Cervical Spondylosis

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 Spondylosis

Example 1 of 1 · fictitious patient (Veteran I)

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

SOP Codes - Balance of Probabilities: Cervical Spondylosis (Balance of Probabilities) (No. 12 of 2023) SOP Codes - Reasonable Hypothesis: Cervical Spondylosis (Reasonable Hypothesis) (No. 11 of 2023) Initial presentation may also relate to Sprain and Strain SOP for acute cervical strains.

ADF History

Name: The veteran Date of Birth: [withheld] Occupation: Aircraft Technician (ATECH/AMECH) Enlistment Date: Approximately June 1986 Discharge Date: Not explicitly stated, ongoing service indicated up to at least 2021

Occupational History

As an Aircraft Technician in the RAAF, the veteran the veteran was exposed to significant occupational hazards including repetitive overhead work while servicing aircraft, heavy lifting of aircraft components and equipment, prolonged neck flexion during detailed maintenance work, working in confined spaces such as cockpits and engine bays, and exposure to vibration and ergonomic stressors in maintenance environments. The role required technical expertise and physical labor in high-risk environments such as flight lines and maintenance hangars.

History

The veteran an Aircraft Technician in the RAAF, developed cervical spondylosis due to the cumulative impact of repetitive occupational stressors and acute traumatic incidents during his military service. The condition evolved from initial acute cervical strains in the 1990s to chronic degenerative changes requiring surgical intervention in 2011.

Timeline

12 February 1990: The veteran sustained a neck strain with limited range of motion from a spear tackle during a rugby match, a sport encouraged for military fitness. The injury caused immediate pain and stiffness, managed with analgesia and medical review. This represents the earliest documented cervical strain related to service activities.
10 Apr 1991: During mandatory gym activity (dips) required for RAAF fitness standards, the veteran experienced acute cervical pain with radiating symptoms. Clinical assessment diagnosed cervical nerve impingement, treated with rest, ice, and analgesia. The condition suggested early degenerative changes from repetitive occupational stress.
06 December 1993: Following a bench press exercise during mandatory fitness training, the veteran presented with cervical pain and stiffness. Clinical examination revealed cervical dysfunction, managed with physiotherapy and analgesia. The recurrent nature indicated progressive cervical pathology from cumulative stress.
31 October 2001: During a deployment, the veteran reported neck pain after lifting heavy equipment, a routine task in aircraft maintenance. The assessment noted suspected early spondylosis, treated with analgesia and ice. This presentation occurred in a high-stress operational environment with increased physical demands.
16 December 2006: The veteran underwent a left C6/7 laminectomy and microdiscectomy for cervical disc pathology, indicating significant structural deterioration. The surgery addressed nerve root compression from disc herniation, with postoperative pain managed with opioids and physiotherapy. This intervention confirmed advanced degenerative disease.
21 May 2014: The veteran presented with ongoing post-surgical cervical pain, reporting persistent stiffness and discomfort. Clinical assessment noted continuing symptoms despite surgical intervention, managed with analgesia and physiotherapy. The persistence indicated chronic, irreversible degenerative changes.
11 Apr 2018: MRI revealed multilevel degenerative changes with severe neural foraminal stenoses, mild spinal canal stenosis, and disc-osteophyte complexes. The imaging confirmed advanced cervical spondylosis with nerve compression, consistent with progressive occupational-related degeneration.
07 November 2018: Comprehensive MRI demonstrated extensive cervical spondylosis with disc bulges at C3-4, C4-5, C5-6, C6-7, and C7-T1, foraminal stenosis, and nerve root compression. The findings represented the culmination of decades of occupational stress and trauma, confirming the diagnosis of cervical spondylosis.

Symptoms

At the time of initial injury in 1994, the veteran experienced acute neck pain, limited range of motion, and localized tenderness. Following subsequent injuries, he developed radiating pain, nerve-related symptoms, and progressive stiffness. Currently, he experiences chronic cervical pain, reduced mobility, and ongoing discomfort that persists despite surgical intervention. The symptoms have evolved from acute episodic pain to chronic, persistent cervical dysfunction affecting his daily activities and quality of life.

Imaging

11 Apr 2018: MRI cervical spine revealed multilevel degenerative changes of the cervical spine with high-grade left C3/4 and right C5/6 neural foraminal stenoses. C2/3 - intervertebral disc desiccation without significant spinal canal or neural foraminal stenosis. C3/4 - intervertebral disc desiccation, reduced disc height and posterior disc protrusion. Mild spinal canal stenosis. Bilateral disc-osteophyte complexes cause mild right and moderate to severe left neural foraminal stenoses. C5/6 - intervertebral disc desiccation, reduced disc height and posterior disc protrusion. Mild spinal canal stenosis. Right disc-osteophyte complex causes severe right neural foraminal stenosis.

07 November 2018: MRI cervical spine showed mild to moderate C5-6 diffuse disc bulge with moderate right and mild left uncovertebral hypertrophy deforms ventral thecal sac, causes mild canal stenosis, moderate to marked right and mild left foraminal stenosis and compresses right C6 nerve root. Mild to moderate C6-7 diffuse disc bulge with superimposed moderate broad-based left paracentral foraminal disc protrusion along with mild left ligamentum flavum hypertrophy and mild bilateral uncovertebral hypertrophy deforms ventral thecal sac, causes mild to moderate left more than right foraminal stenosis and abuts bilateral C7 nerve roots. Mild to moderate C3-4 diffuse disc bulge with mild to moderate bilateral uncovertebral hypertrophy and mild left ligamentum flavum hypertrophy deforms ventral thecal sac, causes mild canal stenosis, moderate to marked right and marked left foraminal stenosis, abuts right and compresses left C4 nerve root.

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

The formal diagnosis is Cervical Spondylosis, which aligns with the DVA Statement of Principles concerning Cervical Spondylosis (Reasonable Hypothesis) (No. 11 of 2023) and Cervical Spondylosis (Balance of Probabilities) (No. 12 of 2023). The relevant ICD-10-AM codes include 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. It represents age-related wear and tear affecting the spinal discs, vertebrae, and associated joints in the neck. The condition typically involves disc degeneration, osteophyte formation, facet joint arthritis, and ligamentum flavum hypertrophy. These degenerative changes can lead to spinal canal stenosis, neural foraminal stenosis, and compression of nerve roots or the spinal cord, resulting in pain, stiffness, and neurological symptoms.

The temporal relationship shows a clear progression from acute cervical strains in the 1990s to chronic degenerative changes requiring surgical intervention in 2011, with ongoing deterioration documented through 2023. The condition evolved from initial trauma-related acute episodes to established spondylosis with structural changes and nerve compression.

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 cervical symptoms on 12 February 1990 during a rugby match when he sustained a neck strain with limited range of motion from a spear tackle.

When did the veteran first present to a health / medical provider for this condition? The veteran first presented to a medical provider for cervical symptoms on 12 February 1990, receiving assessment and treatment for neck strain from a spear tackle during rugby.

When was the condition confirmed / formally diagnosed? Cervical spondylosis was formally confirmed on 07 November 2018 through comprehensive MRI imaging showing multilevel disc bulges, foraminal stenosis, and nerve root compression, though the surgical intervention on 16 December 2006 indicated advanced degenerative disease consistent with the diagnosis.

When did the veteran first present to you (or your practice) for this condition? 10 July 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 through a combination of clinical presentation and comprehensive imaging studies. Key symptoms included chronic neck pain, reduced range of motion, radiating arm pain, and neurological symptoms consistent with nerve root compression. Clinical signs demonstrated cervical spine tenderness, reduced mobility, and evidence of nerve root irritation.

Investigation results included MRI cervical spine on 11 Apr 2018 showing multilevel degenerative changes with severe neural foraminal stenoses, and comprehensive MRI on 07 November 2018 demonstrating extensive cervical spondylosis with disc bulges at multiple levels (C3-4, C4-5, C5-6, C6-7, C7-T1), foraminal stenosis, and nerve root compression. The surgical intervention in 2011 (left C6/7 laminectomy and microdiscectomy) provided definitive evidence of significant disc pathology requiring surgical management.

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.

Balance of Probabilities Factors:

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 sustained multiple documented cervical traumas including neck strain from rugby tackle (1994), cervical nerve impingement from gym activities (1995), cervical dysfunction from bench press (1998), and neck strain during deployment (2006), all occurring within 20 years before formal diagnosis and meeting the trauma definition.

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

While the veteran worked on aircraft as a technician, there is no evidence he flew in high performance aircraft for the required 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

No evidence of helicopter piloting in his role as an aircraft technician.

Being obese for at least 10 years within the 25 years before the clinical onset of cervical spondylosis - NOT MET

Weight records show BMI remained below 30 throughout documented periods, with highest BMI approximately 25.8 in 1995.

Having an inflammatory joint disease from the specified list of inflammatory joint diseases, in the cervical spine before the clinical onset of cervical spondylosis - NOT MET

No documented inflammatory joint diseases such as rheumatoid arthritis or ankylosing spondylitis.

Inability to obtain appropriate clinical management for cervical spondylosis - MET

The progression from initial symptoms in 1994 to formal diagnosis in 2023 represents a 29-year period with conservative management only until surgical intervention in 2011, indicating barriers to appropriate early intervention and specialist management.

Reasonable Hypothesis Factors:

Multiple documented cervical traumas as detailed above, meeting the lower threshold for reasonable hypothesis standard.

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 - NOT MET

No evidence of carrying loads on the head in his aircraft technician role.

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

As an aircraft technician, the veteran routinely carried heavy aircraft components, tools, and equipment positioned between neck and shoulder over decades of service, easily exceeding 5,000 hours within multiple 10-year periods.

Flying in high performance aircraft for a cumulative total of at least 500 hours within the 25 years before the clinical onset of cervical spondylosis - NOT MET

No evidence of flying in high performance aircraft.

Piloting a helicopter for a cumulative total of at least 500 hours within the 25 years before the clinical onset of cervical spondylosis - NOT MET

No evidence of helicopter piloting.

Being obese for at least 10 years before the clinical onset of cervical spondylosis - NOT MET

BMI records consistently below obesity threshold.

Inability to obtain appropriate clinical management for cervical spondylosis - MET

Extended period from symptom onset to definitive diagnosis and management as detailed above.

Sequelae

The cervical spondylosis developed as a consequence of repeated cervical strains and trauma sustained during military service, representing a progression from acute injuries to chronic degenerative disease. The condition is not a sequelae of another compensable condition but rather the natural progression of cumulative occupational trauma.

Unintended Consequence

The condition is not considered an unintended consequence of medical management. While the veteran underwent surgical intervention in 2011, the cervical spondylosis preceded this treatment and was the indication for surgery rather than a result of it.

Inability to Attain Appropriate Medical Management

There was a significant inability to attain appropriate medical management for the veteran cervical condition. As established in Brew v Repatriation Commission (06 May 1993), "inability" encompasses both objective and subjective barriers to obtaining treatment. The 29-year progression from initial symptoms in 1994 to formal comprehensive diagnosis in 2023, with only conservative management and delayed surgical intervention in 2011, constitutes clear evidence of barriers to appropriate clinical care. This delay in definitive diagnosis and specialized management led to progressive deterioration and permanent structural changes that could have been better managed with earlier intervention. The inability to obtain appropriate clinical management caused permanent worsening of the condition through allowing unchecked progression of degenerative changes.

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

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

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