Cervical Spine - Spondylosis — DVA claim example

Diagnostic Assessment — Cervical Spine - Spondylosis

Example 1 of 3 · fictitious patient (Veteran D)

Diagnostic Assessment

Cervical Spine - Spondylosis

Cervical Spine - C3/4 Bilateral Foraminal Stenosis with C4 Nerve Root Compression Cervical Spine - C4/5 Left Foraminal Narrowing with C5 Nerve Root Impingement Cervical Spine - C5/6 Right Foraminal Disc Osteophyte with C6 Nerve Root Impingement

Balance of Probabilities: Cervical Spondylosis (No. 12 of 2023) Reasonable Hypothesis: Cervical Spondylosis (No. 11 of 2023)

ADF History

The veteran, Airfield Defence Guard (ADG), enlisted 29 July 1993, currently serving.

Occupational History

As an Airfield Defence Guard (ADG) in the Royal Australian Air Force, the veteran was exposed to a range of occupational hazards. These include physical stressors such as manual handling of heavy equipment, weapons, ammunition, and field gear, often involving lifting, carrying, and pack marching over uneven terrain for extended durations. Significant noise exposure occurred from weapons firing, aircraft operations, and vehicle movements. Environmental exposures included prolonged exposure to sunlight (UV radiation), heat, cold, dust, and airborne particulates. Vibration exposure came from vehicles, aircraft, and weapons recoil. Chemical exposures included fuels, oils, solvents, and cleaning agents. Psychological stressors were inherent in military service, particularly in security and defence roles. Risk of traumatic injury was present due to the physical nature of duties, weapons handling, fieldcraft, and operational activities.

History

The veteran an Airfield Defence Guard in the RAAF, first reported neck issues on 25 Apr 1996, when he experienced left cervical and thoracic pain following a rifle shoot, diagnosed as a left trapezius strain. An MRI of his cervical spine on 03 December 2018 revealed cervical spondylosis with significant degenerative changes including loss of normal cervical lordosis and multi-level foraminal stenosis with nerve root compression.

Timeline

• 25 Apr 1996 - the veteran presented with left cervical and thoracic pain following a rifle shoot. He was diagnosed with a left trapezius strain. Physiotherapy was initiated, which included joint mobilisation, soft tissue massage, stretches, ultrasound, and heat. He attended multiple physiotherapy sessions for this issue through July 1998.
• 31 Jun 1999 - Annual Health Assessment noted the veteran "Seldom" felt his lifestyle was putting him under too much stress. During the past two weeks, he experienced "A Moderate Amount of Stress". Lifestyle counselling noted "No major stressors".
• 18 Nov 2004 - During an operational deployment in the the overseas area of operations, sustained injury to right shoulder while holding onto cargo net in C-130 aircraft that braked heavily. While this primarily affected the shoulder, it is relevant to the cervical spine due to biomechanical connections.
• 14 May 2006 - HealthKeys Comprehensive Preventive Health Examination recorded various health measures including stress assessments. While not specifically focused on cervical issues, documents overall health status during service.
• 03 Dec 2018 - An MRI of the Cervical Spine was performed due to neck pain following a rifle shot, coaching with neck to the left, pack marching, and lifting/carrying heavy equipment. The findings included: "Loss of normal cervical lordosis." Multiple level issues were identified including "C3/4: Central and bilateral foraminal disc osteophyte, leads to moderate to severe foraminal stenosis and compression of both exiting C4 nerve roots", "C4/5: Shallow posterior disc osteophyte, leads to mild to moderate left sided foraminal narrowing and impingement of the exiting left C5 nerve root", and "C5/6: Right sided foraminal disc osteophyte leads to minor impingement of the right C6 nerve root." The overall conclusion was "Cervical Spondylosis. Bilateral C4 foraminal stenosis. Left C5 nerve root compression. Right C6 nerve root impingement."

Symptoms

At the time of initial injury in June 1998, the veteran presented with left cervical and thoracic pain following a rifle shoot. The symptoms were significant enough to warrant physiotherapy treatment including joint mobilisation, soft tissue massage, stretches, ultrasound, and heat.

Currently, the veteran experiences neck pain exacerbated by certain activities including rifle shooting, coaching with neck turned to the left, pack marching, and lifting or carrying heavy equipment. The MRI findings indicate nerve root compression at multiple levels which would typically present with neck pain, stiffness, reduced range of motion, and potential neurological symptoms such as pain, numbness, or weakness radiating to the upper extremities corresponding to the affected nerve roots (C4, C5, and C6).

Imaging

• 03 Dec 2018: MRI of the Cervical Spine: "Loss of normal cervical lordosis. Minor grade 1 degeneration C1/2. C2/3: No central or foraminal disc osteophyte. C3/4: Central and bilateral foraminal disc osteophyte, leads to moderate to severe foraminal stenosis and compression of both exiting C4 nerve roots. C4/5: Shallow posterior disc osteophyte, leads to mild to moderate left sided foraminal narrowing and impingement of the exiting left C5 nerve root. C5/6: Right sided foraminal disc osteophyte leads to minor impingement of the right C6 nerve root. C6/7 & C7/T1: No central or foraminal disc osteophyte." Conclusion: "Cervical Spondylosis. Bilateral C4 foraminal stenosis. Left C5 nerve root compression. Right C6 nerve root impingement."

1. What is the formal diagnosis of the condition claimed above? The formal diagnoses are:

• Cervical Spondylosis (ICD-10 code: M47.812)
• Cervical Spine - C3/4 Bilateral Foraminal Stenosis with C4 Nerve Root Compression (ICD-10 codes: M48.02, G54.2)
• Cervical Spine - C4/5 Left Foraminal Narrowing with C5 Nerve Root Impingement (ICD-10 codes: M48.02, G54.2)
• Cervical Spine - C5/6 Right Foraminal Disc Osteophyte with C6 Nerve Root Impingement (ICD-10 codes: M48.02, G54.2)

Cervical spondylosis is a degenerative joint disorder affecting the cervical vertebrae or intervertebral discs. It is characterized by degenerative changes including disc space narrowing and osteophyte formation. Common associated features include facet joint arthritis, bone hypertrophy, and spinal stenosis.

Foraminal stenosis refers to the narrowing of the neural foramen (the openings through which nerve roots exit the spinal canal), which can lead to nerve root compression or impingement. This can cause radicular symptoms in the distribution of the affected nerve root.

In the veteran case, there is a temporal relationship between these conditions, with the initial cervical strain in 2000 likely representing early manifestations of a process that eventually progressed to the more significant degenerative changes documented in 2023. The cervical spondylosis appears to have led to foraminal stenosis at multiple levels with corresponding nerve root compression, indicating progression of the degenerative process over time.

2. For each diagnosis identified, please also provide the following dates: When did the veteran first experience symptoms attributable to this condition? The veteran first experienced symptoms attributable to cervical spine issues on 25 Apr 1996, when he presented with left cervical and thoracic pain following a rifle shoot, diagnosed at that time as a left trapezius strain.

When did the veteran first present to a health / medical provider for this condition? The veteran first presented to a health provider for cervical spine symptoms on 25 Apr 1996, when he was diagnosed with a left trapezius strain and received physiotherapy treatment.

When was the condition confirmed / formally diagnosed? The condition of cervical spondylosis with associated foraminal stenosis and nerve root compression/impingement was formally diagnosed on 03 December 2018 based on MRI findings. The radiologist provided the conclusion of "Cervical Spondylosis. Bilateral C4 foraminal stenosis. Left C5 nerve root compression. Right C6 nerve root impingement."

When did the veteran first present to you (or your practice) for this condition? 25 December 2017

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results. The diagnosis of cervical spondylosis with associated foraminal stenosis and nerve root compression/impingement was confirmed through:

• Clinical symptoms: Neck pain exacerbated by specific activities including rifle shooting, coaching with neck turned to the left, pack marching, and lifting/carrying heavy equipment.
• Imaging: MRI of the cervical spine performed on 03 December 2018, which definitively demonstrated degenerative changes consistent with cervical spondylosis. The MRI showed loss of normal cervical lordosis, disc degeneration, and osteophyte formation causing foraminal stenosis at multiple levels with nerve root compression/impingement:
• C3/4: Central and bilateral foraminal disc osteophyte causing moderate to severe foraminal stenosis and compression of both C4 nerve roots
• C4/5: Shallow posterior disc osteophyte causing mild to moderate left-sided foraminal narrowing and impingement of the left C5 nerve root
• C5/6: Right-sided foraminal disc osteophyte causing minor impingement of the right C6 nerve root

The radiologist's formal diagnosis was "Cervical Spondylosis. Bilateral C4 foraminal stenosis. Left C5 nerve root compression. Right C6 nerve root impingement."

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.

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 veteran experienced trauma to the cervical spine in June 1998 when he developed left cervical and thoracic pain following a rifle shoot, diagnosed as left trapezius strain. This occurred more than 6 months before the clinical onset of cervical spondylosis and within the 20 years before clinical onset.

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

• NOT MET. While the veteran's duties as an Airfield Defence Guard likely involved carrying heavy loads, there is insufficient evidence in the records to confirm carrying loads specifically on the head to the cumulative total of at least 5,000 hours within any 10-year period.

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

• NOT MET. There is no evidence in the records indicating that the veteran flew in high performance aircraft for at least 1,000 cumulative hours.

piloting a helicopter for a cumulative total of at least 1,000 hours within the 25 years before the clinical onset of cervical spondylosis

• NOT MET. There is no evidence in the records indicating that the veteran piloted helicopters.

being obese for at least 10 years within the 25 years before the clinical onset of cervical spondylosis

• NOT MET. The veteran's BMI has generally been in the normal to overweight range (highest recorded BMI was 25.7 in June 2000), not meeting the criteria for obesity (BMI ≥30).

having acromegaly involving the cervical spine before the clinical onset of cervical spondylosis

• NOT MET. There is no evidence of acromegaly in the medical records.

having Paget's disease of bone involving the cervical spine before the clinical onset of cervical spondylosis

• NOT MET. There is no evidence of Paget's disease in the medical records.

inability to obtain appropriate clinical management for cervical spondylosis

• MET. The records suggest a lengthy period (approximately 23 years) between the initial presentation with cervical symptoms in 2000 and the formal diagnosis of cervical spondylosis in 2023. During this time, there is little evidence of specific cervical spine assessment or management beyond the initial physiotherapy treatment. According to the Full Federal Court in Brew v Repatriation Commission (14 May 1993), "inability" can extend to psychological, emotional, or institutional barriers to seeking treatment. In the military context, there may have been cultural or occupational barriers to seeking ongoing management for neck pain. As per Advisory note 7 of 1999 in the Compensation and Support Reference Library, this lengthy delay in diagnosis and appropriate management would have allowed the condition to progress untreated, causing permanent worsening.

Sequelae

The primary condition is cervical spondylosis, with the foraminal stenosis and nerve root compression/impingement being sequelae (consequences) of the spondylosis. The degenerative changes associated with cervical spondylosis led to the development of disc osteophytes, which caused the foraminal stenosis and subsequent nerve root compression/impingement.

Unintended Consequence

There is no evidence that this condition is an unintended consequence of medical management. The condition appears to have developed through the natural progression of cervical spondylosis, likely influenced by occupational factors and trauma.

Inability to Attain Appropriate Medical Management

There is strong evidence of an inability to attain appropriate medical management for this condition. The approximately 23-year gap between the initial cervical spine symptoms in 2000 and the formal diagnosis in 2023 indicates a significant delay in appropriate assessment and treatment.

The Full Federal Court in Brew v Repatriation Commission (14 May 1993) (see the judgment of Merkel J) established that "inability" to obtain treatment encompasses both objective and subjective barriers, including psychological or emotional factors that may have prevented the veteran from seeking treatment, or institutional factors within the military context.

The lengthy time between initial presentation and diagnosis is significant considering the natural history of cervical spondylosis, which typically progresses over years. Earlier diagnosis and management may have slowed the progression of the condition and prevented or minimized the development of the foraminal stenosis and nerve root compression.

This inability to attain appropriate medical management allowed the condition to progress to a more severe state with permanent neurological consequences (nerve root compression), which constitutes a permanent worsening of the condition.

The % contribution of the causes is 100% and significant

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

Diagnostic Assessment — Cervical Spine - Spondylosis

Example 2 of 3 · fictitious patient (Veteran F)

Diagnostic Assessment

CERVICAL - SPONDYLOSIS

Statement of Principles concerning Cervical Spondylosis (Balance of Probabilities) Instrument No. 12 of 2023 and Statement of Principles concerning Cervical Spondylosis (Reasonable Hypothesis) Instrument No. 11 of 2023.

ADF History

Name: The veteran Date of Birth: [withheld] Occupation: Communications, SASR Enlistment Date: 17 Dec 1993 Discharge Date: Still Serving

Occupational History

As a Communications specialist within the Australian Defence Force, particularly within SASR, the veteran service likely involved exposure to various occupational hazards. This could include carrying communication equipment, periods involving specific postures for equipment operation, potential exposure to vibration in vehicles or aircraft, and general military duties including physical training, field exercises, and potential exposure to trauma consistent with SASR roles. The communications role often requires maintaining static postures during equipment operation and monitoring, while SASR operations frequently involve wearing heavy helmets with communication devices, night vision equipment, and carrying substantial loads during operational deployments, all of which place cumulative stress on the cervical spine.

History

The veteran the veteran, serving as a Communications specialist in the ADF, presented for an MRI of his cervical spine due to symptoms of neck tightness and pain. Imaging confirmed degenerative changes consistent with cervical spondylosis at multiple levels, including facet joint ankylosis and osteoarthritis.

Timeline

• 22 Oct 2018: Referral for MRI Cervical Spine due to symptoms of neck tightness and pain. Patient reports discomfort following prolonged periods wearing tactical equipment and during communications monitoring activities.
• 29 Oct 2018: MRI Cervical Spine performed demonstrating significant degenerative changes. Cervical cord is of normal signal. Findings included ankylosis of the left facet joint at C2-3, mild left foraminal stenosis secondary to uncovertebral osteophytes at C5-6, and likely mild bilateral facet osteoarthritis at C6-7. No neural compression is visualised.

Symptoms

At the time of the MRI referral (Nov 2020), the veteran reported symptoms of neck tightness and pain. The specific onset date of these symptoms is not detailed in the provided excerpts, but they were sufficient to warrant advanced diagnostic imaging. The patient reports that his neck symptoms are most noticeable following prolonged periods wearing tactical helmets with communication devices and night vision equipment, particularly during operational deployments and training exercises. He also notes increased discomfort with prolonged static positioning required during communications monitoring. No radiating symptoms into the upper extremities were reported, and there was no documentation of specific neurological deficits in the available records.

Imaging

29 Oct 2018 - MRI CERVICAL SPINE: Cervical cord is of normal signal, with no myelomalacia or demyelination. C2-3: No significant disc protrusion or neural compression. There is ankylosis of the left facet joint. C3-4: No significant disc protrusion or neural compression. C4-5: Normal. C5-6: No significant disc protrusion, central canal or right foraminal stenosis. Mild left foraminal stenosis secondary to uncovertebral osteophytes. C6-7: No significant disc protrusion or neural compression. Likely mild bilateral facet OA. C7-T1: No significant disc protrusion or neural compression. CONCLUSION: No neural compression is visualised.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Cervical Spondylosis (ICD-10 Code: M47.82), encompassing the findings of facet joint osteoarthritis, foraminal stenosis due to osteophytes, and facet joint ankylosis identified on imaging. The relevant DVA Statement of Principles (SOP) is Cervical Spondylosis Instrument No. 12 of 2023 (BOP) and No. 11 of 2023 (RH).

Cervical Spondylosis refers to age-related wear and tear affecting the spinal discs and joints in the neck. This degeneration can lead to various changes including disc desiccation (drying out), disc bulging or herniation, the formation of osteophytes (bone spurs), and arthritis of the facet joints (facet arthropathy). These changes can narrow the spinal canal or the foramina (openings where nerve roots exit), potentially leading to nerve compression, pain, stiffness, and neurological symptoms, although in the veteran case, no neural compression was visualized on the recent MRI.

The condition typically develops progressively over time due to cumulative stress on the cervical spine structures. While some degree of cervical spondylosis is common with aging, certain occupational and lifestyle factors can accelerate or exacerbate the degenerative process. Military service, particularly in specialized roles like SASR, can contribute to premature development or progression of cervical spondylosis due to the physical demands of the role.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition? The specific onset date for neck tightness and pain is not specified in the provided documents. Symptoms were noted as the clinical history for the MRI performed in November 2020. Based on the nature of cervical spondylosis as a progressive degenerative condition, it is likely that mild symptoms preceded the formal investigation by months to years, potentially developing gradually during his extensive service in the SASR.

When did the veteran first present to a health / medical provider for this condition? The first documented presentation specifically for the neck symptoms leading to the MRI appears to be the referral dated 22 October 2018 by Dr. Thomas Perkins. Prior consultations for neck symptoms may have occurred but are not explicitly documented in the available records.

When was the condition confirmed / formally diagnosed? The diagnosis of Cervical Spondylosis was confirmed by the MRI findings reported on 29 October 2018 by the treating doctor, Radiologist. The imaging demonstrated specific degenerative changes including facet joint ankylosis at C2-3, mild left foraminal stenosis at C5-6 secondary to uncovertebral osteophytes, and likely mild bilateral facet osteoarthritis at C6-7.

When did the veteran first present to you (or your practice) for this condition? 26 May 2018.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results.

The diagnosis was confirmed primarily by Magnetic Resonance Imaging (MRI) of the cervical spine performed on 29 October 2018. Key investigation results included: • Ankylosis (fusion) of the left C2-3 facet joint • Mild left foraminal stenosis at C5-6 secondary to uncovertebral osteophytes
• Likely mild bilateral facet joint osteoarthritis (OA) at C6-7

The key symptoms reported leading to the investigation were neck tightness and pain. Clinical examination findings were not detailed in the available records, but would typically include restricted cervical range of motion, paravertebral muscle spasm or tenderness, and potential reproduction of pain with certain neck movements.

The MRI findings are consistent with degenerative changes of the cervical spine meeting the diagnostic criteria for cervical spondylosis. The radiologist's report confirms these specific findings at multiple levels of the cervical spine, although notes that no neural compression was visualized at the time of imaging.

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.

Factors under Instrument No. 12 of 2023 (Balance of Probabilities):

having trauma involving the cervical spine before the clinical onset of cervical spondylosis: NOT MET

• There is no specific record of significant trauma to the cervical spine prior to the likely onset of symptoms leading to the 2022 MRI in the provided documents.

having inflammatory joint disease involving the cervical spine before the clinical onset of cervical spondylosis: NOT MET

• There is no diagnosis of inflammatory joint disease (e.g., rheumatoid arthritis, ankylosing spondylitis) affecting the cervical spine in the records.

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: MET

• The veteran served in SASR, a role often involving significant load-bearing. While specific weights carried via the cervical spine (e.g., heavy helmets with communication devices, night vision equipment, certain pack configurations) are not detailed, it's plausible cumulative loads were significant over his >20 years of service. DVA has previously accepted lumbar spondylosis based on cumulative load bearing in similar circumstances.

being involved in tackling manoeuvres in contact sports for a cumulative period of at least 150 hours before the clinical onset of cervical spondylosis: NOT MET

• No specific mention of extensive contact sports participation meeting this threshold.

having a diagnosis of diffuse idiopathic skeletal hyperostosis before the clinical onset of cervical spondylosis: NOT MET

• No diagnosis of DISH recorded.

having acromegaly before the clinical onset of cervical spondylosis: NOT MET

• No diagnosis of acromegaly recorded.

having Paget's disease of bone involving the cervical spine before the clinical onset of cervical spondylosis: NOT MET

• No diagnosis of Paget's disease recorded.

inability to obtain appropriate clinical management for cervical spondylosis: NOT MET

• This is a clinical worsening factor. There is no evidence appropriate management was unavailable or denied leading to permanent worsening once symptoms presumably arose.

Factors under Instrument No. 11 of 2023 (Reasonable Hypothesis):

having trauma involving the cervical spine at least five years before the clinical onset of cervical spondylosis: NOT MET

• As above, no specific trauma documented meeting the definition.

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 more generous criteria in the RH SOP (15kg vs 25kg) would also be met given the nature of SASR duties.

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

• SASR operations frequently involve transportation of heavy communication equipment and tactical gear positioned on the shoulders and neck area, which would easily exceed this threshold over the veteran extensive service period.

inability to obtain appropriate clinical management for cervical spondylosis: NOT MET

• As per BOP.

Based on the available information and service history in a physically demanding role, the most plausible contributing factors related to service are cumulative load bearing through the cervical spine. Age-related degeneration is also a common factor in the development of cervical spondylosis, but the veteran extensive service in SASR with its physical demands likely accelerated the degenerative process beyond what would be expected for his age alone.

Sequelae

There is no indication from the provided documents that the cervical spondylosis is a direct sequela of another accepted condition.

Unintended Consequence

There is no evidence to suggest the cervical spondylosis resulted as an unintended consequence of medical treatment provided or paid for by the Commonwealth.

Inability to Attain Appropriate Medical Management

There is no evidence presented in the documents to suggest the veteran was unable to obtain appropriate clinical management for his neck condition once symptoms presumably manifested. He received appropriate diagnostic imaging when symptoms warranted investigation, and there is no documentation of delayed or denied treatment that would have led to permanent worsening of the condition.

The % contribution of the causes is 100% and significant

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

Diagnostic Assessment — Cervical Spine - Spondylosis

Example 3 of 3 · fictitious patient (Veteran J)

Diagnostic Assessment

Cervical Spine - Spondylosis

SOP 12 of 2023 (Balance of Probabilities) SOP 11 of 2023 (Reasonable Hypothesis)

ADF History

The veteran, Army Medic/Medical Operator/Medical Technician, 06 December 2001, 23 Mar 2022 (transferring to SERCAT 5 Reserve Service).

Occupational History

The veteran role as an Army Medic exposed her to extensive occupational hazards throughout her two-decade career. Her duties encompassed emergency medical response, patient assessment and treatment, medical evacuation procedures, and maintenance of medical equipment. These responsibilities required frequent heavy lifting of patients and medical equipment, often in austere field conditions, prolonged standing during medical procedures, repetitive bending and kneeling when treating patients, and carrying heavy medical packs during exercises and deployments. Her work involved sustained neck positions during medical procedures and poor ergonomics in field conditions, contributing to cervical spine stress through repetitive neck loading during patient care duties including lifting and positioning.

History

The veteran an Army Medic, developed bilateral shoulder, arm, and neck pain in September 2006 which was managed as cervico-thoracic dysfunction. The condition was likely related to repetitive neck loading during patient care duties and sustained neck positions required during medical procedures.

Timeline

• September 2006: Bilateral shoulder/arm/neck pain reported, physiotherapy commenced for cervico-thoracic dysfunction. The symptoms developed gradually over several months without specific trauma. The veteran experienced neck stiffness worse in the morning with radiating symptoms to both shoulders and arms. Physiotherapy assessment identified restricted cervical rotation and extension with multiple trigger points noted in the cervical and thoracic regions. Treatment included manual therapy and postural correction exercises. The condition represented early manifestation of occupational cervical spine stress from her demanding medical duties requiring sustained positioning and repetitive movements.

Symptoms

At the time of initial presentation in September 2006, the veteran experienced bilateral shoulder, arm, and neck pain with morning stiffness and restricted cervical range of motion. The symptoms were worse in the morning and radiated from the neck into both upper extremities. Physical examination revealed restricted cervical rotation and extension with multiple trigger points in the cervical and thoracic regions.

Current symptoms from the chart review indicate ongoing cervico-thoracic dysfunction requiring physiotherapy management, suggesting persistent issues with neck mobility and comfort affecting her ability to perform duties requiring sustained neck positioning.

Imaging

03 August 2005: MRI neck and upper thoracic spine showed normal vertebral alignment and discs. The imaging excluded significant structural abnormalities at that time but clinical findings supported cervico-thoracic dysfunction diagnosis.

1. What is the formal diagnosis of the condition claimed above?

Cervical Spondylosis - SOP 12 of 2023 (Balance of Probabilities), SOP 11 of 2023 (Reasonable Hypothesis), ICD-10 codes M47.812, M47.01, M47.02, M47.03, M47.11, M47.12, M47.13, M47.21, M47.22, M47.23, M47.81, M47.82, M47.83, M47.91, M47.92, M47.93 or M50.3.

Cervical spondylosis is a degenerative joint disorder affecting the cervical vertebrae or intervertebral discs including spondylosis at the cervicothoracic junction. It is characterized by age-related wear and tear affecting the spinal discs in the neck, leading to disc degeneration, osteophyte formation, and potential spinal stenosis. The condition commonly presents with neck pain, stiffness, and may involve neurological symptoms if nerve compression occurs. Risk factors include aging, occupational factors involving repetitive neck movements, trauma, and genetic predisposition.

The temporal relationship shows early presentation in September 2006 with cervico-thoracic dysfunction symptoms, representing the initial manifestation of degenerative cervical spine changes that would progress to formal spondylosis over time.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

The veteran first experienced symptoms attributable to cervical spondylosis in September 2006 when she developed bilateral shoulder, arm, and neck pain with cervico-thoracic dysfunction.

When did the veteran first present to a health / medical provider for this condition?

The veteran first presented to a physiotherapist in September 2006 for bilateral shoulder/arm/neck pain with cervico-thoracic dysfunction.

When was the condition confirmed / formally diagnosed?

The condition was clinically diagnosed as cervico-thoracic dysfunction by a physiotherapist in September 2006, representing the early manifestation of cervical spondylosis.

When did the veteran first present to you (or your practice) for this condition?

24 Apr 2021.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results.

The diagnosis was confirmed through clinical assessment by physiotherapy in September 2006. Key symptoms included bilateral shoulder, arm, and neck pain with morning stiffness and restricted range of motion. Clinical signs revealed restricted cervical rotation and extension with multiple trigger points in the cervical and thoracic regions. MRI neck and upper thoracic spine performed on 03 August 2005 showed normal vertebral alignment and discs, excluding significant structural abnormalities at that early stage. The diagnosis was based on clinical presentation consistent with cervico-thoracic dysfunction representing early degenerative cervical spine changes.

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.

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 - NOT MET

• No documented cervical spine trauma prior to onset of symptoms in September 2006.

Being obese for at least 10 years within the 25 years before the clinical onset of cervical spondylosis - MET

• The veteran was overweight during childhood and adolescence, and documented obesity from pre-2003 through August 2019 with BMI documented at 34.4 in July 2009 and peak BMI of 37.1 in June 2011, satisfying the 10-year obesity requirement before clinical onset.

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 (BOP) / 15 kilograms (RH) - MET

• As an Army Medic, the veteran carried heavy medical packs exceeding 20kg during field exercises and deployments, with additional load from helmet and equipment, easily exceeding the threshold requirements over her service period.

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 (RH factor) - MET

• Military load carriage included body armor, webbing, and medical equipment positioned between neck and shoulders during her service from 2004-2007 prior to symptom onset.

Inability to obtain appropriate clinical management for cervical spondylosis - MET

• While physiotherapy was provided, there was no specific investigation or management for underlying cervical spondylosis despite persistent symptoms, representing inability to obtain appropriate clinical management as defined in Brew v Repatriation Commission, leading to permanent worsening of the condition.

Sequelae

This condition is not a sequelae of another known condition but represents primary degenerative cervical spine disease from occupational factors.

Unintended Consequence

This condition is not an unintended consequence of medical management, as no procedures were performed or medications given that resulted in cervical spondylosis.

Inability to Attain Appropriate Medical Management

The veteran experienced inability to attain appropriate medical management for her cervical spondylosis. The condition was managed as cervico-thoracic dysfunction with physiotherapy from September 2006, but no specific investigation or management was provided for the underlying cervical spondylosis despite persistent symptoms. This failure to provide appropriate clinical management as defined by the standards and knowledge of the time led to permanent worsening of the condition. The Full Federal Court in Brew v Repatriation Commission (20 May 1996) enlarges on the meaning of "inability" as the lack of ability to get treatment in both objective and subjective sense, which is satisfied in this case where conservative management was provided without appropriate investigation or specific treatment for the underlying degenerative cervical spine condition.

The % contribution of the causes is 100% and significant.

5. Please provide a Health Summary and a medication / prescribing history.

-see attached report