Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been withheld or altered and all dates changed. It must not be relied upon as a record of any real claim.
Diagnostic Assessment — Cervical Spine - Pain, Disc Narrowing at C5/6 and Perineural Cyst
Example 1 of 2 · fictitious patient (Veteran L)
Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.
Diagnostic Assessment
Cervical Spine - Pain, Disc Narrowing at C5/6 and Perineural Cyst
Balance of Probabilities SOP: Strain SOP No. 28 of 2020 - Factors (1), (2), (5) Reasonable Hypothesis SOP: Strain SOP No. 29 of 2020 - Factors (1), (2), (5)
ADF History
The veteran, Date of Birth: [withheld] Electronic Warfare Operator, enlistment date 09 Feb 1990, discharge date 17 February 2000.
Occupational History
As an Electronic Warfare Operator in the Australian Army, the veteran served in operational environments where vehicle accidents and trauma were occupational hazards. The role required operating in challenging conditions including convoy operations, vehicle maintenance, and deployment activities where motor vehicle accidents could occur. Military operations often involved rapid movement and transportation in austere environments with increased risk of vehicular trauma. The nature of deployment operations exposed personnel to various physical risks including whiplash-type injuries from vehicle accidents.
History
The veteran an Electronic Warfare Operator, experienced cervical spine pain in January 1999 following an accident during deployment, likely a whiplash-type injury, which resulted in disc narrowing at C5/6 and development of a perineural cyst.
Timeline
15 November 1996: The veteran experienced cervical pain and stiffness post-accident during a deployment, diagnosed as a cervical strain per the Strain SOP. The injury was likely whiplash-associated, caused by sudden neck movement during the accident. He received physiotherapy treatment including joint mobilization techniques to address the acute cervical injury and restore normal neck function. The pain persisted following the initial incident, causing ongoing discomfort and functional limitation. The condition was attributed to the physical demands and trauma risks inherent in his deployment role as an Electronic Warfare Operator. The incident marked the onset of chronic cervical spine issues that would affect his remaining military service.
23 July 1997: X-rays revealed slight narrowing of the C5/6 intervertebral disc space, confirming structural changes related to the March accident. The veteran reported ongoing intermittent neck pain, particularly during physical tasks and activities requiring neck movement. The disc narrowing suggested early degenerative changes secondary to the March trauma, indicating that the acute injury had progressed to structural compromise. No neuroforaminal narrowing or other significant abnormalities were noted at this time. Physiotherapy was likely continued to manage ongoing symptoms and maintain cervical function. The condition remained a source of ongoing discomfort affecting his operational capabilities.
24 September 2018: An MRI identified a small left perineural cyst at C5-C6, deemed non-significant, with no spinal stenosis or neuroforaminal narrowing. The veteran reported persistent neck pain, particularly during prolonged activities requiring neck positioning. The cervical lordosis was straightened, suggesting chronic strain and altered biomechanics from the original injury. The perineural cyst was noted as an incidental finding but may represent a sequela of the chronic cervical dysfunction. The pain was attributed to the 2001 injury and ongoing degenerative changes from the original trauma. Conservative management continued to be the primary treatment approach.
Symptoms
At the time of the January 1999 injury, the veteran experienced cervical pain and stiffness following the deployment accident, consistent with whiplash-type trauma to the cervical spine. Following the injury, symptoms included ongoing intermittent neck pain, stiffness, and functional limitation particularly during physical tasks requiring neck movement. Current symptoms include persistent cervical spine pain particularly during prolonged activities, with confirmed disc narrowing at C5/6 and straightened cervical lordosis indicating chronic structural changes, and a perineural cyst contributing to ongoing discomfort and functional limitation affecting daily activities and quality of life.
Imaging
23 July 1997: X-rays revealed slight narrowing of the C5/6 intervertebral disc space indicating early degenerative changes. No neuroforaminal narrowing or other significant abnormalities were noted.
24 September 2018: MRI identified a small left perineural cyst at C5-C6, deemed non-significant, with no spinal stenosis or neuroforaminal narrowing. The cervical lordosis was straightened, suggesting chronic strain patterns from the original injury.
1. What is the formal diagnosis of the condition claimed above?
Cervical Spine - Pain (M54.2), Disc Narrowing at C5/6 (M50.222), and Perineural Cyst (M71.38), DVA SOP Strain SOP No. 28 of 2020, ICD-10 codes M54.2, M50.222, and M71.38.
Cervical spine pain encompasses discomfort and dysfunction affecting the neck region, often resulting from trauma, muscle strain, or degenerative changes. This can significantly impact function and quality of life, particularly when chronic.
Disc narrowing at C5/6 refers to the reduction in intervertebral disc space height at this specific level, typically resulting from disc degeneration following trauma or as part of degenerative processes. The C5/6 level is commonly affected due to its mobility and stress concentration.
A perineural cyst is a fluid-filled sac that forms around nerve roots, typically developing secondary to chronic inflammation or trauma. While often considered incidental, these can develop as a consequence of chronic spinal dysfunction and altered biomechanics.
The temporal relationship shows the initial cervical trauma in January 1999, disc narrowing identified in September 1999, and perineural cyst formation noted in 2023, indicating progressive changes from acute injury to chronic complications.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? 15 November 1996 - following deployment accident.
When did the veteran first present to a health/medical provider for this condition? 15 November 1996 - the veteran first presented to a medical provider, likely a Military Medic or Physiotherapist, immediately following the cervical injury during deployment.
When was the condition confirmed/formally diagnosed? 15 November 1996 - The cervical strain was diagnosed at the time of injury. 23 July 1997 - The disc narrowing at C5/6 was formally diagnosed by the treating doctor, Radiologist, at the state X-Ray. 24 September 2018 - The perineural cyst was identified by the treating doctor, Radiologist, at I-MED Radiology through MRI imaging.
When did the veteran first present to you (or your practice) for this condition? 25 November 2017
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis of cervical spine pain was confirmed by clinical assessment in January 1999 based on the mechanism of injury (whiplash-type trauma) and immediate symptoms of cervical pain and stiffness. Physiotherapy assessment confirmed the need for joint mobilization and ongoing treatment.
The diagnosis of disc narrowing at C5/6 was confirmed by X-rays on 23 July 1997, reported by the treating doctor at the state X-Ray, showing slight narrowing of the C5/6 intervertebral disc space. The diagnosis of perineural cyst was confirmed by MRI on 24 September 2018, reported by the treating doctor at I-MED Radiology, identifying a small left perineural cyst at C5-C6 with straightened cervical lordosis. The clinical history and imaging findings established the diagnoses, linking the progressive changes to the January 1999 traumatic injury.
4. What do you consider to be the cause(s) of the condition in this veteran?
Experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament - MET
- The veteran experienced significant physical force to his cervical spine during the January 1999 accident, causing immediate whiplash-type trauma and subsequent structural changes.
Forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon - MET
- The accident subjected the cervical muscles, ligaments, and supporting structures to forceful stretching beyond their normal capacity, causing the initial strain.
Inability to obtain appropriate clinical management for sprain or strain - MET
- While initial physiotherapy was provided, there is evidence of inadequate ongoing clinical management as demonstrated by the 22-year delay between the 2001 disc narrowing identification and comprehensive MRI in 2023, and the progression from simple strain to chronic changes including perineural cyst formation, representing failure to provide appropriate ongoing specialized care per Brew v Repatriation Commission.
Note: As this condition has an onset date of 15 November 1996, which is before 13 Mar 1998, and did not occur on warlike deployment, it falls under DRCA legislation. However, the factors analysis above demonstrates clear causal relationship to military service.
Sequelae
The disc narrowing at C5/6 and perineural cyst are direct sequelae of the original January 1999 cervical strain, developing due to chronic structural changes, altered biomechanics, and ongoing stress that resulted from the initial whiplash-type trauma.
Unintended Consequence
This condition is not an unintended consequence of medical management as no specific medical procedures or medications directly caused the condition.
Inability to Attain Appropriate Medical Management
There was evidence of inability to attain fully appropriate medical management as demonstrated by the 22-year delay between identification of disc narrowing in 2001 and comprehensive MRI investigation in 2023. The Full Federal Court in Brew v Repatriation Commission establishes that inability encompasses the lack of ability to get treatment in both objective and subjective senses. While initial physiotherapy was provided, the progression to chronic changes including straightened cervical lordosis and perineural cyst formation suggests that more comprehensive ongoing management was warranted. The extensive delay in advanced imaging and the development of secondary complications indicate that optimal specialized care was not consistently available, potentially contributing to the permanent worsening evidenced by the progressive structural changes.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication/prescribing history.
Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.
Diagnostic Assessment — Cervical Spine - Pain, Disc Narrowing at C5/6 and Perineural Cyst
Example 2 of 2 · fictitious patient (Veteran L)
Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.
Diagnostic Assessment
Cervical Spine - Pain, Disc Narrowing at C5/6 and Perineural Cyst
Balance of Probabilities SOP: Strain SOP No. 28 of 2020 - Factors (1), (2), (5) Reasonable Hypothesis SOP: Strain SOP No. 29 of 2020 - Factors (1), (2), (5)
ADF History
The veteran, Date of Birth: [withheld] Electronic Warfare Operator, enlistment date 09 Feb 1990, discharge date 17 February 2000.
Occupational History
As an Electronic Warfare Operator in the Australian Army, the veteran served in operational environments where vehicle accidents and trauma were occupational hazards. The role required operating in challenging conditions including convoy operations, vehicle maintenance, and deployment activities where motor vehicle accidents could occur. Military operations often involved rapid movement and transportation in austere environments with increased risk of vehicular trauma. The nature of deployment operations exposed personnel to various physical risks including whiplash-type injuries from vehicle accidents.
History
The veteran an Electronic Warfare Operator, experienced cervical spine pain in January 1999 following an accident during deployment, likely a whiplash-type injury, which resulted in disc narrowing at C5/6 and development of a perineural cyst.
Timeline
15 November 1996: The veteran experienced cervical pain and stiffness post-accident during a deployment, diagnosed as a cervical strain per the Strain SOP. The injury was likely whiplash-associated, caused by sudden neck movement during the accident. He received physiotherapy treatment including joint mobilization techniques to address the acute cervical injury and restore normal neck function. The pain persisted following the initial incident, causing ongoing discomfort and functional limitation. The condition was attributed to the physical demands and trauma risks inherent in his deployment role as an Electronic Warfare Operator. The incident marked the onset of chronic cervical spine issues that would affect his remaining military service.
23 July 1997: X-rays revealed slight narrowing of the C5/6 intervertebral disc space, confirming structural changes related to the March accident. The veteran reported ongoing intermittent neck pain, particularly during physical tasks and activities requiring neck movement. The disc narrowing suggested early degenerative changes secondary to the March trauma, indicating that the acute injury had progressed to structural compromise. No neuroforaminal narrowing or other significant abnormalities were noted at this time. Physiotherapy was likely continued to manage ongoing symptoms and maintain cervical function. The condition remained a source of ongoing discomfort affecting his operational capabilities.
24 September 2018: An MRI identified a small left perineural cyst at C5-C6, deemed non-significant, with no spinal stenosis or neuroforaminal narrowing. The veteran reported persistent neck pain, particularly during prolonged activities requiring neck positioning. The cervical lordosis was straightened, suggesting chronic strain and altered biomechanics from the original injury. The perineural cyst was noted as an incidental finding but may represent a sequela of the chronic cervical dysfunction. The pain was attributed to the 2001 injury and ongoing degenerative changes from the original trauma. Conservative management continued to be the primary treatment approach.
Symptoms
At the time of the January 1999 injury, the veteran experienced cervical pain and stiffness following the deployment accident, consistent with whiplash-type trauma to the cervical spine. Following the injury, symptoms included ongoing intermittent neck pain, stiffness, and functional limitation particularly during physical tasks requiring neck movement. Current symptoms include persistent cervical spine pain particularly during prolonged activities, with confirmed disc narrowing at C5/6 and straightened cervical lordosis indicating chronic structural changes, and a perineural cyst contributing to ongoing discomfort and functional limitation affecting daily activities and quality of life.
Imaging
23 July 1997: X-rays revealed slight narrowing of the C5/6 intervertebral disc space indicating early degenerative changes. No neuroforaminal narrowing or other significant abnormalities were noted.
24 September 2018: MRI identified a small left perineural cyst at C5-C6, deemed non-significant, with no spinal stenosis or neuroforaminal narrowing. The cervical lordosis was straightened, suggesting chronic strain patterns from the original injury.
1. What is the formal diagnosis of the condition claimed above?
Cervical Spine - Pain (M54.2), Disc Narrowing at C5/6 (M50.222), and Perineural Cyst (M71.38), DVA SOP Strain SOP No. 28 of 2020, ICD-10 codes M54.2, M50.222, and M71.38.
Cervical spine pain encompasses discomfort and dysfunction affecting the neck region, often resulting from trauma, muscle strain, or degenerative changes. This can significantly impact function and quality of life, particularly when chronic.
Disc narrowing at C5/6 refers to the reduction in intervertebral disc space height at this specific level, typically resulting from disc degeneration following trauma or as part of degenerative processes. The C5/6 level is commonly affected due to its mobility and stress concentration.
A perineural cyst is a fluid-filled sac that forms around nerve roots, typically developing secondary to chronic inflammation or trauma. While often considered incidental, these can develop as a consequence of chronic spinal dysfunction and altered biomechanics.
The temporal relationship shows the initial cervical trauma in January 1999, disc narrowing identified in September 1999, and perineural cyst formation noted in 2023, indicating progressive changes from acute injury to chronic complications.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? 15 November 1996 - following deployment accident.
When did the veteran first present to a health/medical provider for this condition? 15 November 1996 - the veteran first presented to a medical provider, likely a Military Medic or Physiotherapist, immediately following the cervical injury during deployment.
When was the condition confirmed/formally diagnosed? 15 November 1996 - The cervical strain was diagnosed at the time of injury. 23 July 1997 - The disc narrowing at C5/6 was formally diagnosed by the treating doctor, Radiologist, at the state X-Ray. 24 September 2018 - The perineural cyst was identified by the treating doctor, Radiologist, at I-MED Radiology through MRI imaging.
When did the veteran first present to you (or your practice) for this condition? 25 November 2017
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis of cervical spine pain was confirmed by clinical assessment in January 1999 based on the mechanism of injury (whiplash-type trauma) and immediate symptoms of cervical pain and stiffness. Physiotherapy assessment confirmed the need for joint mobilization and ongoing treatment.
The diagnosis of disc narrowing at C5/6 was confirmed by X-rays on 23 July 1997, reported by the treating doctor at the state X-Ray, showing slight narrowing of the C5/6 intervertebral disc space. The diagnosis of perineural cyst was confirmed by MRI on 24 September 2018, reported by the treating doctor at I-MED Radiology, identifying a small left perineural cyst at C5-C6 with straightened cervical lordosis. The clinical history and imaging findings established the diagnoses, linking the progressive changes to the January 1999 traumatic injury.
4. What do you consider to be the cause(s) of the condition in this veteran?
Experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament - MET
- The veteran experienced significant physical force to his cervical spine during the January 1999 accident, causing immediate whiplash-type trauma and subsequent structural changes.
Forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon - MET
- The accident subjected the cervical muscles, ligaments, and supporting structures to forceful stretching beyond their normal capacity, causing the initial strain.
Inability to obtain appropriate clinical management for sprain or strain - MET
- While initial physiotherapy was provided, there is evidence of inadequate ongoing clinical management as demonstrated by the 22-year delay between the 2001 disc narrowing identification and comprehensive MRI in 2023, and the progression from simple strain to chronic changes including perineural cyst formation, representing failure to provide appropriate ongoing specialized care per Brew v Repatriation Commission.
Note: As this condition has an onset date of 15 November 1996, which is before 13 Mar 1998, and did not occur on warlike deployment, it falls under DRCA legislation. However, the factors analysis above demonstrates clear causal relationship to military service.
Sequelae
The disc narrowing at C5/6 and perineural cyst are direct sequelae of the original January 1999 cervical strain, developing due to chronic structural changes, altered biomechanics, and ongoing stress that resulted from the initial whiplash-type trauma.
Unintended Consequence
This condition is not an unintended consequence of medical management as no specific medical procedures or medications directly caused the condition.
Inability to Attain Appropriate Medical Management
There was evidence of inability to attain fully appropriate medical management as demonstrated by the 22-year delay between identification of disc narrowing in 2001 and comprehensive MRI investigation in 2023. The Full Federal Court in Brew v Repatriation Commission establishes that inability encompasses the lack of ability to get treatment in both objective and subjective senses. While initial physiotherapy was provided, the progression to chronic changes including straightened cervical lordosis and perineural cyst formation suggests that more comprehensive ongoing management was warranted. The extensive delay in advanced imaging and the development of secondary complications indicate that optimal specialized care was not consistently available, potentially contributing to the permanent worsening evidenced by the progressive structural changes.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication/prescribing history.
Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.
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