Diagnostic Assessment — Cervical Spine - Cervical Radiculopathy
Example 1 of 1 · fictitious patient (Veteran W)
Diagnostic Assessment
Cervical Spine - Cervical Radiculopathy
BOP Code: 67 of 2023 (Cervical Intervertebral Disc Prolapse)
RH Code: 66 of 2023 (Cervical Intervertebral Disc Prolapse)
ADF History
Veteran W, date of birth 22 August 1966, Royal Australian Air Force from 13 January 1986 (Pilot, fast jet), transferred to the Australian Army in January 2000 (Pilot, Army aviation, helicopters), medically discharged 09 October 2015. Operational service: East Timor, 10 October 2000 to 15 April 2001 (warlike); Afghanistan, 05 March 2006 to 30 June 2006, 10 January 2008 to 15 May 2008, 02 March 2010 to 15 June 2010 and 12 May 2013 to 21 August 2013 (all warlike).
Occupational History
Fast jet pilots are exposed to repeated high sustained acceleration of up to 7.5g with the head turned to maintain visual lookout, which loads the cervical discs and facet joints. Helicopter pilots sit for long periods in a forward-flexed, rotated posture, wear heavy helmets with night-vision goggles and counterweights, and are exposed to whole-body vibration.
Military aviators also face hard landings, crash and ejection forces, and in combat, ground fire and fragment injury. Long standby periods on flight lines and in deployed locations were associated with high rates of smoking during this veteran's service.
History
Veteran W, an RAAF fast jet pilot who became an Army helicopter pilot, developed a C5/6 cervical disc prolapse with left C6 radiculopathy on 14 June 2010, hours after his helicopter was hit by ground fire and landed heavily on warlike service in Afghanistan, with a penetrating fragment and bacterial discitis. The condition worsened on 18 August 2013, after a further hard landing and a disc aspiration in Afghanistan, and required anterior cervical discectomy and fusion.
Timeline
- 15 Jan 2010 — Pre-deployment medical examination recorded a full, painless range of cervical movement and normal upper limb neurology. The veteran had flown 1,240 hours in F/A-18 aircraft in the 1990s and about 5,100 hours as a helicopter pilot since 2000. He had stopped smoking on 01 January 2009 after 24 pack-years. "neck full ROM, neuro normal"
- 14 Jun 2010 — On warlike service in Afghanistan his helicopter was struck by small-arms fire and landed heavily. A metal fragment penetrated the left neck, and CT at the role 3 hospital showed it lodged in the anterior C6 vertebral body below the C5/6 disc. His neck was immobilised in a hard collar. That evening he developed severe left arm pain radiating to the thumb, with paraesthesia. "fragment C6 body, left arm pain"
- 16 Jun 2010 — MRI after evacuation showed a left posterolateral C5/6 disc extrusion compressing the exiting C6 nerve root, with enhancement of the disc space. Examination showed weakness of elbow flexion and wrist extension (4/5), a reduced biceps reflex and C6 sensory loss. A neurosurgeon diagnosed C5/6 disc prolapse with C6 radiculopathy. "C5/6 extrusion, C6 radiculopathy"
- 17 Jun 2010 — A limited anterior exploration removed the fragment without discectomy. Cultures from the track and the adjacent disc grew Staphylococcus aureus, and six weeks of intravenous flucloxacillin were given. The radicular pain improved over the following months. "S. aureus discitis, IV antibiotics"
- 12 Mar 2012 — At review the veteran reported intermittent left arm paraesthesia and neck stiffness. Follow-up MRI was requested but not obtained because of a nine-month waiting list, and he was cleared to deploy again in 2013 without it. "MRI requested, not obtained"
- 18 Aug 2013 — On warlike service in Afghanistan the veteran's helicopter landed heavily in a brownout on 17 August 2013. Next morning, with fever and neck pain, he underwent CT-guided aspiration of the C5/6 disc at the role 3 hospital. That afternoon left arm pain intensified and he developed new weakness of elbow flexion (3/5) and grip, with an absent biceps reflex. A dust storm delayed evacuation for three days. "worse C6 weakness after landing"
- 20 Aug 2013 — MRI showed enlargement of the C5/6 extrusion with severe left foraminal stenosis, disc space enhancement and endplate oedema. The aspirate grew Staphylococcus aureus. Anterior cervical discectomy and fusion at C5/6 was performed on 02 September 2013, with partial recovery of strength. "larger extrusion, recurrent discitis"
Symptoms
At onset the veteran had neck pain and stiffness with severe left arm pain radiating along the lateral forearm into the thumb and index finger, paraesthesia in the same distribution, and weakness of elbow flexion and wrist extension. Pain was worse on neck extension and rotation to the left.
He now has persistent neck pain and stiffness after fusion, residual left C6 numbness and weakness of grip, and difficulty with overhead work, prolonged computer use and driving with head rotation.
Imaging
- 14 Jun 2010 — CT cervical spine: "Metallic fragment 9 mm in the anterior C6 vertebral body adjacent to the C5/6 disc. No fracture of the posterior elements."
- 16 Jun 2010 — MRI cervical spine: "Left posterolateral C5/6 disc extrusion compressing the exiting left C6 nerve root. Enhancement of the C5/6 disc space consistent with early discitis."
- 20 Aug 2013 — MRI cervical spine: "Enlarged left C5/6 extrusion with severe left foraminal stenosis. Disc space enhancement and endplate oedema at C5/6 consistent with recurrent discitis."
Onset Date
The most likely date of onset of this condition is 14 Jun 2010.
At that date the veteran was on warlike service in Afghanistan as a helicopter pilot. At about 1430 his aircraft was struck by small-arms fire and landed heavily, and a metal fragment penetrated his neck into the C6 vertebral body. That evening he developed left arm pain and paraesthesia in a C6 distribution.
This date is appropriate because his pre-deployment medical examination of 15 January 2010 recorded a normal neck and normal upper limb neurology, and he presented with radicular symptoms on the evening of the injury, confirmed on MRI on 16 June 2010. It falls within continuous full-time service on warlike operations.
For the trauma and penetrating injury factors, the 24 hours before onset run from the evening of 13 Jun 2010 to the evening of 14 Jun 2010, and both the heavy landing and the fragment injury occurred at about 1430 on 14 Jun 2010. For the helicopter factor, the 10 years before onset run from 14 Jun 2000 to 14 Jun 2010, during which he flew 5,150 hours. For the high performance aircraft factor, the 10 year period ran from January 1990 to December 1999 (1,240 hours), and onset fell within the 25 years following it. For the smoking factor, he stopped on 01 Jan 2009 after 24 pack-years, and the 5 years after cessation run to 01 Jan 2014. The bacterial infection was introduced by the fragment and present at onset.
For the worsening factors, the period after onset runs from 14 Jun 2010 to the documented worsening on 18 Aug 2013. The 24 hours before the worsening run from the afternoon of 17 Aug 2013 and contain the heavy landing (about 1500, 17 Aug 2013) and the disc aspiration (0900, 18 Aug 2013). The 10 years before the worsening run from 18 Aug 2003 to 18 Aug 2013, during which he flew 5,620 helicopter hours, and the worsening fell within 5 years of his smoking cessation.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is cervical radiculopathy due to C5/6 cervical intervertebral disc prolapse (ICD-10-AM M50.1), decided under the Statements of Principles concerning cervical intervertebral disc prolapse, Balance of Probabilities No. 67 of 2023 and Reasonable Hypothesis No. 66 of 2023.
A cervical intervertebral disc prolapse is the displacement of the nucleus pulposus or annulus fibrosus of a cervical disc into the vertebral canal or neural foramen. When it compresses an exiting nerve root it causes radiculopathy: pain, paraesthesia, weakness and reflex loss in the distribution of that root. A C5/6 prolapse compresses the C6 root, producing pain into the thumb, weakness of elbow flexion and wrist extension and a reduced biceps reflex. Trauma, infection and repetitive axial loading damage the annulus and predispose to prolapse.
The diagnosis followed a heavy landing with a penetrating fragment and bacterial discitis on warlike service in Afghanistan on 14 June 2010. It was confirmed on MRI on 16 June 2010, worsened on 18 August 2013 and was treated by anterior cervical discectomy and fusion.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
14 June 2010.
When did the veteran first present to a health / medical provider for this condition?
14 June 2010.
When was the condition confirmed / formally diagnosed?
16 June 2010.
When did the veteran first present to you (or your practice) for this condition?
07 May 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 16 June 2010, which showed a left posterolateral C5/6 disc extrusion compressing the exiting C6 nerve root, together with clinical signs of C6 root compression: weakness of elbow flexion and wrist extension, a reduced biceps reflex and sensory loss over the thumb. This meets the Statement of Principles requirement for clinical manifestations of nerve root compression with imaging evidence of disc prolapse into the vertebral canal.
A neurosurgeon confirmed the diagnosis, and nerve conduction studies and electromyography in July 2010 showed an acute left C6 radiculopathy. MRI on 20 August 2013 confirmed enlargement of the prolapse at the time of the worsening.
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 14 June 2010, after 1 July 2004, during warlike service in Afghanistan. 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 East Timor and Afghanistan, where the injury, the infection and the worsening occurred and much of his helicopter flying was done. The Balance of Probabilities instrument applies to his peacetime service, including his fast jet flying in the 1990s and his peacetime helicopter flying and smoking.
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 Intervertebral Disc Prolapse, No. 67 of 2023
Causative factors
Factor 9(1): having trauma to the affected intervertebral disc within the 24 hours before the clinical onset of cervical intervertebral disc prolapse; — MET
- At about 1430 on 14 June 2010, on warlike service in Afghanistan, the veteran's helicopter was struck by small-arms fire on approach and landed heavily, driving his helmeted head and neck into flexion and compression. He had immediate neck pain, tenderness and loss of rotation, his neck was immobilised in a hard collar, and pain and restricted movement persisted for months. Left arm pain in a C6 distribution began that evening, within 24 hours.
Factor 9(2): having a penetrating injury to the affected intervertebral disc or adjacent vertebral body, within the 24 hours before the clinical onset of cervical intervertebral disc prolapse; — MET
- In the same incident a metal spall fragment from the cockpit penetrated the left side of his neck and lodged in the anterior body of C6, immediately below the C5/6 disc, as shown on CT at the role 3 hospital on 14 June 2010. The penetrating injury to the vertebral body adjacent to the affected disc occurred some seven hours before the onset of radicular symptoms.
Factor 9(3): flying in high performance aircraft for a cumulative total of at least 1,000 hours within any 10 year period before the clinical onset of cervical intervertebral disc prolapse, and where the clinical onset of cervical intervertebral disc prolapse occurred within the 25 years following that period; — MET
- Between January 1990 and December 1999 the veteran flew 1,240 hours in F/A-18 fighter aircraft, which routinely produce accelerations of 7 to 7.5g, as recorded in his flying logbook. This is more than 1,000 hours within a 10 year period, and the onset on 14 June 2010 occurred within the 25 years following that period. Much of this flying was air combat training in peacetime service.
Factor 9(4): flying in a helicopter as operational aircrew, for a cumulative total of at least 5,000 hours within the 10 years before the clinical onset of cervical intervertebral disc prolapse; — MET
- After transferring to Army aviation in 2000 the veteran flew as a helicopter pilot, logging 5,150 hours as operational aircrew between 14 June 2000 and 14 June 2010, the 10 years before onset, including night-vision goggle flying with a helmet and goggle mount of about 2.5 kg. This exceeds the 5,000 hours required.
Factor 9(5): having smoked tobacco products in an amount of at least 10 pack-years before the clinical onset of cervical intervertebral disc prolapse, and if smoking has ceased before the clinical onset of cervical intervertebral disc prolapse, then that onset occurred within 5 years of cessation; — MET
- The veteran smoked 20 cigarettes a day from 1985 until he stopped on 01 January 2009, a total of 24 pack-years, more than the 10 required. Onset on 14 June 2010 was 1 year and 5 months after cessation, within 5 years. The smoking was established and sustained during his service, including long standby periods on flight lines.
Factor 9(6): having bacterial infection of the affected disc at the time of the clinical onset of cervical intervertebral disc prolapse; — MET
- Culture of the C6 fragment track and of disc material sampled at the anterior exploration on 17 June 2010 grew Staphylococcus aureus, and MRI on 16 June 2010 showed enhancement of the C5/6 disc space. The fragment had carried bacteria into the vertebral body and adjacent disc at the moment of injury, so bacterial infection of the affected disc was present at onset and was treated with six weeks of intravenous flucloxacillin.
Worsening factors
Factor 9(7): having trauma to the affected intervertebral disc within the 24 hours before the clinical worsening of cervical intervertebral disc prolapse; — MET
- At about 1500 on 17 August 2013, on warlike service in Afghanistan, the veteran's helicopter landed heavily in a brownout at a forward patrol base. He had immediate neck pain, tenderness and restricted movement, which persisted until surgery on 02 September 2013. The radiculopathy worsened the next afternoon, within 24 hours.
Factor 9(8): having a penetrating injury to the affected intervertebral disc or adjacent vertebral body, within the 24 hours before the clinical worsening of cervical intervertebral disc prolapse; — MET
- At 0900 on 18 August 2013, at the role 3 hospital, a CT-guided needle aspiration of the C5/6 disc was performed for neck pain, fever and a C-reactive protein of 96 mg/L. This penetrating injury to the affected disc occurred about five hours before the documented worsening that afternoon.
Factor 9(9): flying in high performance aircraft for a cumulative total of at least 1,000 hours within any 10 year period before the clinical worsening of cervical intervertebral disc prolapse, and where the clinical worsening of cervical intervertebral disc prolapse occurred within the 25 years following that period; — MET
- The 1,240 hours flown in F/A-18 aircraft between January 1990 and December 1999 exceed 1,000 hours within a 10 year period, and the worsening on 18 August 2013 occurred within the 25 years following that period.
Factor 9(10): flying in a helicopter as operational aircrew, for a cumulative total of at least 5,000 hours within the 10 years before the clinical worsening of cervical intervertebral disc prolapse; — MET
- The veteran logged 5,620 hours as helicopter operational aircrew between 18 August 2003 and 18 August 2013, the 10 years before the worsening, having returned to flying in 2011 after recovering from the initial injury.
Factor 9(11): having smoked tobacco products in an amount of at least 10 pack-years before the clinical worsening of cervical intervertebral disc prolapse, and if smoking has ceased before the clinical worsening of cervical intervertebral disc prolapse, then that worsening occurred within 5 years of cessation; — MET
- He smoked 24 pack-years before stopping on 01 January 2009, and the worsening on 18 August 2013 occurred 4 years and 7 months after cessation, within 5 years.
Factor 9(12): having bacterial infection of the affected disc at the time of the clinical worsening of cervical intervertebral disc prolapse; — MET
- The aspirate of 18 August 2013 grew Staphylococcus aureus, confirming recurrent bacterial infection of the C5/6 disc at the time of the worsening, and MRI on 20 August 2013 showed disc space enhancement with endplate oedema.
Factor 9(13): inability to obtain appropriate clinical management for cervical intervertebral disc prolapse before the clinical worsening of cervical intervertebral disc prolapse. — MET
- After the onset in 2010 a follow-up MRI recommended for 2012 was not performed because of a nine-month waiting list, and the persisting C5/6 prolapse and smouldering infection were not identified before redeployment. On 18 August 2013 a dust storm prevented aeromedical evacuation for three days, delaying MRI and decompression. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management before the worsening.
Reasonable Hypothesis — Statement of Principles concerning Cervical Intervertebral Disc Prolapse, No. 66 of 2023
Causative factors
Factor 9(1): having trauma to the affected intervertebral disc within the 24 hours before the clinical onset of cervical intervertebral disc prolapse; — MET
- The heavy landing of 14 June 2010, when the veteran's helicopter was hit by small-arms fire on warlike service in Afghanistan, applied significant force to the C5/6 disc, with neck pain, tenderness and loss of movement persisting for months and the neck immobilised in a hard collar. Radicular symptoms began within 24 hours.
Factor 9(2): having a penetrating injury to the affected intervertebral disc or adjacent vertebral body, within the 24 hours before the clinical onset of cervical intervertebral disc prolapse; — MET
- A spall fragment penetrated the neck and lodged in the C6 vertebral body adjacent to the C5/6 disc in the same warlike-service incident on 14 June 2010, about seven hours before onset.
Factor 9(3): flying in high performance aircraft for a cumulative total of at least 500 hours within any 10 year period before the clinical onset of cervical intervertebral disc prolapse; — MET
- The veteran flew 1,240 hours in F/A-18 aircraft between January 1990 and December 1999, more than 500 hours within a 10 year period before onset on 14 June 2010.
Factor 9(4): flying in a helicopter as operational aircrew, for a cumulative total of at least 2,500 hours within the 10 years before the clinical onset of cervical intervertebral disc prolapse; — MET
- He logged 5,150 hours as helicopter operational aircrew in the 10 years before onset, including three warlike deployments to Afghanistan (2006, 2008 and 2010) and East Timor (2000 to 2001), far exceeding 2,500 hours.
Factor 9(5): having smoked tobacco products in an amount of at least 5 pack-years before the clinical onset of cervical intervertebral disc prolapse, and if smoking has ceased before the clinical onset of cervical intervertebral disc prolapse, then that onset occurred within 5 years of cessation; — MET
- He smoked 24 pack-years before stopping on 01 January 2009, more than 5, and onset was within 5 years of cessation. Consumption rose to 30 a day during his warlike deployment to East Timor in 2000 to 2001.
Factor 9(6): having bacterial infection of the affected disc at the time of the clinical onset of cervical intervertebral disc prolapse; — MET
- Staphylococcus aureus infection of the C5/6 disc and C6 vertebral body was introduced by the penetrating fragment on warlike service on 14 June 2010 and was present at onset, as confirmed by culture on 17 June 2010.
Worsening factors
Factor 9(7): having trauma to the affected intervertebral disc within the 24 hours before the clinical worsening of cervical intervertebral disc prolapse; — MET
- The heavy landing in a brownout on 17 August 2013, on warlike service in Afghanistan, caused persisting neck pain and restricted movement and preceded the worsening by less than 24 hours.
Factor 9(8): having a penetrating injury to the affected intervertebral disc or adjacent vertebral body, within the 24 hours before the clinical worsening of cervical intervertebral disc prolapse; — MET
- The CT-guided needle aspiration of the C5/6 disc at the role 3 hospital in Afghanistan on 18 August 2013 was a penetrating injury to the affected disc about five hours before the worsening.
Factor 9(9): flying in high performance aircraft for a cumulative total of at least 500 hours within any 10 year period before the clinical worsening of cervical intervertebral disc prolapse; — MET
- The 1,240 hours of F/A-18 flying between 1990 and 1999 exceed 500 hours within a 10 year period before the worsening.
Factor 9(10): flying in a helicopter as operational aircrew, for a cumulative total of at least 2,500 hours within the 10 years before the clinical worsening of cervical intervertebral disc prolapse; — MET
- He logged 5,620 hours as helicopter aircrew in the 10 years before the worsening, including warlike deployments to Afghanistan in 2006, 2008, 2010 and 2013.
Factor 9(11): having smoked tobacco products in an amount of at least 5 pack-years before the clinical worsening of cervical intervertebral disc prolapse, and if smoking has ceased before the clinical worsening of cervical intervertebral disc prolapse, then that worsening occurred within 5 years of cessation; — MET
- The worsening on 18 August 2013 followed 24 pack-years of smoking and was within 5 years of cessation on 01 January 2009.
Factor 9(12): having bacterial infection of the affected disc at the time of the clinical worsening of cervical intervertebral disc prolapse; — MET
- Recurrent Staphylococcus aureus discitis, grown from the aspirate taken in Afghanistan on 18 August 2013, was present at the worsening.
Factor 9(13): inability to obtain appropriate clinical management for cervical intervertebral disc prolapse before the clinical worsening of cervical intervertebral disc prolapse. — MET
- During warlike service in Afghanistan from 18 to 21 August 2013 a dust storm prevented evacuation for MRI and decompression, and the 2012 follow-up MRI had been missed because of waiting lists. The condition worsened before appropriate management could be obtained.
The % contribution of the causes is 100% and significant.
Sequelae
The cervical radiculopathy is a sequela of the trauma, penetrating fragment injury and bacterial discitis sustained on warlike service in Afghanistan on 14 June 2010. Its own sequelae include post-fusion neck pain, adjacent segment loading at C4/5 and C6/7, and chronic pain with sleep disturbance.
Unintended Consequence
Met. The worsening on 18 August 2013 followed the CT-guided aspiration of the C5/6 disc performed by Defence health services, which was a penetrating injury to the affected disc and was followed within hours by increased weakness. 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 onset in 2010 the follow-up MRI requested in March 2012 was not obtained because of a nine-month waiting list, and the veteran was redeployed without the persisting prolapse and infection being identified. During warlike service on 18 to 21 August 2013 a dust storm prevented evacuation for three days, delaying MRI and decompression while weakness progressed. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), these delays, imposed by service circumstances and not by the veteran, are an inability to obtain appropriate clinical management before the worsening.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 15 Jan 2010, Pre-deployment medical examination, Medical Officer, Army aviation regiment
- 14 Jun 2010, Trauma admission and CT report, Role 3 hospital, Afghanistan
- 16 Jun 2010, MRI cervical spine and neurosurgical consultation, Neurosurgeon
- 17 Jun 2010, Operation report and microbiology, Neurosurgeon
- 22 Jul 2010, Nerve conduction studies and electromyography, Neurologist
- 12 Mar 2012, Outpatient health record, Medical Officer, Base medical centre
- 18 Aug 2013, Emergency record and CT-guided aspiration, Role 3 hospital, Afghanistan
- 20 Aug 2013, MRI cervical spine, Radiologist
- 02 Sep 2013, Operation report, Spinal surgeon
- Flying logbook summaries, 1990 to 2013, Flight records
- Statement of Principles concerning Cervical Intervertebral Disc Prolapse (Balance of Probabilities) No. 67 of 2023, Repatriation Medical Authority
- Statement of Principles concerning Cervical Intervertebral Disc Prolapse (Reasonable Hypothesis) No. 66 of 2023, Repatriation Medical Authority
