Diagnostic Assessment — Cervical Spine - Intervertebral Disc Prolapse
Example 1 of 1 · fictitious patient (Veteran AO)
Diagnostic Assessment
Cervical Spine - Intervertebral Disc Prolapse
BOP Code: 67 of 2023 (Cervical Intervertebral Disc Prolapse)
RH Code: 66 of 2023 (Cervical Intervertebral Disc Prolapse)
ADF History
Veteran AO, date of birth 02 February 1970, Royal Australian Air Force 15 January 1988 to 30 June 2004, then Australian Army (Army Aviation) by inter-service transfer from 01 July 2004, Pilot (fast-jet pilot and instructor, later rotary-wing pilot), enlisted 15 January 1988, medically discharged 14 November 2017. Operational service: Diego Garcia, 05 December 2001 to 20 May 2002 (warlike); Middle East (Iraq), 10 February 2003 to 15 May 2003 (warlike); Solomon Islands, 01 August 2006 to 30 December 2006 (non-warlike); East Timor, 01 March 2007 to 30 August 2007 (non-warlike); Afghanistan, 01 March 2008 to 31 October 2008 (warlike); Afghanistan, 15 February 2011 to 20 October 2011 (warlike); Afghanistan, 01 March 2013 to 20 September 2013 (warlike, ended by aeromedical evacuation); Middle East Area of Operations, 10 January 2015 to 13 May 2015 (warlike, ended by aeromedical evacuation).
Occupational History
As a fast-jet pilot and instructor the veteran flew aircraft that routinely produce accelerations of 4 to 7.5g, with the head and neck loaded by the helmet and night-vision equipment and repeatedly rotated to look behind under load. As a rotary-wing pilot he flew long sorties seated in a fixed, forward-flexed posture, exposed to whole-body vibration, wearing helmets with night-vision goggles and counterweights, and conducted tactical, low-level and brownout landings.
Operational aircrew face hard landings, crash landings, hostile ground fire and fragmentation injuries. Smoking was common and tolerated in aircrew crew rooms and on operations during the period, and forward operating bases had no access to MRI or specialist spinal or infectious diseases care.
History
Veteran AO, a fast-jet pilot who later transferred to Army Aviation as a helicopter pilot, sustained a heavy landing and a shell fragment injury to the C6 vertebral body when his helicopter was hit by ground fire in Afghanistan on 18 September 2013, with the clinical onset of a C5-6 intervertebral disc prolapse that day and an infective discitis of the same disc. The prolapse worsened on 12 May 2015 in the Middle East after a brownout hard landing and a needle aspiration of the disc, on a background of more than 1,400 hours in high performance aircraft, more than 5,000 helicopter hours and 25 years of smoking.
Timeline
- 15 May 2003 — At the end of warlike service in the Middle East the veteran's flying logbook recorded 1,410 hours in high performance aircraft between 01 January 1993 and 15 May 2003, including 548 hours flown on warlike service at Diego Garcia in 2001 and 2002 and over Iraq in 2003. He reported intermittent neck aching after high-g sorties, settling within a day, with no radicular symptoms. "1,410 hours fast-jet, neck ache"
- 02 Aug 2013 — At his annual aircrew medical before the second half of his Afghanistan rotation the veteran had a full, pain-free range of cervical movement and normal upper limb neurology. His logbook recorded 5,320 rotary-wing hours since 01 July 2004, of which 2,710 were flown on warlike and non-warlike service. He smoked 25 cigarettes a day and had done so since recruit training in 1988, about 31 pack-years. "neck full range, neurology normal"
- 18 Sep 2013 — At 05:40 on warlike service in Afghanistan the veteran's helicopter was struck by ground fire on approach and made a heavy landing. He had immediate severe neck pain and left arm pain, and a small entry wound at the left anterior neck. CT at the role 3 hospital showed a metallic shell fragment embedded in the anterior C6 vertebral body abutting the C5-6 disc, with prevertebral swelling. The cervical spine was immobilised in a rigid collar. "heavy landing, fragment C6 body"
- 23 Sep 2013 — After aeromedical evacuation, MRI showed a left posterolateral extrusion of the C5-6 disc compressing the left C6 nerve root, with high signal in the disc and adjacent endplates consistent with early discitis. He had left C6 radicular pain, reduced biceps reflex and weakness of elbow flexion. On 25 September 2013 a spinal surgeon removed the fragment by an anterior approach and debrided the vertebral body without fusion. "C5-6 extrusion, left C6 compression"
- 27 Sep 2013 — Cultures from the fragment track and a CT-guided aspirate of the C5-6 disc grew Staphylococcus aureus. An infectious diseases physician diagnosed bacterial discitis of C5-6 introduced by the penetrating fragment and gave six weeks of intravenous flucloxacillin, followed by oral antibiotics. CRP fell from 142 to 9 mg/L. "Staph aureus discitis C5-6"
- 20 Mar 2014 — The veteran had residual neck pain and intermittent left C6 paraesthesia but had regained full strength. He was returned to flying duties with restrictions. He had not stopped smoking. "returned to restricted flying"
- 12 May 2015 — On warlike service in the Middle East the veteran had had fever and rising neck pain since 24 April 2015, but no imaging or intravenous antibiotics were available at his forward base. At 09:15 on 11 May 2015 his helicopter made a hard landing in brownout, and at 17:00 that day a CT-guided needle aspiration of the C5-6 disc was performed at the role 3 hospital. On waking on 12 May 2015 he had severe neck pain and new weakness of the left biceps and wrist extensors. "new left C6 weakness, fever"
- 15 May 2015 — MRI after aeromedical evacuation showed enlargement of the C5-6 extrusion, now contacting the spinal cord, with recurrent discitis and endplate oedema. The aspirate grew Staphylococcus aureus. A spinal surgeon recorded clinical worsening, with C6 motor weakness graded 4 out of 5 and a Neck Disability Index of 56 per cent compared with 22 per cent in March 2014. "larger extrusion, recurrent discitis"
Symptoms
At onset the veteran had severe neck pain and stiffness with pain radiating down the left arm to the thumb and index finger, numbness in the same distribution and weakness of elbow flexion. Neck movement was markedly restricted, particularly extension and rotation to the left.
He now reports constant neck pain, stiffness, headaches from the neck, left arm paraesthesia and weakness of grip, worse with looking up or prolonged sitting. He cannot tolerate wearing a helmet, driving long distances or working overhead.
Imaging
- 18 Sep 2013 — CT cervical spine: "Metallic fragment 9 mm embedded in the anterior C6 vertebral body abutting the inferior endplate of C5-6. Prevertebral soft tissue swelling. No fracture-dislocation."
- 23 Sep 2013 — MRI cervical spine: "Left posterolateral extrusion of the C5-6 intervertebral disc compressing the exiting left C6 nerve root. High T2 signal within the disc and adjacent endplates consistent with early discitis. Fragment artefact in the C6 vertebral body."
- 15 May 2015 — MRI cervical spine: "Enlarged left paracentral and posterolateral C5-6 disc extrusion contacting and indenting the left side of the spinal cord, with severe left foraminal narrowing. Recurrent discitis with endplate oedema at C5-6 and a small prevertebral collection."
Onset Date
The most likely date of onset of this condition is 18 Sep 2013.
At that date the veteran was on warlike service in Afghanistan as a rotary-wing pilot. At 05:40 his helicopter was struck by ground fire and made a heavy landing, and a shell fragment pierced the C6 vertebral body. Neck and left arm pain began immediately and were persistently present from that time until the confirming MRI on 23 September 2013.
This date is appropriate because his annual aircrew medical of 02 August 2013 recorded a full, pain-free cervical range of movement and normal neurology, and he was assessed at the role 3 hospital within hours of the injury. Under the Statement of Principles, clinical onset is the date from which the symptoms were persistently present, worked back from the first imaging confirming the prolapse.
For the trauma and penetrating injury factors, the 24 hours before onset run from 05:40 on 17 Sep 2013 to 05:40 on 18 Sep 2013; the heavy landing and fragment injury occurred at the end of that period and the symptoms began immediately. For the helicopter factor, the 10 years before onset run from 18 Sep 2003 to 18 Sep 2013, during which he flew 5,320 rotary-wing hours, 2,710 of them on operational service. For the high performance aircraft factor, the 10-year period from 01 Jan 1993 to 31 Dec 2002 contains 1,280 hours of his 1,410 high performance hours, and onset fell within the 25 years following that period. For the smoking factor, he had smoked about 31 pack-years by onset and was still smoking. The bacterial infection was introduced by the fragment at onset and confirmed on culture on 27 Sep 2013.
For the worsening factors, the documented worsening was on 12 May 2015. The 24 hours before the worsening run from 07:00 on 11 May 2015 to 07:00 on 12 May 2015, and contain the brownout hard landing at 09:15 and the needle aspiration of the disc at 17:00. The 10 years before the worsening run from 12 May 2005 to 12 May 2015, during which he flew 5,610 rotary-wing hours, 2,980 of them on operational service. He was still smoking, with about 33 pack-years, and recurrent discitis was present from late April 2015.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Cervical Intervertebral Disc Prolapse at C5-6 with left C6 radiculopathy (ICD-10-AM M50.1), 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 a protrusion, herniation, extrusion or rupture of the nucleus pulposus or annulus fibrosus of a cervical disc into the vertebral canal, causing symptoms or signs. It may produce local neck pain and stiffness, compression of an exiting nerve root with pain, numbness and weakness in the arm, or compression of the spinal cord. Disc bulging and Schmorl's nodes are excluded. It may arise from a single episode of significant force on the disc, from cumulative loading such as high-g and helicopter flying, or from weakening of the disc by infection and smoking.
The condition began on 18 September 2013 with a heavy landing and fragment injury on warlike service in Afghanistan, was confirmed on MRI on 23 September 2013, and worsened on 12 May 2015 on warlike service in the Middle East.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
18 September 2013.
When did the veteran first present to a health / medical provider for this condition?
18 September 2013.
When was the condition confirmed / formally diagnosed?
23 September 2013.
When did the veteran first present to you (or your practice) for this condition?
06 August 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed by MRI on 23 September 2013, which showed a left posterolateral extrusion of the C5-6 disc into the vertebral canal compressing the left C6 nerve root. This was accompanied by neck pain and stiffness and by the symptoms and signs of left C6 nerve root compression: radicular pain and numbness to the thumb and index finger, a reduced biceps reflex and weakness of elbow flexion. This meets both limbs of the Statement of Principles definition: clinical manifestations of pain and stiffness or nerve root compression, and imaging evidence of disc extrusion into the vertebral canal.
A spinal surgeon confirmed the diagnosis. The worsening was confirmed clinically on 12 May 2015, with new C6 motor weakness, and on MRI on 15 May 2015, which showed an enlarged extrusion contacting the spinal cord.
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 18 September 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 Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's warlike and non-warlike service, including his high performance flying at Diego Garcia and over Iraq, his helicopter flying in the Solomon Islands, East Timor and Afghanistan, the heavy landing and fragment injury in Afghanistan in 2013 that caused the onset, and his service in the Middle East in 2015, where the condition worsened.
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 05:40 on 18 September 2013 the veteran's helicopter made a heavy landing after being struck by ground fire, applying a large axial and flexion force to the cervical spine. It caused immediate neck pain, tenderness and restricted movement, which persisted for more than 7 days, and the neck was immobilised in a rigid collar. The symptoms of the prolapse began immediately, within the 24 hours after the trauma. The landing occurred while he was flying as a service pilot.
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 9 mm metallic shell fragment entered the left anterior neck and pierced the anterior C6 vertebral body, the vertebral body adjacent to the affected C5-6 disc, as shown on CT on 18 September 2013. The onset of the prolapse followed immediately, within 24 hours of the penetrating injury.
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
- The veteran's flying logbook records 1,280 hours in fast-jet trainers and fighter aircraft capable of routinely producing at least 4g in the 10 years from 01 January 1993 to 31 December 2002, as a fighter pilot and flying instructor. The onset on 18 September 2013 occurred 10 years and 9 months after the end of that period, within the 25 years following it.
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
- The veteran flew 5,320 hours as a helicopter pilot between 01 July 2004 and 18 September 2013, all within the 10 years before onset, from 18 September 2003 to 18 September 2013, wearing a helmet with night-vision goggles and counterweights on most sorties.
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 began smoking during recruit training in January 1988 and smoked 20 to 25 cigarettes a day from then on, about 31 pack-years by the onset on 18 September 2013. He had not stopped smoking. Smoking was tolerated and widespread in aircrew crew rooms and on operations, and nicotine replacement was not offered to him on deployment.
Factor 9(6): having bacterial infection of the affected disc at the time of the clinical onset of cervical intervertebral disc prolapse; — MET
- The shell fragment that pierced the C6 vertebral body carried bacteria into the C5-6 disc space at the moment of onset. MRI on 23 September 2013 showed high signal in the disc and endplates, and a CT-guided aspirate of the C5-6 disc on 27 September 2013 grew Staphylococcus aureus. An infectious diseases physician confirmed bacterial discitis present from the time of the injury.
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 09:15 on 11 May 2015 the veteran's helicopter made a hard landing in brownout, jarring his neck with immediate pain, tenderness and loss of rotation that persisted beyond 7 days. The clinical worsening, with new C6 motor weakness, was documented on waking at 07:00 on 12 May 2015, 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 17:00 on 11 May 2015 a CT-guided needle aspiration was performed through the C5-6 disc at the role 3 hospital to investigate suspected recurrent discitis. The needle pierced the affected disc. The worsening followed within 24 hours, on 12 May 2015.
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 1,280 hours flown in high performance aircraft from 01 January 1993 to 31 December 2002 fell within a 10-year period before the worsening on 12 May 2015, which occurred 12 years and 4 months after that period ended, within the 25 years following it.
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's logbook records 5,610 helicopter hours between 12 May 2005 and 12 May 2015, the 10 years before the worsening, after his return to flying in March 2014.
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
- The veteran was still smoking 20 cigarettes a day at the worsening on 12 May 2015, with a cumulative total of about 33 pack-years.
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 of C5-6 was present at the worsening, with fever and a CRP of 85 mg/L from late April 2015, endplate oedema and a prevertebral collection on MRI on 15 May 2015, and a positive culture of the aspirate taken on 11 May 2015.
Factor 9(13): inability to obtain appropriate clinical management for cervical intervertebral disc prolapse before the clinical worsening of cervical intervertebral disc prolapse. — MET
- From 24 April to 11 May 2015 the veteran had fever and increasing neck pain at a forward base where no MRI, intravenous antibiotics or spinal review were available, and operational demands kept him flying. The recurrent infection and prolapse went untreated for 17 days before the worsening. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
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 at 05:40 on 18 September 2013 occurred on warlike service in Afghanistan, when the helicopter was struck by ground fire on approach. It caused immediate neck pain and restricted movement requiring collar immobilisation, and the onset followed within the 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
- The shell fragment that pierced the C6 vertebral body adjacent to the C5-6 disc was from hostile fire on warlike service in Afghanistan on 18 September 2013. The onset followed within 24 hours.
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 548 hours in fighter aircraft capable of routinely producing at least 4g on warlike service, at Diego Garcia from December 2001 to May 2002 and over Iraq from February to May 2003. These hours fall within the 10-year period from 01 June 1993 to 31 May 2003, before onset on 18 September 2013.
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
- The veteran flew 2,710 helicopter hours on operational service within the 10 years before onset, from 18 September 2003 to 18 September 2013: 410 hours in the Solomon Islands in 2006, 360 hours in East Timor in 2007, 680 hours in Afghanistan in 2008, 690 hours in Afghanistan in 2011 and 570 hours in Afghanistan in 2013.
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
- The veteran smoked about 31 pack-years by onset and was still smoking. His intake rose from 20 to 30 cigarettes a day on each of his warlike deployments, where smoking was the accepted means of coping with prolonged alert periods, and the deployed periods alone totalled more than 5 pack-years.
Factor 9(6): having bacterial infection of the affected disc at the time of the clinical onset of cervical intervertebral disc prolapse; — MET
- The Staphylococcus aureus discitis of C5-6 was introduced by the shell fragment from hostile fire on warlike service in Afghanistan at the moment of onset on 18 September 2013, and was confirmed on culture on 27 September 2013.
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 brownout hard landing at 09:15 on 11 May 2015 occurred on warlike service in the Middle East, and the worsening followed within 24 hours, on 12 May 2015.
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 needle aspiration through the C5-6 disc at 17:00 on 11 May 2015 was performed at a role 3 hospital during warlike service in the Middle East, and the worsening followed within 24 hours.
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 548 hours flown in high performance aircraft on warlike service at Diego Garcia and over Iraq fall within the 10-year period from 01 June 1993 to 31 May 2003, before the worsening on 12 May 2015.
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
- In the 10 years before the worsening, from 12 May 2005 to 12 May 2015, the veteran flew 2,980 helicopter hours on operational service, including 270 hours on warlike service in the Middle East in 2015.
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 veteran was smoking up to 30 cigarettes a day on warlike service in the Middle East at the worsening on 12 May 2015, with about 33 pack-years in total.
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 of C5-6, a recrudescence of the infection introduced by hostile fire in Afghanistan, was present at the worsening on warlike service in the Middle East on 12 May 2015.
Factor 9(13): inability to obtain appropriate clinical management for cervical intervertebral disc prolapse before the clinical worsening of cervical intervertebral disc prolapse. — MET
- On warlike service in the Middle East from 24 April to 11 May 2015 the veteran had no access to MRI, intravenous antibiotics or spinal review at his forward base and was kept on flying duties, and the condition worsened on 12 May 2015.
The % contribution of the causes is 100% and significant.
Sequelae
The cervical intervertebral disc prolapse is a sequela of the veteran's accepted fragment wound of the neck and C6 vertebral body and of the bacterial discitis of C5-6 introduced by that wound. In turn it has caused chronic left C6 radiculopathy with weakness of grip, cervicogenic headache and sleep disturbance from neck pain.
Unintended Consequence
Met. The CT-guided needle aspiration of the C5-6 disc on 11 May 2015 was performed by a Defence medical team while the veteran was serving, and was followed within 24 hours by the clinical worsening of the prolapse. The worsening is in part an unintended consequence of that procedure, provided and paid for by the Commonwealth (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. From 24 April to 11 May 2015, on warlike service in the Middle East, the veteran had fever, a rising CRP and increasing neck pain at a forward base with no MRI, no intravenous antibiotics and no spinal or infectious diseases review, and operational demands kept him flying. The recurrent infection of the prolapsed disc went untreated for 17 days and the prolapse then worsened, with new C6 motor weakness and cord contact on MRI. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the unavailability of investigation and treatment because of his service circumstances amounts to an inability to obtain appropriate clinical management before the clinical worsening.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 15 May 2003, Flying logbook summary, Fighter squadron
- 02 Aug 2013, Annual aircrew medical, Medical Officer (Aviation Medicine)
- 18 Sep 2013, Trauma admission and CT cervical spine report, Role 3 hospital, Afghanistan
- 23 Sep 2013, MRI cervical spine report, Radiologist
- 25 Sep 2013, Operation report, Spinal surgeon
- 27 Sep 2013, Microbiology report and specialist letter, Infectious diseases physician
- 20 Mar 2014, Specialist review and return to flying assessment, Spinal surgeon and Medical Officer (Aviation Medicine)
- 11 May 2015, CT-guided aspiration report, Role 3 hospital, Middle East
- 12 May 2015, Deployed health record, Medical Officer, Role 3 hospital, Middle East
- 15 May 2015, MRI cervical spine report and spinal surgery consultation, Radiologist and Spinal surgeon
- 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
