arthritis and the C6/7 fusion that loaded the segment above. Its own sequela is cervical myelopathy, with impaired hand function, gait and bladder control.
Unintended Consequence
Met. The C6/7 fusion performed on 15 July 2008 by Defence-funded surgeons eliminated motion immediately below C5/6 and increased the load on the affected segment, accelerating its degeneration. This is an unintended consequence of treatment provided by the Commonwealth (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. After the diagnosis on 09 April 2013 the veteran waited 14 months for a spinal surgical opinion, and decompression recommended in June 2014 was deferred through his medical discharge process until after the worsening. During that delay the canal narrowed from 8.5 mm to 6 mm and myelopathy developed. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), a recommended operation that the veteran sought but could not obtain amounts to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 01 Jul 2008, Trauma admission and CT report, Role 3 hospital, Afghanistan
- 03 Jul 2008, MRI cervical spine, Radiologist
- 15 Jul 2008, Operation report, Spinal surgeon
- 12 Aug 2008, Microbiology and infectious diseases letter, Infectious diseases physician
- 22 Sep 2008, Rheumatology consultation, Rheumatologist
- 01 Feb 2011, CT cervical spine, Radiologist
- 06 Jun 2011, Endocrinology consultation, Endocrinologist
- 19 Mar 2012, CT and joint aspirate report, Rheumatologist
- 14 Nov 2012, Bone scan and endocrinology letter, Endocrinologist
- 18 Mar 2013, Outpatient health record, Medical Officer, Base medical centre
- 09 Apr 2013, MRI cervical spine and surgical opinion, Spinal surgeon
- 04 Oct 2017, MRI cervical spine, Radiologist
- 21 Nov 2017, Operation report, Spinal surgeon
- Annual aircrew medical examinations, 2002 to 2013, Aviation Medical Officer
- Statement of Principles concerning Cervical Spondylosis (Balance of Probabilities) No. 12 of 2023, Repatriation Medical Authority
- Statement of Principles concerning Cervical Spondylosis (Reasonable Hypothesis) No. 11 of 2023, Repatriation Medical Authority
