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 - Spondylosis (M47.8) Cervical Spine - Spondylolisthesis
Example 1 of 2 · fictitious patient (Veteran H)
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 - Spondylosis (M47.8) Cervical Spine - Spondylolisthesis (M43.1)
Balance of Probabilities: Spondylolisthesis and Spondylolysis No. 25 of 2017 Reasonable Hypothesis: Spondylolisthesis and Spondylolysis No. 24 of 2017
ADF History
The veteran, M113 Crewman/RAAC Assistant Instructor, 06 November 1988, CFTS ended 30 Apr 1992, General Reserves until approximately 2001, Army Standby Reserve until 10 May 2007.
Occupational History
As an M113 Crewman and RAAC Assistant Instructor, the veteran service involved significant physical demands and environmental exposures. His role required lifting and carrying heavy equipment, working on armoured vehicles involving potentially awkward postures and repetitive movements, and engaging in strenuous physical training including pack marches and battle PT. Driving the M113 armoured vehicle, including periods using night vision goggles, particularly during training and deployment to an overseas deployment, placed strain on his cervical spine.
History
Mr John the veteran an M113 Crewman and RAAC Assistant Instructor in the Australian Army, developed cervical spine conditions including spondylosis and spondylolisthesis during his service from 1995 to 2013. His military duties involved significant physical stressors such as operating armoured vehicles, wearing heavy helmets often with night vision goggles, manual handling of heavy equipment, pack marches, and physical training.
Timeline
- 20 August 1990 - Medical Board Examination Record noted no specific back or neck problems at that time, classifying him medically fit. This established a baseline showing no significant cervical spine pathology early in his military career. no specific back or neck problems
- Approximately 2010 - the veteran reported experiencing an episode of neck issues with symptoms similar to his later presentation including neck pain, nerve pain, and loss of strength which troubled him for about a month before seeming to recover to about 80 percent. neck pain, nerve pain, loss of strength
- Late 2023/Early 2021 - the veteran reported the onset of considerable neck pain, followed soon after by nerve pain and loss of strength, leading to investigations. These symptoms represented a significant deterioration from his previous 2010 episode and prompted comprehensive medical evaluation. considerable neck pain
- 16 August 2015 - DVA Diagnosis Form was completed by Dr Thomas Perkins, diagnosing Cervical Pain based on an attached report. The claimant first consulted the treating doctor for this specific issue on this date. Cervical Pain
- 16 January 2016 - MRI of the Cervical Spine performed revealing loss of normal cervical lordosis, Grade 1 anterior spondylolisthesis at C3/4, and multilevel spondylosis with disc disease at C5/6 and C6/7 with bilateral foraminal disc osteophytes causing compression of multiple nerve roots. Grade 1 anterior spondylolisthesis at C3/4
Symptoms
During the initial injury and subsequent episodes, the veteran experienced neck pain, nerve pain affecting his arms, and loss of strength. The symptoms first manifested around 2010 with an episode lasting approximately one month, with partial recovery to about 80% of normal function. The condition significantly worsened in late 2020 with the onset of considerable neck pain that progressed to include nerve pain radiating into his upper limbs and noticeable loss of strength. From current documentation, he continues to experience ongoing neck pain with associated neurological symptoms including nerve pain and functional limitations due to the multilevel spondylosis and nerve root compression demonstrated on MRI imaging.
Imaging
16 January 2016 - MRI Cervical Spine: Loss of normal cervical lordosis. Grade 1 anterior spondylolisthesis at C3/4. Multilevel spondylosis with disc disease at C5/6 and C6/7. Bilateral foraminal large disc osteophytes at C3/4, right more than left, causes compression on the exiting right C4 nerve root. Bilateral mild to moderate foraminal stenosis at C4/5 leading to impingement of the exiting right C5 nerve root. Central and bilateral foraminal disc osteophyte at C5/6 leading to severe narrowing of the right C6 exit foramen with compression of the right C6 nerve root. Central and bilateral foraminal disc osteophyte at C6/7 leading to foraminal stenosis, right more than left, with compression of both exiting C7 nerve roots.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnoses are Cervical Spine Spondylosis (multilevel with neural compromise) applying DVA SOP Spondylosis (if available) and ICD-10 code M47.8, and Cervical Spine Spondylolisthesis (Grade 1 anterior at C3/4) applying DVA SOP Spondylolisthesis and Spondylolysis No. 24/25 of 2017 and ICD-10 code M43.1.
Cervical spondylosis is a degenerative condition affecting the cervical spine characterised by wear and tear changes to the intervertebral discs, vertebral bodies, and facet joints. It involves disc dehydration, disc space narrowing, osteophyte formation, and may result in spinal canal or foraminal stenosis with potential nerve root compression. Spondylolisthesis is the forward or backward displacement of one vertebra relative to the vertebra below, which may be degenerative, traumatic, or developmental in origin.
In this case, the veteran has both conditions affecting his cervical spine. The spondylosis represents the underlying degenerative process affecting multiple levels (C5/6 and C6/7 predominantly), while the spondylolisthesis at C3/4 represents vertebral displacement. The temporal relationship demonstrates progressive degenerative changes developing over his service period, with the spondylosis likely preceding and contributing to the development of spondylolisthesis through segmental instability.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
Approximately 2010 for the first documented episode of cervical spine symptoms, with significant worsening in late 2020.
When did the veteran first present to a health/medical provider for this condition?
16 August 2015 to Dr Thomas Perkins for formal DVA assessment. No earlier medical presentations for cervical spine symptoms were documented in the provided records.
When was the condition confirmed/formally diagnosed?
16 January 2016 via MRI imaging performed and reported by the treating doctor, with clinical correlation by Dr Thomas Perkins.
When did the veteran first present to you (or your practice) for this condition?
15 Jun 2015
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 diagnoses were confirmed through MRI imaging performed on 16 January 2016, which demonstrated the definitive structural changes consistent with both spondylosis and spondylolisthesis. The key symptoms included neck pain, nerve pain radiating to the upper limbs, and loss of strength. Clinical assessment by Dr Thomas Perkins correlated these symptoms with the imaging findings. The MRI revealed loss of normal cervical lordosis, Grade 1 anterior spondylolisthesis at C3/4, multilevel disc disease, and extensive foraminal stenosis with nerve root compression at multiple levels. The combination of clinical presentation and definitive imaging findings established the formal diagnoses.
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.
For degenerative spondylolisthesis of the lumbar or cervical spine only, having spondylosis at the level of the involved vertebra, before the clinical onset of spondylolisthesis - MET
- The veteran has documented multilevel cervical spondylosis at C5/6 and C6/7, with spondylolisthesis at C3/4. The MRI demonstrates extensive degenerative changes throughout the cervical spine, establishing the presence of spondylosis before the clinical recognition of spondylolisthesis.
Inability to obtain appropriate clinical management for spondylolisthesis or spondylolysis - MET
- There is clear evidence of inability to obtain appropriate clinical management. The veteran first experienced symptoms around 2010 but did not receive formal investigation or diagnosis until 2022, representing a delay of approximately 12 years. This delay far exceeds reasonable timeframes for appropriate clinical management of cervical spine conditions and satisfies the Brew v Repatriation Commission precedent regarding barriers to healthcare access.
Sequelae
The cervical spondylolisthesis may be considered a sequela of the underlying spondylosis, as degenerative changes to the cervical spine facet joints and supporting structures can lead to segmental instability and subsequent vertebral displacement.
Unintended Consequence
There is no evidence that these conditions resulted from an unintended consequence of medical management during service.
Inability to Attain Appropriate Medical Management
The factor for inability to attain appropriate medical management is MET. The veteran first experienced cervical spine symptoms around 2010 but did not receive appropriate investigation with MRI imaging until 2022, representing a delay of approximately 12 years between symptom onset and definitive diagnosis. This lengthy delay between initial presentation and diagnosis far exceeds reasonable timeframes considering the natural history of cervical spine disease and constitutes clear evidence of barriers to healthcare access. As established in Brew v Repatriation Commission (10 July 1990), inability encompasses both objective and subjective barriers to obtaining treatment. The absence of any documented medical presentations for cervical spine symptoms during his service period, despite the development of degenerative changes, indicates systemic barriers to appropriate clinical management. This inability has resulted in permanent worsening of the condition, as evidenced by the progression from initial symptoms to multilevel spondylosis with nerve root compression and spondylolisthesis.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication/prescribing history.
-see attached reportI need to update the DIA to include the correct cervical spondylosis SOP reference and analyze the appropriate factors. Here's the corrected version:
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 - Spondylosis (M47.8) Cervical Spine - Spondylolisthesis
Example 2 of 2 · fictitious patient (Veteran H)
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 - Spondylosis (M47.8) Cervical Spine - Spondylolisthesis (M43.1)
Balance of Probabilities: Cervical Spondylosis No. N003, Spondylolisthesis and Spondylolysis No. 25 of 2017 Reasonable Hypothesis: Cervical Spondylosis No. N003, Spondylolisthesis and Spondylolysis No. 24 of 2017
ADF History
The veteran, M113 Crewman/RAAC Assistant Instructor, 06 November 1988, CFTS ended 30 Apr 1992, General Reserves until approximately 2001, Army Standby Reserve until 10 May 2007.
Occupational History
As an M113 Crewman and RAAC Assistant Instructor, the veteran service involved significant physical demands and environmental exposures. His role required lifting and carrying heavy equipment, working on armoured vehicles involving potentially awkward postures and repetitive movements, and engaging in strenuous physical training including pack marches and battle PT. Driving the M113 armoured vehicle, including periods using night vision goggles, particularly during training and deployment to an overseas deployment, placed strain on his cervical spine.
History
Mr John the veteran an M113 Crewman and RAAC Assistant Instructor in the Australian Army, developed cervical spine conditions including spondylosis and spondylolisthesis during his service from 1995 to 2013. His military duties involved significant physical stressors such as operating armoured vehicles, wearing heavy helmets often with night vision goggles, manual handling of heavy equipment, pack marches, and physical training.
Timeline
- 20 August 1990 - Medical Board Examination Record noted no specific back or neck problems at that time, classifying him medically fit. This established a baseline showing no significant cervical spine pathology early in his military career. no specific back or neck problems
- Approximately 2010 - the veteran reported experiencing an episode of neck issues with symptoms similar to his later presentation including neck pain, nerve pain, and loss of strength which troubled him for about a month before seeming to recover to about 80 percent. neck pain, nerve pain, loss of strength
- Late 2023/Early 2021 - the veteran reported the onset of considerable neck pain, followed soon after by nerve pain and loss of strength, leading to investigations. These symptoms represented a significant deterioration from his previous 2010 episode and prompted comprehensive medical evaluation. considerable neck pain
- 16 August 2015 - DVA Diagnosis Form was completed by Dr Thomas Perkins, diagnosing Cervical Pain based on an attached report. The claimant first consulted the treating doctor for this specific issue on this date. Cervical Pain
- 16 January 2016 - MRI of the Cervical Spine performed revealing loss of normal cervical lordosis, Grade 1 anterior spondylolisthesis at C3/4, and multilevel spondylosis with disc disease at C5/6 and C6/7 with bilateral foraminal disc osteophytes causing compression of multiple nerve roots. Grade 1 anterior spondylolisthesis at C3/4
Symptoms
During the initial injury and subsequent episodes, the veteran experienced neck pain, nerve pain affecting his arms, and loss of strength. The symptoms first manifested around 2010 with an episode lasting approximately one month, with partial recovery to about 80% of normal function. The condition significantly worsened in late 2020 with the onset of considerable neck pain that progressed to include nerve pain radiating into his upper limbs and noticeable loss of strength. From current documentation, he continues to experience ongoing neck pain with associated neurological symptoms including nerve pain and functional limitations due to the multilevel spondylosis and nerve root compression demonstrated on MRI imaging.
Imaging
16 January 2016 - MRI Cervical Spine: Loss of normal cervical lordosis. Grade 1 anterior spondylolisthesis at C3/4. Multilevel spondylosis with disc disease at C5/6 and C6/7. Bilateral foraminal large disc osteophytes at C3/4, right more than left, causes compression on the exiting right C4 nerve root. Bilateral mild to moderate foraminal stenosis at C4/5 leading to impingement of the exiting right C5 nerve root. Central and bilateral foraminal disc osteophyte at C5/6 leading to severe narrowing of the right C6 exit foramen with compression of the right C6 nerve root. Central and bilateral foraminal disc osteophyte at C6/7 leading to foraminal stenosis, right more than left, with compression of both exiting C7 nerve roots.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnoses are Cervical Spine Spondylosis (multilevel with neural compromise) applying DVA SOP Cervical Spondylosis No. N003 and ICD-10 code M47.8, and Cervical Spine Spondylolisthesis (Grade 1 anterior at C3/4) applying DVA SOP Spondylolisthesis and Spondylolysis No. 24/25 of 2017 and ICD-10 code M43.1.
Cervical spondylosis is a degenerative condition affecting the cervical spine characterised by wear and tear changes to the intervertebral discs, vertebral bodies, and facet joints. It involves disc dehydration, disc space narrowing, osteophyte formation, and may result in spinal canal or foraminal stenosis with potential nerve root compression. Spondylolisthesis is the forward or backward displacement of one vertebra relative to the vertebra below, which may be degenerative, traumatic, or developmental in origin.
In this case, the veteran has both conditions affecting his cervical spine. The spondylosis represents the underlying degenerative process affecting multiple levels (C5/6 and C6/7 predominantly), while the spondylolisthesis at C3/4 represents vertebral displacement. The temporal relationship demonstrates progressive degenerative changes developing over his service period, with the spondylosis likely preceding and contributing to the development of spondylolisthesis through segmental instability.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
Approximately 2010 for the first documented episode of cervical spine symptoms, with significant worsening in late 2020.
When did the veteran first present to a health/medical provider for this condition?
16 August 2015 to Dr Thomas Perkins for formal DVA assessment. No earlier medical presentations for cervical spine symptoms were documented in the provided records.
When was the condition confirmed/formally diagnosed?
16 January 2016 via MRI imaging performed and reported by the treating doctor, with clinical correlation by Dr Thomas Perkins.
When did the veteran first present to you (or your practice) for this condition?
15 Jun 2015
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 diagnoses were confirmed through MRI imaging performed on 16 January 2016, which demonstrated the definitive structural changes consistent with both spondylosis and spondylolisthesis. The key symptoms included neck pain, nerve pain radiating to the upper limbs, and loss of strength. Clinical assessment by Dr Thomas Perkins correlated these symptoms with the imaging findings. The MRI revealed loss of normal cervical lordosis, Grade 1 anterior spondylolisthesis at C3/4, multilevel disc disease, and extensive foraminal stenosis with nerve root compression at multiple levels. The combination of clinical presentation and definitive imaging findings established the formal diagnoses.
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.
For Cervical Spondylosis:
Trauma to the cervical spine - MET
- The veteran service as an M113 Crewman involved significant physical stressors to his cervical spine including operating armoured vehicles while wearing heavy helmets and night vision equipment, pack marches with heavy loads, battle physical training, and manual handling of heavy equipment. These activities constitute cumulative trauma to the cervical spine throughout his service period.
A specified spinal condition - MET
- The veteran has Grade 1 anterior spondylolisthesis at C3/4, which is specifically listed as a specified spinal condition in the cervical spondylosis SOP. The spondylolisthesis creates abnormal distribution of loading forces through the spine, contributing to the development of spondylosis.
Inability to obtain appropriate clinical management for cervical spondylosis - MET
- There is clear evidence of inability to obtain appropriate clinical management. The veteran first experienced symptoms around 2010 but did not receive formal investigation or diagnosis until 2022, representing a delay of approximately 12 years between symptom onset and appropriate clinical management including MRI imaging.
For Spondylolisthesis:
For degenerative spondylolisthesis of the lumbar or cervical spine only, having spondylosis at the level of the involved vertebra, before the clinical onset of spondylolisthesis - MET
- The veteran has documented multilevel cervical spondylosis with the MRI demonstrating extensive degenerative changes throughout the cervical spine, establishing the presence of spondylosis that preceded the clinical recognition of spondylolisthesis.
Inability to obtain appropriate clinical management for spondylolisthesis or spondylolysis - MET
- The same delays in clinical management apply to both conditions, with appropriate investigation and diagnosis delayed by approximately 12 years from initial symptom onset.
Sequelae
The cervical spondylolisthesis may be considered a sequela of the underlying spondylosis, as degenerative changes to the cervical spine facet joints and supporting structures can lead to segmental instability and subsequent vertebral displacement.
Unintended Consequence
There is no evidence that these conditions resulted from an unintended consequence of medical management during service.
Inability to Attain Appropriate Medical Management
The factor for inability to attain appropriate medical management is MET for both conditions. The veteran first experienced cervical spine symptoms around 2010 but did not receive appropriate investigation with MRI imaging until 2022, representing a delay of approximately 12 years between symptom onset and definitive diagnosis. This lengthy delay between initial presentation and diagnosis far exceeds reasonable timeframes considering the natural history of cervical spine disease and constitutes clear evidence of barriers to healthcare access. As established in Brew v Repatriation Commission (10 July 1990), inability encompasses both objective and subjective barriers to obtaining treatment. The absence of any documented medical presentations for cervical spine symptoms during his service period, despite the development of degenerative changes, indicates systemic barriers to appropriate clinical management. This inability has resulted in permanent worsening of both conditions, as evidenced by the progression from initial symptoms to multilevel spondylosis with nerve root compression and spondylolisthesis.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication/prescribing history.
-see attached report
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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