Lumbar Spine - Intervertebral Disc Prolapse — ICD-10 M51.1

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 invented and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Lumbar Spine - Intervertebral Disc Prolapse

Example 1 of 1 · fictitious patient (Veteran C)

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 invented and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

Lumbar Spine - Intervertebral Disc Prolapse

BOP Code: 69 of 2023 (Thoracolumbar Intervertebral Disc Prolapse)
RH Code: 68 of 2023 (Thoracolumbar Intervertebral Disc Prolapse)

ADF History

Veteran C, date of birth 14 June 1977, Australian Army, Driver and later Army Aviation helicopter pilot, enlisted 19 January 1996, medically discharged 30 June 2020. Operational service: Afghanistan, 15 February 2008 to 20 August 2008 (warlike); Timor-Leste, 03 March 2009 to 28 April 2011 (non-warlike, consecutive rotations); Middle East Area of Operations, 01 December 2014 to 06 April 2015 (warlike); Middle East Area of Operations, 10 May 2018 to 23 August 2018 (warlike).

Occupational History

As a driver the veteran spent long periods seated in heavy vehicles with whole-body vibration and loaded and unloaded stores by hand. As a helicopter pilot he flew long sorties in a fixed seated posture with constant airframe vibration, wearing body armour, a survival vest and helmet that loaded the spine, and he kept up the soldier skills of Army aviators, including loaded pack marches and field exercises.

Aircrew are exposed to heavy landings, crash and ejection forces, rocket and indirect fire on forward operating bases, and the musculoskeletal effects of night-vision goggles and armour. Smoking was common in the aviation and deployed environment of the period.

History

Veteran C, an Army helicopter pilot, developed an L4/5 intervertebral disc prolapse with nerve root compression on 15 March 2015, the day after a heavy helicopter landing on warlike service in the Middle East in which a metal fragment pierced the disc and infected it. The prolapse worsened on 22 August 2018, after a fall during a rocket attack alarm on a second Middle East deployment, with cauda equina compression requiring emergency decompression.

Timeline

18 Jun 2006 — Periodic health examination at the aviation regiment's health centre. Weight 109 kg, height 1.85 m, BMI 31.8, unchanged from a BMI above 30 recorded at each examination since May 1998. Smoker of 20 cigarettes a day since 1994. No back pain. Logbook total at that date 2,410 hours as a helicopter pilot. "BMI 31.8, smoker 20/day"
28 Apr 2011 — End-of-detachment medical review after 26 months on consecutive rotations in Timor-Leste. The veteran had flown 1,720 hours on the detachment and driven a utility vehicle an average of 31 hours per week between the airfield, headquarters and outlying landing sites. He reported intermittent low back stiffness after long flying days, settling with rest. Examination normal. "26 months Timor, back stiffness"
10 Nov 2014 — Pre-deployment health assessment before deployment to the Middle East. No current back pain, full lumbar range of movement, normal neurological examination of the lower limbs. Still smoking 20 cigarettes a day. Fit to deploy as a helicopter pilot. "no back complaints, fit to deploy"
14 Mar 2015 — During warlike service in the Middle East the veteran's helicopter landed heavily after a tail rotor malfunction. He had immediate severe low back pain and a penetrating wound of the lower back from a sheared seat-frame fragment. At the role 2 facility there was tenderness at L4 and L5 and marked loss of lumbar flexion. CT showed a metallic fragment track through the L4/5 annulus into the L5 superior endplate. The fragment was removed and the wound washed out on 15 March 2015, when he first described left buttock and leg pain. "heavy landing, fragment L4/5 annulus"
06 Apr 2015 — After waiting 22 days in theatre for evacuation, the veteran had MRI in Australia showing an L4/5 left paracentral disc extrusion compressing the left L5 nerve root, with discitis at the same level. Disc space material from 15 March 2015 had grown Staphylococcus aureus. Twelve weeks of intravenous then oral antibiotics were commenced. Straight leg raise was positive on the left at 35 degrees, with reduced sensation over the dorsum of the left foot. "L4/5 extrusion, L5 root, discitis"
14 Mar 2016 — Review by a sports and exercise physician. Infection markers had normalised and the leg pain had largely settled with physiotherapy, but low back pain and intermittent left leg paraesthesia persisted. He returned to full flying and field training duties. He was referred for spinal surgical review in 2017 and remained on a public waiting list for nine months without being seen. "returned to flying, residual L5"
22 Aug 2018 — On warlike service in the Middle East he fell down concrete bunker stairs during a rocket attack alarm on the night of 21 August 2018. Next morning a CT-guided needle aspiration of the L4/5 disc was performed for fever and grew Staphylococcus aureus. At 1600 hours he developed a new left foot drop and saddle anaesthesia. MRI showed a much larger L4/5 extrusion compressing the cauda equina, with recurrent discitis. "foot drop, saddle anaesthesia, MRI"
24 Aug 2018 — After aeromedical evacuation he underwent emergency L4/5 laminectomy and discectomy with washout of the disc space. Bladder function recovered over six weeks but a partial left foot drop (ankle dorsiflexion power 3 out of 5) persisted. He was medically downgraded from flying and commenced pregabalin and controlled-release opioid analgesia. "emergency decompression, residual foot drop"

Symptoms

At onset the veteran had severe low back pain with left buttock and leg pain in an L5 distribution, paraesthesia over the dorsum of the left foot, and pain on sitting, coughing and bending. After onset he had persistent low back pain with intermittent left leg symptoms, worse after long flying days. After the 2018 worsening he had a left foot drop, saddle numbness and urinary retention, which partly resolved.

He now reports constant low back pain, left leg pain and numbness, a partial left foot drop requiring an ankle-foot orthosis on long walks, and difficulty sitting for more than 30 minutes, driving long distances, lifting and sleeping.

Imaging

14 Mar 2015 — CT lumbar spine: "2 cm metallic fragment track through the left posterolateral annulus of the L4/5 disc into the superior endplate of L5. No vertebral fracture."
06 Apr 2015 — MRI lumbar spine: "Left paracentral L4/5 disc extrusion compressing the traversing left L5 nerve root. Endplate oedema and disc space enhancement at L4/5 consistent with discitis."
20 Jul 2015 — MRI lumbar spine: "Resolving discitis at L4/5. Persisting smaller left paracentral L4/5 disc protrusion contacting the left L5 nerve root."
22 Aug 2018 — MRI lumbar spine: "Large central and left L4/5 disc extrusion with caudal migration, severe canal stenosis and compression of the cauda equina. Recurrent L4/5 discitis with a small epidural collection."
10 Feb 2019 — MRI lumbar spine: "Post-operative changes of L4/5 laminectomy and discectomy. Small residual left paracentral protrusion and epidural fibrosis around the left L5 nerve root. No recurrent infection."

Onset Date

The most likely date of onset of this condition is 15 Mar 2015.

At that date the veteran was a helicopter pilot on warlike service in the Middle East. On 14 March 2015 his aircraft landed heavily and a seat-frame fragment pierced the L4/5 disc. By the morning of 15 March 2015, at wound exploration, he had persistent low back pain with left L5 radicular pain, and these symptoms were continuously present from then until the imaging confirmation on 06 April 2015.

This date is appropriate because his pre-deployment health assessment on 10 November 2014 recorded no back pain and a normal neurological examination, and the clinical onset definition runs back from the first confirming MRI on 06 April 2015 to the date the symptoms were persistently present, 15 March 2015. It falls within continuous full-time service.

For the trauma and penetrating injury factors, the 24 hours before onset run from the morning of 14 Mar 2015 to the morning of 15 Mar 2015 and contain the heavy landing and the fragment injury; the infected disc material was taken at onset on 15 Mar 2015. For the BoP lifting factor, the 5 years before onset run from 15 Mar 2010 to 15 Mar 2015, and weekly 35 kg pack marches with armour and stores handling gave a Load-Factor above 300,000. For the RH lifting, driving and flying factors, the 10 years before onset run from 15 Mar 2005 to 15 Mar 2015; this period contains 26 months of driving at 31 hours a week in Timor-Leste (March 2009 to April 2011) and 5,240 helicopter hours. For the obesity factor, the 25 years before onset run from 15 Mar 1990 to 15 Mar 2015 and contain 8 years with a BMI above 30 (May 1998 to June 2006). He had smoked about 21 pack-years by onset and had not stopped.

For the worsening factors, the documented worsening was at 1600 hours on 22 Aug 2018. The 24 hours before it, from 1600 hours on 21 Aug 2018, contain the fall down bunker stairs and the needle aspiration of the disc. The 5 years before it run from 22 Aug 2013 to 22 Aug 2018 and the 10 years before it from 22 Aug 2008 to 22 Aug 2018, which contain the Timor-Leste driving, 5,060 flying hours and continued loaded marching and stores handling. The 25 years before it run from 22 Aug 1993 to 22 Aug 2018 and contain the 8 years of obesity.

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

The formal diagnosis is Lumbar Spine - Intervertebral Disc Prolapse at L4/5 with left L5 radiculopathy and later cauda equina compression (ICD-10-AM M51.1), under the Statements of Principles concerning thoracolumbar intervertebral disc prolapse, Balance of Probabilities No. 69 of 2023 and Reasonable Hypothesis No. 68 of 2023.

A lumbar intervertebral disc prolapse is the protrusion, extrusion or rupture of the nucleus pulposus through the annulus fibrosus into the vertebral canal, where it can compress the nerve roots or the cauda equina. It causes low back pain and stiffness, with radicular leg pain, numbness and weakness in the distribution of the compressed root. Large central prolapses can compress the cauda equina, causing saddle anaesthesia, bladder and bowel dysfunction and bilateral leg weakness, which is a surgical emergency. Infection of the disc (discitis) weakens the annulus and endplate and promotes prolapse.

The prolapse began on 15 March 2015 after a heavy helicopter landing and penetrating fragment injury on warlike service, was confirmed on MRI on 06 April 2015, and worsened on 22 August 2018 with cauda equina compression.

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

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

15 March 2015.

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

15 March 2015.

When was the condition confirmed / formally diagnosed?

06 April 2015.

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

18 June 2025.

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

The diagnosis was confirmed by MRI of the lumbar spine on 06 April 2015, which showed a left paracentral L4/5 disc extrusion compressing the traversing left L5 nerve root, with discitis at the same level. This is imaging evidence of herniation of the nucleus pulposus into the vertebral canal of the thoracolumbar spine and is not a disc bulge or Schmorl's node.

The clinical manifestations met the Statement of Principles definition: low back pain and stiffness with left L5 radicular pain, a positive straight leg raise at 35 degrees and reduced sensation over the dorsum of the left foot. The 2018 MRI confirmed a much larger extrusion compressing the cauda equina, and the diagnosis was confirmed at surgery on 24 August 2018.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

Legislation: the clinical onset of this condition was on 15 March 2015, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan in 2008 and the Middle East in 2014-15 and 2018, and his non-warlike service in Timor-Leste from 2009 to 2011, during which the onset and the worsening both occurred.

Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.

Balance of Probabilities — Statement of Principles concerning Thoracolumbar Intervertebral Disc Prolapse, No. 69 of 2023

Causative factors

Factor 9(1): having trauma to the affected intervertebral disc within the 24 hours before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET

- On 14 March 2015, during warlike service in the Middle East, the helicopter the veteran was flying made a heavy landing after a tail rotor malfunction, with an estimated vertical deceleration of 14 g transmitted through his seat to the lumbar spine. He had immediate severe low back pain, tenderness over L4 and L5 and a marked loss of lumbar flexion at the role 2 facility, and these signs persisted well beyond 7 days, until and after the L4/5 disc prolapse was confirmed on MRI on 06 April 2015. Clinical onset was the following morning, 15 March 2015, well within 24 hours of the trauma.

Factor 9(2): having a penetrating injury to the affected intervertebral disc or adjacent vertebral body, within the 24 hours before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET

- In the same heavy landing on 14 March 2015 a sheared fragment of the seat frame pierced his lower back. CT that day showed a 2 cm metallic fragment track through the posterolateral annulus of the L4/5 disc into the superior endplate of the L5 vertebral body, and the fragment was removed surgically on 15 March 2015. The penetrating injury to the affected disc and adjacent vertebral body occurred within 24 hours of the clinical onset on 15 March 2015.

Factor 9(3): physically carrying or lifting loads of at least 10 kilograms, to a cumulative total Load-Factor of at least 300,000 within the 5 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET

- Flight records and unit training records show that in the 5 years before onset, from 15 March 2010 to 15 March 2015, the veteran completed weekly loaded pack marches with 35 kg for an average of 3 hours (Load-Factor 3,675 per march; about 180 marches, total 661,500), and on deployment wore 18 kg of body armour and survival equipment and manually loaded 20 to 40 kg stores into the aircraft. His cumulative Load-Factor in the 5-year window was well above 300,000.

Factor 9(4): driving a motor vehicle for an average of at least 30 hours per week, for a period of at least 2 years within the 10 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET

- From 03 March 2009 to 28 April 2011 the veteran served on back-to-back rotations with a helicopter detachment in Timor-Leste, where he also drove a four-wheel-drive utility vehicle between the airfield, headquarters and outlying landing sites. Detachment vehicle logs record an average of 31 hours of driving per week over those 26 months, a period of more than 2 years inside the 10 years before onset (15 March 2005 to 15 March 2015).

Factor 9(5): piloting an engine powered aircraft for a cumulative total of at least 5,000 hours within the 10 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET

- The veteran was an Army helicopter pilot from 2002. His flying logbook records 5,240 hours as pilot or co-pilot of engine powered aircraft (multi-role and reconnaissance helicopters) between 15 March 2005 and 15 March 2015, the 10 years before onset. Prolonged seated posture with whole-body vibration in helicopter cockpits loads the lumbar discs.

Factor 9(6): flying in a helicopter as operational aircrew, for a cumulative total of at least 5,000 hours within the 10 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET

- The same logbook records 5,240 hours flown in helicopters as operational aircrew in the 10 years before onset, from 15 March 2005 to 15 March 2015, including training, domestic support tasks and his deployments to Afghanistan, Timor-Leste and the Middle East.

Factor 9(7): having smoked tobacco products in an amount of at least 10 pack-years before the clinical onset of thoracolumbar intervertebral disc prolapse, and if smoking has ceased before the clinical onset of thoracolumbar intervertebral disc prolapse, then that onset occurred within 5 years of cessation; — MET

- The veteran began smoking 20 cigarettes a day at 16 in January 1994, and smoking increased in the service environment, particularly on deployment. By onset on 15 March 2015 he had smoked about 21 pack-years. He had not ceased smoking. Smoking impairs nutrition of the intervertebral disc through its effect on the endplate blood supply.

Factor 9(8): having bacterial infection of the affected disc at the time of the clinical onset of thoracolumbar intervertebral disc prolapse; — MET

- The fragment wound of 14 March 2015 introduced bacteria into the L4/5 disc. Material from the disc space taken at the wound exploration on 15 March 2015 grew Staphylococcus aureus, and MRI on 06 April 2015 showed discitis at L4/5 together with the disc extrusion. The bacterial infection of the affected disc was present at clinical onset on 15 March 2015.

Factor 9(9): being obese for at least 5 years within the 25 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET

- Periodic health examinations recorded a BMI of 30.4 to 32.0 from 12 May 1998 to 18 June 2006 (weight 104 to 109 kg, height 1.85 m), a period of 8 years, all within the 25 years before onset (15 March 1990 to 15 March 2015).

Worsening factors

Factor 9(10): having trauma to the affected intervertebral disc within the 24 hours before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET

- On the night of 21 August 2018, during warlike service in the Middle East, the veteran fell down concrete bunker stairs during a rocket attack alarm, landing heavily on his lower back. He had immediate severe low back pain, tenderness at L4/5 and loss of lumbar movement, which persisted for more than 7 days and led to surgery on 24 August 2018. The clinical worsening, new left foot drop and saddle anaesthesia, was documented at 1600 hours on 22 August 2018, within 24 hours of the fall.

Factor 9(11): having a penetrating injury to the affected intervertebral disc or adjacent vertebral body, within the 24 hours before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET

- At 0800 hours on 22 August 2018 a CT-guided needle aspiration of the L4/5 disc space was performed at the coalition role 3 hospital because of fever after the fall. The needle pierced the affected disc. The clinical worsening was documented eight hours later, within 24 hours of the penetrating injury.

Factor 9(12): physically carrying or lifting loads of at least 10 kilograms, to a cumulative total Load-Factor of at least 300,000 within the 5 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET

- In the 5 years before the worsening, from 22 August 2013 to 22 August 2018, the veteran resumed weekly 35 kg pack marches after his return to full flying duties in 2016 and continued manual loading of aircraft stores and wearing 18 kg of armour on his 2014-15 and 2018 deployments. Training records give a cumulative Load-Factor of more than 300,000 in that window.

Factor 9(13): driving a motor vehicle for an average of at least 30 hours per week, for a period of at least 2 years within the 10 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET

- The 26 months of driving in Timor-Leste from 03 March 2009 to 28 April 2011, averaging 31 hours per week, fall within the 10 years before the worsening, from 22 August 2008 to 22 August 2018.

Factor 9(14): piloting an engine powered aircraft for a cumulative total of at least 5,000 hours within the 10 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET

- His logbook records 5,060 hours piloting helicopters from 22 August 2008 to 22 August 2018, the 10 years before the worsening.

Factor 9(15): flying in a helicopter as operational aircrew, for a cumulative total of at least 5,000 hours within the 10 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET

- The same 5,060 hours were flown in helicopters as operational aircrew in the 10 years before the worsening on 22 August 2018.

Factor 9(16): having smoked tobacco products in an amount of at least 10 pack-years before the clinical worsening of thoracolumbar intervertebral disc prolapse, and if smoking has ceased before the clinical worsening of thoracolumbar intervertebral disc prolapse, then that worsening occurred within 5 years of cessation; — MET

- The veteran continued to smoke about 20 cigarettes a day up to the worsening, a total of about 24 pack-years by 22 August 2018, and had not ceased.

Factor 9(17): having bacterial infection of the affected disc at the time of the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET

- The disc aspirate of 22 August 2018 grew Staphylococcus aureus, and MRI the same evening showed recurrent L4/5 discitis with an enlarged extrusion. The bacterial infection of the affected disc was present at the time of the clinical worsening.

Factor 9(18): being obese for at least 5 years within the 25 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET

- The 8 years of obesity from May 1998 to June 2006 lie within the 25 years before the worsening, from 22 August 1993 to 22 August 2018.

Factor 9(19): inability to obtain appropriate clinical management for thoracolumbar intervertebral disc prolapse before the clinical worsening of thoracolumbar intervertebral disc prolapse. — MET

- After clinical onset on 15 March 2015 in the Middle East the veteran waited 22 days for aeromedical evacuation and MRI because there was no MRI or spinal surgeon in theatre, and he flew as a passenger in a seated position during that period. In 2017 he waited nine months on a Defence-referred public waiting list for spinal surgical review of persisting L5 radicular pain and was returned to deployable status without that review. Both delays came before the worsening on 22 August 2018.

Reasonable Hypothesis — Statement of Principles concerning Thoracolumbar Intervertebral Disc Prolapse, No. 68 of 2023

Causative factors

Factor 9(1): having trauma to the affected intervertebral disc within the 24 hours before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET

- The heavy landing on 14 March 2015 occurred during warlike service in the Middle East and applied significant force to the L4/5 disc, with pain, tenderness and loss of lumbar movement persisting for more than 7 days. Clinical onset on 15 March 2015 was within 24 hours.

- The seat-frame fragment that pierced the L4/5 disc and the L5 vertebral body on 14 March 2015 was sustained in the heavy landing on warlike service in the Middle East, within 24 hours of the clinical onset on 15 March 2015.

Factor 9(3): physically carrying or lifting loads of at least 10 kilograms, to a cumulative total Load-Factor of at least 150,000 within the 10 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET

- In the 10 years before onset, from 15 March 2005 to 15 March 2015, the veteran deployed to Afghanistan (February to August 2008), Timor-Leste (March 2009 to April 2011) and the Middle East (from December 2014), wearing 18 kg of armour and survival equipment for flying and manually loading 20 to 40 kg stores. Together with field training marches of 35 kg, his cumulative Load-Factor was well over 150,000.

Factor 9(4): driving a motor vehicle for an average of at least 25 hours per week, for a period of at least 2 years within the 10 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET

- The veteran drove an average of 31 hours per week for 26 months while on non-warlike service in Timor-Leste, from 03 March 2009 to 28 April 2011, within the 10 years before onset.

Factor 9(5): flying in an engine powered aircraft as operational crew, for a cumulative total of at least 2,500 hours within the 10 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET

- Of the 5,240 hours the veteran flew as crew in engine powered aircraft in the 10 years before onset, more than 2,500 were flown on operational service: 610 hours in Afghanistan in 2008, 1,720 hours in Timor-Leste from 2009 to 2011 and 290 hours in the Middle East before 15 March 2015, together with the domestic training required to prepare for those deployments.

Factor 9(6): flying in a helicopter as operational aircrew, for a cumulative total of at least 2,500 hours within the 10 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET

- The same hours were flown in helicopters as operational aircrew, including 2,620 hours on warlike and non-warlike service in Afghanistan, Timor-Leste and the Middle East, within the 10 years before onset.

Factor 9(7): having smoked tobacco products in an amount of at least 5 pack-years before the clinical onset of thoracolumbar intervertebral disc prolapse, and if smoking has ceased before the clinical onset of thoracolumbar intervertebral disc prolapse, then that onset occurred within 5 years of cessation; — MET

- The veteran smoked about 21 pack-years by onset on 15 March 2015 and had not ceased. His intake rose to 25 to 30 cigarettes a day on deployment in Afghanistan, Timor-Leste and the Middle East, where tobacco was cheap and used to manage long duty hours.

Factor 9(8): having bacterial infection of the affected disc at the time of the clinical onset of thoracolumbar intervertebral disc prolapse; — MET

- The Staphylococcus aureus infection of the L4/5 disc came from the contaminated fragment wound sustained on warlike service in the Middle East on 14 March 2015, and was present at clinical onset on 15 March 2015.

Factor 9(9): being obese for at least 5 years within the 25 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET

- The veteran was obese, with a BMI of 30.4 to 32.0, from May 1998 to June 2006, within the 25 years before onset. This was recorded during full-time service and preceded his deployments.

Worsening factors

Factor 9(10): having trauma to the affected intervertebral disc within the 24 hours before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET

- The fall down bunker stairs during a rocket attack alarm on 21 August 2018 occurred on warlike service in the Middle East. Pain, tenderness and loss of lumbar movement followed and persisted, and the worsening was documented within 24 hours.

- The CT-guided needle aspiration of the L4/5 disc on 22 August 2018 was performed at a coalition role 3 hospital during warlike service in the Middle East, eight hours before the documented worsening.

Factor 9(12): physically carrying or lifting loads of at least 10 kilograms, to a cumulative total Load-Factor of at least 150,000 within the 10 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET

- In the 10 years before the worsening, from 22 August 2008 to 22 August 2018, his deployments to Timor-Leste and the Middle East in 2014-15 and 2018 required armour, survival equipment and manual stores handling, giving a cumulative Load-Factor well above 150,000.

Factor 9(13): driving a motor vehicle for an average of at least 25 hours per week, for a period of at least 2 years within the 10 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET

- The 26 months of driving at 31 hours per week on non-warlike service in Timor-Leste, from March 2009 to April 2011, lie within the 10 years before the worsening.

Factor 9(14): flying in an engine powered aircraft as operational crew, for a cumulative total of at least 2,500 hours within the 10 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET

- More than 2,500 of the 5,060 hours flown in the 10 years before the worsening were flown on operational service in Timor-Leste and the Middle East, including 340 hours on the 2018 deployment.

Factor 9(15): flying in a helicopter as operational aircrew, for a cumulative total of at least 2,500 hours within the 10 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET

- The same operational helicopter hours on warlike and non-warlike service fall within the 10 years before the worsening on 22 August 2018.

Factor 9(16): having smoked tobacco products in an amount of at least 5 pack-years before the clinical worsening of thoracolumbar intervertebral disc prolapse, and if smoking has ceased before the clinical worsening of thoracolumbar intervertebral disc prolapse, then that worsening occurred within 5 years of cessation; — MET

- The veteran was still smoking at the worsening, about 24 pack-years, with heavier smoking on his 2018 warlike deployment.

Factor 9(17): having bacterial infection of the affected disc at the time of the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET

- Recurrent Staphylococcus aureus discitis was confirmed on the aspirate of 22 August 2018, taken on warlike service, and was present at the worsening.

Factor 9(18): being obese for at least 5 years within the 25 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET

- The 8 years of obesity from 1998 to 2006 lie within the 25 years before the worsening on 22 August 2018.

- On warlike service in the Middle East in March and April 2015 the veteran waited 22 days for evacuation and MRI because there was no MRI or spinal surgeon in theatre. He was then redeployed to the Middle East in May 2018 without the spinal surgical review he had been waiting for since 2017, and the worsening followed in August 2018.

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

Sequelae

The disc prolapse has resulted in a chronic left L5 radiculopathy with a partial foot drop, a period of cauda equina syndrome with urinary retention, chronic low back pain and post-laminectomy epidural fibrosis. Chronic pain has led to sleep disturbance and an adjustment disorder with depressed mood, and the altered gait from the foot drop has caused left hip and knee pain. These are sequelae of the accepted disc prolapse.

Unintended Consequence

Met. The recurrent infection and the worsening of 22 August 2018 followed a CT-guided needle aspiration of the affected disc performed by Commonwealth-provided health services on deployment, which pierced the disc within 24 hours of the worsening. The worsening is in part an unintended consequence of that treatment (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. After the onset on 15 March 2015 the veteran waited 22 days on warlike service in the Middle East for evacuation and MRI, because neither MRI nor a spinal surgeon was available in theatre, and during that time he travelled seated with an infected, extruded disc. In 2017 he waited nine months on a public waiting list for the spinal surgical review his treating doctors had requested and was redeployed before he was seen. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the unavailability of investigation and specialist review because of operational and service circumstances amounts to an inability to obtain appropriate clinical management, and that inability preceded the clinical worsening on 22 August 2018.

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

See attached report.

References

18 Jun 2006, Periodic health examination, Medical Officer, Aviation regiment health centre
28 Apr 2011, End-of-detachment medical review, Medical Officer, Timor-Leste
28 Apr 2011, Detachment vehicle logs and flying logbook summary, Aviation detachment
10 Nov 2014, Pre-deployment health assessment, Medical Officer
14 Mar 2015, Role 2 facility trauma record and CT report, Middle East
15 Mar 2015, Operation report and microbiology, Surgeon, Role 3 hospital
06 Apr 2015, MRI lumbar spine, Radiologist
20 Jul 2015, MRI lumbar spine and infectious diseases review, Infectious diseases physician
14 Mar 2016, Specialist consultation, Sports and exercise physician
22 Aug 2018, CT-guided aspiration, microbiology and MRI report, Coalition role 3 hospital
24 Aug 2018, Operation report, Neurosurgeon
10 Feb 2019, MRI lumbar spine, Radiologist
Statement of Principles concerning Thoracolumbar Intervertebral Disc Prolapse (Balance of Probabilities) No. 69 of 2023, Repatriation Medical Authority
Statement of Principles concerning Thoracolumbar Intervertebral Disc Prolapse (Reasonable Hypothesis) No. 68 of 2023, Repatriation Medical Authority

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Lumbar Spine - Intervertebral Disc Prolapse — DVA claim example