Diagnostic Assessment — Lumbar Spine - Lumbar Radiculopathy
Example 1 of 1 · fictitious patient (Veteran V)
Diagnostic Assessment
Lumbar Spine - Lumbar Radiculopathy
BOP Code: 14 of 2023 (Thoracolumbar Spondylosis)
RH Code: 13 of 2023 (Thoracolumbar Spondylosis)
ADF History
Veteran V, date of birth 03 August 1968, Australian Army, Infantry Soldier (Rifleman) from 1986 and Army Aviation Aircrewman from 2004 (Warrant Officer Class 2), enlisted 21 January 1986, medically discharged 15 June 2018. Operational service: Somalia, 15 January 1993 to 20 May 1993 (warlike); East Timor, 20 September 1999 to 15 February 2000 (warlike); Iraq, 10 February 2003 to 30 June 2003 (warlike); Afghanistan, 05 June 2008 to 15 December 2008 (warlike); Middle East Area of Operations, 10 April 2017 to 30 October 2017 (warlike).
Occupational History
As an infantry soldier the veteran carried packs, body armour, weapons and ammunition weighing 30 to 45 kilograms on foot for long periods, dug in, and manually loaded and unloaded ammunition, water and stores weighing 20 to 40 kilograms. Infantry duties carry a high risk of blast, fragment and gunshot injury, falls and vehicle accidents, and of capture on operations.
As an Army aviation aircrewman he flew as operational crew in utility and heavy-lift helicopters, exposed to whole-body vibration in a seated, flexed posture, and manually handled cargo, stretchers and underslung loads. Aircrew wear helmets, body armour and survival equipment that add sustained axial load to the spine.
History
Veteran V, an infantry soldier who later became an Army aviation aircrewman, sustained a penetrating fragment injury and fracture of the lumbar spine in East Timor in 1999, after earlier being held captive in Somalia, and later required an L5–S1 fusion. He developed lumbar spondylosis at L4–L5 with left L5 radiculopathy in March 2016, which worsened during and after his 2017 deployment to the Middle East.
Timeline
- 02 Apr 1993 — During warlike service in Somalia the veteran's patrol was ambushed and he was captured by an armed militia group and held for nine days before release through negotiation. He was beaten and thrown from a moving vehicle during his captivity, fracturing his right femoral shaft. The fracture was treated late and healed with 2.5 cm of shortening. He was recorded as a former prisoner of war in his medical documents. "held captive nine days, femur fracture"
- 14 Dec 1999 — During warlike service in East Timor a grenade detonated beside the veteran. A metal fragment entered the left lower back and pierced the L4–L5 intervertebral disc and the L4 vertebral body. CT showed a fracture of the left L4 inferior articular process extending into the L4–L5 facet joint and bilateral L5 pars interarticularis fractures. He was immobilised in a brace for eight weeks. He had severe back pain, tenderness and restricted movement from the time of injury. "fragment L4–5 disc, facet fracture"
- 02 Feb 2000 — He developed fever and escalating back pain, and MRI confirmed Staphylococcus aureus discitis at L4–L5 with inflammation of the disc space and end plates, a consequence of the fragment injury. He received eight weeks of intravenous antibiotics. X-rays in 2001 showed a grade 1 isthmic spondylolisthesis of L5 on S1 with increased lumbar lordosis. "L4–5 discitis, IV antibiotics"
- 28 May 2003 — After Campylobacter enteritis during warlike service in Iraq in April 2003, the veteran developed reactive arthritis with inflammatory back pain, bilateral sacroiliitis and anterior spondylitis of L1 to L3 on MRI. HLA-B27 was positive. A rheumatologist confirmed reactive arthritis involving the lumbar spine. His weight had risen to 102 kg at a height of 1.81 m, BMI 31.1, and his BMI stayed above 30 from then on. "reactive arthritis, lumbar spondylitis, BMI 31"
- 16 Oct 2012 — Investigation of headaches and enlarging hands showed a raised IGF-1 and a pituitary macroadenoma, and an endocrinologist diagnosed acromegaly. Lumbar X-rays showed vertebral body enlargement with anterior osteophytes consistent with acromegalic spondylopathy. In 2013 a bone scan and raised alkaline phosphatase confirmed Paget's disease of bone in the L3 vertebra. Gout, which first presented in Afghanistan in 2008, was shown on dual-energy CT in 2014 to involve the L4–L5 facet joints. "acromegaly, Paget's L3, spinal gout"
- 18 Feb 2014 — After an L4–L5 disc prolapse in June 2013, treated conservatively and settled by November 2013, and progression of the L5–S1 spondylolisthesis, a spinal surgeon performed an instrumented L5–S1 fusion. By then he had flown about 2,650 hours as operational helicopter aircrew since 2004. At a post-operative review on 21 October 2015 he had no leg pain and minimal back pain. "L5–S1 instrumented fusion performed"
- 15 Mar 2016 — At the garrison health centre the veteran reported eight days of constant low back pain and stiffness with pain radiating down the left buttock, lateral thigh and calf to the dorsum of the foot, with tingling of the great toe. Straight leg raise was positive on the left at 40 degrees and great toe extension was weak. He was referred for MRI. "left L5 radicular pain, SLR 40"
- 04 Apr 2016 — MRI showed L4–L5 disc space narrowing with desiccation, posterior osteophytes, facet joint hypertrophy and left foraminal stenosis compressing the exiting L4 and traversing L5 nerve roots, above the solid L5–S1 fusion. A spinal surgeon diagnosed lumbar spondylosis at L4–L5 with left L5 radiculopathy and commenced physiotherapy and pregabalin. "L4–5 spondylosis, foraminal stenosis"
- 22 Nov 2017 — On return from six months in the Middle East, where he wore body armour daily and could obtain no physiotherapy, imaging or surgical review, he reported constant left leg pain and foot drop when tired. Repeat MRI showed progression to severe left foraminal and lateral recess stenosis. Nerve conduction studies confirmed an active left L5 radiculopathy, and great toe extension power had fallen to 3/5. "worsening radiculopathy, EHL 3/5"
Symptoms
At onset the veteran had constant low back pain and stiffness with sharp pain radiating from the left buttock down the lateral thigh and calf to the dorsum of the foot, tingling of the left great toe and pain on sitting, bending and coughing. Examination showed a positive straight leg raise and weakness of great toe extension.
After onset the leg pain became constant and the weakness progressed, with episodes of foot drop after walking, particularly after his 2017 deployment. He now reports daily back and left leg pain, numbness over the dorsum of the left foot, difficulty walking more than 500 metres and sitting more than 30 minutes, and disturbed sleep from pain.
Imaging
- 14 Dec 1999 — CT lumbar spine: "Metallic fragment track through the left paraspinal muscles into the L4–L5 disc and L4 vertebral body. Fracture of the left L4 inferior articular process extending into the L4–L5 facet joint. Bilateral L5 pars interarticularis fractures."
- 02 Feb 2000 — MRI lumbar spine: "L4–L5 discitis with end plate oedema and disc space fluid."
- 12 Jul 2001 — X-ray lumbar spine: "Grade 1 isthmic spondylolisthesis of L5 on S1. Increased lumbar lordosis, 72 degrees."
- 28 May 2003 — MRI lumbar spine and sacroiliac joints: "Bilateral active sacroiliitis. Anterior corner inflammatory lesions at L1, L2 and L3."
- 10 Jun 2013 — MRI lumbar spine: "Left paracentral L4–L5 disc prolapse. Preserved disc height, no osteophytes. Expanded, coarsened L3 vertebral body."
- 04 Apr 2016 — MRI lumbar spine: "L4–L5 disc space narrowing and desiccation with posterior osteophytes, facet hypertrophy and left foraminal stenosis compressing the L4 and L5 nerve roots. Solid L5–S1 fusion."
- 22 Nov 2017 — MRI lumbar spine: "Progression of L4–L5 spondylosis with severe left foraminal and lateral recess stenosis."
Onset Date
The most likely date of onset of this condition is 07 Mar 2016.
At that date the veteran was a serving Warrant Officer in an Army aviation regiment in Australia, on ground duties after his L5–S1 fusion. From that day his low back pain and stiffness became constant and left leg pain in an L5 distribution was persistently present.
This date is appropriate because his post-fusion review on 21 October 2015 recorded no leg pain and minimal back pain, and the June 2013 MRI showed preserved disc height without osteophytes. He presented on 15 March 2016 reporting eight days of persistent symptoms, and MRI on 04 April 2016 confirmed degenerative change at L4–L5. Under the Statement of Principles, clinical onset is the point back from that imaging to when the symptoms were persistently present, which is 07 March 2016. It falls within continuous full-time service.
For the six-month factors, the 6 months before onset run from 07 Sep 2015 to 07 Mar 2016; the spondylolisthesis, vertebral deformity and lordotic abnormality were present throughout, and the 1999 fracture and 2000 discitis, the 2013 disc prolapse and the 2014 fusion all occurred more than 6 months before onset. For the trauma factor, the 20 years before onset run from 07 Mar 1996 to 07 Mar 2016 and contain the fragment injury of 14 December 1999. For leg length inequality, the 2 years before onset run from 07 Mar 2014 and the 5 years from 07 Mar 2011; the uncorrected 2.5 cm shortening had been present since 1993. For lifting, the 10-year period from 01 Jan 1990 to 31 Dec 1999 contains about 190,000 kilograms of lifting, and onset fell 16 years after it. For carrying, the 10-year period from 01 Jan 1987 to 31 Dec 1996 contains about 4,600 hours of load carriage, and onset fell 19 years after it. For flying, the 25 years before onset run from 07 Mar 1991 to 07 Mar 2016 and contain about 2,650 hours as operational aircrew from 2004 to 2015. For obesity, his BMI was above 30 from May 2003 to onset, more than 12 years.
For the worsening factors, the documented worsening was on 22 Nov 2017. The 6 months before it run from 22 May 2017 to 22 Nov 2017, during which the spondylolisthesis and lordotic abnormality persisted. The 20 years before it run from 22 Nov 1997 to 22 Nov 2017 and contain the 1999 trauma. The lifting and carrying periods ended 18 and 21 years before the worsening, within 25 years, and the flying hours fell within the 25 years before it. His BMI remained above 30 throughout.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Lumbar Spine - Lumbar Radiculopathy, being lumbar spondylosis at L4–L5 with left L5 radiculopathy (ICD-10-AM M47.26), under the Statements of Principles concerning thoracolumbar spondylosis, Balance of Probabilities No. 14 of 2023 and Reasonable Hypothesis No. 13 of 2023.
Lumbar radiculopathy is dysfunction of a lumbar nerve root, producing pain, numbness, tingling and weakness in the distribution of that root in the leg. In this veteran it is caused by lumbar spondylosis, a degenerative disorder of the intervertebral disc and facet joints in which disc space narrowing, osteophytes and facet hypertrophy narrow the intervertebral foramen and lateral recess and compress the nerve root. Degeneration commonly develops at the segment adjacent to a previous spinal fusion, and is accelerated by previous fracture, infection, disc prolapse, inflammatory and depositional joint disease and heavy occupational loading.
The diagnosis followed spinal fragment injury, fracture and discitis in 1999 and 2000, decades of load carriage, lifting and helicopter flying, and an L5–S1 fusion in 2014. It began on 07 March 2016, was confirmed on MRI on 04 April 2016 and worsened in 2017.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
07 March 2016.
When did the veteran first present to a health / medical provider for this condition?
15 March 2016.
When was the condition confirmed / formally diagnosed?
04 April 2016.
When did the veteran first present to you (or your practice) for this condition?
08 April 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on MRI of 04 April 2016, which showed L4–L5 disc space narrowing and desiccation, posterior osteophytes and facet joint hypertrophy with left foraminal stenosis compressing the L4 and L5 nerve roots. This is imaging evidence of degenerative change, including disc space narrowing and osteophytes, and with the symptoms and signs of nerve root compression it meets the Statement of Principles definition of thoracolumbar spondylosis.
The clinical picture was consistent: constant low back pain and stiffness, left leg pain in an L5 distribution, a positive straight leg raise at 40 degrees and weakness of great toe extension. A spinal surgeon confirmed the diagnosis. The worsening was confirmed on 22 November 2017 by repeat MRI showing severe foraminal and lateral recess stenosis and by nerve conduction studies showing active left L5 radiculopathy, with great toe extension power falling from 4/5 to 3/5.
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 07 March 2016, 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, including the veteran's years of infantry training, load carriage and lifting, and his helicopter flying in Australia. The Reasonable Hypothesis instrument applies to his warlike service in Somalia in 1993, where he was held captive and his femur was fractured; East Timor in 1999 and 2000, where the spinal fragment injury, fracture and discitis occurred; Iraq in 2003, where the reactive arthritis began; Afghanistan in 2008, where gout first presented and he flew as aircrew; and the Middle East in 2017, where the condition worsened.
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 Spondylosis, No. 14 of 2023
Causative factors
Factor 9(1): having an inflammatory joint disease from the specified list of inflammatory joint diseases, in the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis; — MET
- A rheumatologist confirmed reactive arthritis on 28 May 2003, HLA-B27 positive, with MRI showing anterior spondylitis of L1 to L3 and sacroiliitis. Reactive arthritis is on the specified list, and it involved the lumbar spine 13 years before onset on 07 March 2016.
Factor 9(2): having non-viral infection of the affected joint, resulting in inflammation within that joint, at least 6 months before the clinical onset of thoracolumbar spondylosis; — MET
- Staphylococcus aureus discitis of the L4–L5 joint, confirmed on MRI on 02 February 2000 with inflammation of the disc space and end plates, followed the fragment injury. L4–L5 is the affected joint, and the infection occurred 16 years before onset.
Factor 9(3): having an intra-articular fracture of the spine, at the level of, or adjacent to, the affected joint, at least 6 months before the clinical onset of thoracolumbar spondylosis; — MET
- CT on 14 December 1999 showed a fracture of the left L4 inferior articular process extending into the L4–L5 facet joint, an intra-articular fracture at the level of the affected joint, more than 16 years before onset.
Factor 9(4): having a spinal condition from the specified list of spinal conditions, affecting the thoracolumbar spine for at least the 6 months before the clinical onset of thoracolumbar spondylosis; — MET
- A grade 1 isthmic spondylolisthesis of L5 on S1 was shown on X-ray in July 2001 and persisted after fusion in situ, and the L3 vertebra was deformed by Paget's disease. Spondylolisthesis and deformity of a vertebra are on the specified list, and both were present throughout the 6 months before onset, from 07 September 2015 to 07 March 2016.
Factor 9(5): having undergone a spinal fusion, immediately above or below the affected joint, at least 6 months before the clinical onset of thoracolumbar spondylosis; — MET
- A spinal surgeon performed an instrumented L5–S1 fusion on 18 February 2014, immediately below the affected L4–L5 joint, two years before onset. The fusion was for spondylolisthesis arising from pars fractures sustained in service.
Factor 9(6): for lumbar spondylosis only, having leg length inequality for at least the 5 years before the clinical onset of thoracolumbar spondylosis; — MET
- The right femoral fracture of April 1993 healed with 2.5 cm of shortening. The inequality was never corrected by surgery or a raised heel, and it involved the limb in daily use. It was present for 23 years before onset, including the 5 years from 07 March 2011 to 07 March 2016.
Factor 9(7): having a depositional joint disease from the specified list of depositional joint diseases, in the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis; — MET
- Gout first presented in 2008, and dual-energy CT in 2014 showed urate deposition in the L4–L5 facet joints. Gout is on the specified list and involved the lumbar spine before onset.
Factor 9(8): having trauma to the thoracolumbar spine at least 6 months before the clinical onset of thoracolumbar spondylosis, and where the trauma to the thoracolumbar spine occurred within the 20 years before the clinical onset of thoracolumbar spondylosis; — MET
- The grenade blast of 14 December 1999 applied significant force to the lumbar spine, causing fracture and fragment penetration, with immediate pain, tenderness and restricted movement, and the spine was immobilised in a brace for eight weeks. This was more than 6 months before onset and within the 20 years before it, from 07 March 1996 to 07 March 2016.
Factor 9(9): having a penetrating injury to an intervertebral disc before the clinical onset of thoracolumbar spondylosis at the level of, or adjacent to, the intervertebral disc injury; — MET
- A grenade fragment pierced the L4–L5 intervertebral disc on 14 December 1999, as shown on CT. The spondylosis arose at that same level.
Factor 9(10): having a thoracolumbar intervertebral disc prolapse at least 6 months before the clinical onset of thoracolumbar spondylosis at the level of the intervertebral disc prolapse; — MET
- MRI on 10 June 2013 showed a left paracentral L4–L5 disc prolapse, nearly three years before onset of the spondylosis at the same level.
Factor 9(11): lifting loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine: (a) to a cumulative total of at least 150,000 kilograms within any 10 year period before the clinical onset of thoracolumbar spondylosis; and (b) where the clinical onset of thoracolumbar spondylosis occurred within the 25 years following that period; — MET
- From 1990 to 1999 the veteran manually lifted ammunition boxes, water jerry cans, sandbags and stores weighing 20 to 40 kilograms, recorded by his unit as about 19,000 kilograms a year, a cumulative total of about 190,000 kilograms. Onset on 07 March 2016 fell 16 years after that period ended.
Factor 9(12): carrying loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine: (a) to a cumulative total of at least 3,800 hours within any 10 year period before the clinical onset of thoracolumbar spondylosis; and (b) where the clinical onset of thoracolumbar spondylosis occurred within the 25 years following that period; — MET
- As a rifleman from 1987 to 1996 the veteran carried packs, webbing and weapons of 30 to 45 kilograms on exercises, patrols and courses for about 460 hours a year, a cumulative total of about 4,600 hours. Onset fell 19 years after that period ended.
Factor 9(13): for lumbar spondylosis only, flying in an engine powered aircraft as operational aircrew, for a cumulative total of at least 2,000 hours within the 25 years before the clinical onset of thoracolumbar spondylosis; — MET
- His flying logbook records about 2,650 hours as operational aircrew in utility and heavy-lift helicopters between 2004 and 2015, within the 25 years before onset, from 07 March 1991 to 07 March 2016.
Factor 9(14): being obese for at least 10 years within the 25 years before the clinical onset of thoracolumbar spondylosis; — MET
- The veteran's BMI was 31.1 on 28 May 2003 and remained above 30 at every periodic health examination to onset, more than 12 years within the 25 years before onset.
Factor 9(15): having acromegaly involving the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis; — MET
- An endocrinologist diagnosed acromegaly on 16 October 2012, and lumbar X-rays showed vertebral body enlargement and anterior osteophytes from acromegalic spondylopathy, more than three years before onset.
Factor 9(16): having Paget's disease of bone involving the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis; — MET
- A bone scan and raised alkaline phosphatase in 2013 confirmed Paget's disease of bone in the L3 vertebra, which was expanded and coarsened on the MRI of 10 June 2013, before onset.
Worsening factors
Factor 9(17): having an inflammatory joint disease from the specified list of inflammatory joint diseases, in the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis; — MET
- Reactive arthritis involving the lumbar spine from 2003 preceded the documented worsening on 22 November 2017, when MRI showed severe stenosis and great toe extension fell to 3/5.
Factor 9(18): having non-viral infection of the affected joint, resulting in inflammation within that joint, at least 6 months before the clinical worsening of thoracolumbar spondylosis; — MET
- L4–L5 bacterial discitis in February 2000 occurred more than 17 years before the worsening.
Factor 9(19): having an intra-articular fracture of the spine, at the level of, or adjacent to, the affected joint, at least 6 months before the clinical worsening of thoracolumbar spondylosis; — MET
- The intra-articular L4 facet fracture of 14 December 1999 occurred at the affected level, nearly 18 years before the worsening.
Factor 9(20): having a spinal condition from the specified list of spinal conditions, affecting the thoracolumbar spine for at least the 6 months before the clinical worsening of thoracolumbar spondylosis; — MET
- The L5–S1 spondylolisthesis and the Pagetic deformity of L3 persisted throughout the 6 months before the worsening, from 22 May 2017 to 22 November 2017.
Factor 9(21): having undergone a spinal fusion, immediately above or below the affected joint, at least 6 months before the clinical worsening of thoracolumbar spondylosis; — MET
- The L5–S1 fusion of 18 February 2014, immediately below the affected joint, preceded the worsening by more than three years.
Factor 9(22): for lumbar spondylosis only, having leg length inequality for at least the 5 years before the clinical worsening of thoracolumbar spondylosis; — MET
- The uncorrected 2.5 cm right leg shortening persisted throughout the 5 years before the worsening, from 22 November 2012 to 22 November 2017.
Factor 9(23): having trauma to the thoracolumbar spine at least 6 months before the clinical worsening of thoracolumbar spondylosis, and where the trauma to the thoracolumbar spine occurred within the 20 years before the clinical worsening of thoracolumbar spondylosis; — MET
- The spinal trauma of 14 December 1999 occurred within the 20 years before the worsening, from 22 November 1997 to 22 November 2017, and more than 6 months before it.
Factor 9(24): having a depositional joint disease from the specified list of depositional joint diseases, in the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis; — MET
- Gout involving the L4–L5 facet joints, shown on dual-energy CT in 2014, preceded the worsening, and a further spinal flare was recorded in August 2017.
Factor 9(25): having a penetrating injury to an intervertebral disc before the clinical worsening of thoracolumbar spondylosis at the level of, or adjacent to, the intervertebral disc injury; — MET
- The fragment injury to the L4–L5 disc in 1999 preceded the worsening at that level.
Factor 9(26): having a thoracolumbar intervertebral disc prolapse at least 6 months before the clinical worsening of thoracolumbar spondylosis at the level of the intervertebral disc prolapse; — MET
- The L4–L5 disc prolapse of June 2013 occurred more than four years before the worsening at the same level.
Factor 9(27): lifting loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine: (a) to a cumulative total of at least 150,000 kilograms within any 10 year period before the clinical worsening of thoracolumbar spondylosis; and (b) where the clinical worsening of thoracolumbar spondylosis occurred within the 25 years following that period; — MET
- The 190,000 kilograms lifted from 1990 to 1999 fell within a 10-year period before the worsening, which occurred 18 years after that period ended.
Factor 9(28): carrying loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine: (a) to a cumulative total of at least 3,800 hours within any 10 year period before the clinical worsening of thoracolumbar spondylosis; and (b) where the clinical worsening of thoracolumbar spondylosis occurred within the 25 years following that period; — MET
- The 4,600 hours of load carriage from 1987 to 1996 fell within a 10-year period before the worsening, which occurred 21 years after that period ended.
Factor 9(29): for lumbar spondylosis only, flying in an engine powered aircraft as operational aircrew, for a cumulative total of at least 2,000 hours within the 25 years before the clinical worsening of thoracolumbar spondylosis; — MET
- The 2,650 hours as operational helicopter aircrew from 2004 to 2015 fell within the 25 years before the worsening.
Factor 9(30): being obese for at least 10 years within the 25 years before the clinical worsening of thoracolumbar spondylosis; — MET
- His BMI was above 30 from May 2003 to the worsening, more than 14 years, and was 32.4 on 22 November 2017.
Factor 9(31): having acromegaly involving the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis; — MET
- Acromegalic spondylopathy of the lumbar spine, diagnosed in 2012, preceded the worsening.
Factor 9(32): having Paget's disease of bone involving the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis; — MET
- Paget's disease of the L3 vertebra, confirmed in 2013, preceded the worsening.
Factor 9(33): inability to obtain appropriate clinical management for thoracolumbar spondylosis. — MET
- From April to October 2017, while deployed, the veteran could obtain no physiotherapy, repeat imaging or spinal surgical review, and his pregabalin supply ran out for five weeks. The radiculopathy progressed to severe stenosis with motor weakness by 22 November 2017. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Thoracolumbar Spondylosis, No. 13 of 2023
Causative factors
Factor 9(1): being a prisoner of war before the clinical onset of thoracolumbar spondylosis; — MET
- On warlike service in Somalia on 02 April 1993 the veteran was captured by an armed militia group and held as a prisoner for nine days, during which he was beaten and thrown from a moving vehicle. This was 23 years before onset.
Factor 9(2): having an inflammatory joint disease from the specified list of inflammatory joint diseases, in the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis; — MET
- Reactive arthritis followed Campylobacter enteritis contracted on warlike service in Iraq in April 2003, and involved the lumbar spine with anterior spondylitis of L1 to L3, before onset.
Factor 9(3): having non-viral infection of the affected joint, resulting in inflammation within that joint, at least 6 months before the clinical onset of thoracolumbar spondylosis; — MET
- Bacterial discitis of the L4–L5 joint in February 2000 resulted from the grenade fragment wound sustained on warlike service in East Timor, 16 years before onset.
Factor 9(4): having an intra-articular fracture of the spine, at the level of, or adjacent to, the affected joint, at least 6 months before the clinical onset of thoracolumbar spondylosis; — MET
- The fracture of the L4 inferior articular process into the L4–L5 facet joint was sustained in the grenade blast on warlike service in East Timor on 14 December 1999, more than 16 years before onset.
Factor 9(5): having a spinal condition from the specified list of spinal conditions, affecting the thoracolumbar spine for at least the 6 months before the clinical onset of thoracolumbar spondylosis; — MET
- The L5–S1 spondylolisthesis arose from bilateral pars fractures sustained in the blast on warlike service in East Timor, and it persisted throughout the 6 months before onset, from 07 September 2015 to 07 March 2016.
Factor 9(6): for lumbar spondylosis only, having a kyphotic abnormality or lordotic abnormality affecting the lumbar spine for at least the 6 months before the clinical onset of thoracolumbar spondylosis; — MET
- X-rays from July 2001 showed abnormally increased lumbar lordosis of 72 degrees, secondary to the spondylolisthesis from the East Timor blast injury on warlike service. The lordotic abnormality persisted above the fusion throughout the 6 months before onset.
Factor 9(7): having undergone a spinal fusion, immediately above or below the affected joint, at least 6 months before the clinical onset of thoracolumbar spondylosis; — MET
- The L5–S1 fusion of 18 February 2014, immediately below the affected joint, treated the spondylolisthesis caused by the pars fractures sustained on warlike service in East Timor, two years before onset.
Factor 9(8): for lumbar spondylosis only, having leg length inequality for at least the 2 years before the clinical onset of thoracolumbar spondylosis; — MET
- The uncorrected 2.5 cm right leg shortening followed the femoral fracture sustained while held captive on warlike service in Somalia in 1993, and was present throughout the 2 years before onset, from 07 March 2014 to 07 March 2016.
Factor 9(9): having a depositional joint disease from the specified list of depositional joint diseases, in the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis; — MET
- Gout first presented during warlike service in Afghanistan in 2008, in extreme heat with recurrent dehydration, and later involved the L4–L5 facet joints on dual-energy CT in 2014, before onset.
Factor 9(10): having trauma to the thoracolumbar spine at least 6 months before the clinical onset of thoracolumbar spondylosis, and where the trauma to the thoracolumbar spine occurred within the 20 years before the clinical onset of thoracolumbar spondylosis; — MET
- The lumbar spine trauma from the grenade blast on warlike service in East Timor on 14 December 1999 occurred more than 6 months before onset and within the 20 years before it.
Factor 9(11): having a penetrating injury to an intervertebral disc before the clinical onset of thoracolumbar spondylosis at the level of, or adjacent to, the intervertebral disc injury; — MET
- A grenade fragment pierced the L4–L5 disc on warlike service in East Timor on 14 December 1999, at the level where the spondylosis developed.
Factor 9(12): having a thoracolumbar intervertebral disc prolapse at least 6 months before the clinical onset of thoracolumbar spondylosis at the level of the intervertebral disc prolapse; — MET
- The L4–L5 disc prolapse of June 2013 occurred in a disc previously penetrated and infected after the East Timor fragment injury on warlike service, nearly three years before onset at that level.
Factor 9(13): lifting loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine to a cumulative total of at least 100,000 kilograms within any 10 year period before the clinical onset of thoracolumbar spondylosis; — MET
- The veteran lifted about 190,000 kilograms of loads of 20 to 40 kilograms from 1990 to 1999, including loading ammunition, water and stores on warlike service in East Timor.
Factor 9(14): carrying loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine to a cumulative total of at least 3,800 hours within any 10 year period before the clinical onset of thoracolumbar spondylosis; — MET
- The veteran carried 30 to 45 kilogram loads for about 4,600 hours from 1987 to 1996, including foot patrols with full equipment on warlike service in Somalia in 1993.
Factor 9(15): for lumbar spondylosis only, flying in an engine powered aircraft as operational aircrew, for a cumulative total of at least 1,000 hours within the 25 years before the clinical onset of thoracolumbar spondylosis; — MET
- The veteran flew about 2,650 hours as operational helicopter aircrew from 2004 to 2015, including about 480 hours on warlike service in Afghanistan in 2008, within the 25 years before onset.
Factor 9(16): being obese for at least 10 years before the clinical onset of thoracolumbar spondylosis; — MET
- His BMI was above 30 from 28 May 2003, recorded during the reactive arthritis that followed warlike service in Iraq and limited his activity, to the onset on 07 March 2016, more than 12 years.
Factor 9(17): having acromegaly involving the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis; — MET
- Acromegaly, symptomatic from his warlike service in Afghanistan in 2008 and diagnosed on 16 October 2012, involved the lumbar spine with vertebral enlargement and osteophytes before onset.
Factor 9(18): having Paget's disease of bone involving the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis; — MET
- Paget's disease of the L3 vertebra was confirmed in 2013, before onset, in a veteran with extensive warlike service.
Worsening factors
Factor 9(19): being a prisoner of war before the clinical worsening of thoracolumbar spondylosis; — MET
- The veteran's nine days as a prisoner on warlike service in Somalia in 1993 preceded the worsening documented on 22 November 2017, after his warlike service in the Middle East.
Factor 9(20): having an inflammatory joint disease from the specified list of inflammatory joint diseases, in the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis; — MET
- Reactive arthritis of the lumbar spine following warlike service in Iraq preceded the worsening.
Factor 9(21): having non-viral infection of the affected joint, resulting in inflammation within that joint, at least 6 months before the clinical worsening of thoracolumbar spondylosis; — MET
- The L4–L5 discitis following the East Timor fragment wound on warlike service occurred more than 17 years before the worsening.
Factor 9(22): having an intra-articular fracture of the spine, at the level of, or adjacent to, the affected joint, at least 6 months before the clinical worsening of thoracolumbar spondylosis; — MET
- The L4 facet fracture from warlike service in East Timor occurred nearly 18 years before the worsening, at the affected level.
Factor 9(23): having a spinal condition from the specified list of spinal conditions, affecting the thoracolumbar spine for at least the 6 months before the clinical worsening of thoracolumbar spondylosis; — MET
- The spondylolisthesis from the East Timor pars fractures persisted throughout the 6 months before the worsening, which included his warlike service in the Middle East.
Factor 9(24): for lumbar spondylosis only, having a kyphotic abnormality or lordotic abnormality affecting the lumbar spine for at least the 6 months before the clinical worsening of thoracolumbar spondylosis; — MET
- The lumbar hyperlordosis persisted throughout the 6 months before the worsening, from 22 May 2017 to 22 November 2017, aggravated by daily body armour on warlike service in the Middle East.
Factor 9(25): having undergone a spinal fusion, immediately above or below the affected joint, at least 6 months before the clinical worsening of thoracolumbar spondylosis; — MET
- The 2014 L5–S1 fusion for the East Timor injury preceded the worsening by more than three years.
Factor 9(26): for lumbar spondylosis only, having leg length inequality for at least the 2 years before the clinical worsening of thoracolumbar spondylosis; — MET
- The 2.5 cm leg shortening from captivity in Somalia remained uncorrected throughout the 2 years before the worsening.
Factor 9(27): having a depositional joint disease from the specified list of depositional joint diseases, in the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis; — MET
- Spinal gout preceded the worsening, with a flare in August 2017 during warlike service in the Middle East.
Factor 9(28): having trauma to the thoracolumbar spine at least 6 months before the clinical worsening of thoracolumbar spondylosis, and where the trauma to the thoracolumbar spine occurred within the 20 years before the clinical worsening of thoracolumbar spondylosis; — MET
- The spinal trauma on warlike service in East Timor on 14 December 1999 fell within the 20 years before the worsening and more than 6 months before it.
Factor 9(29): having a penetrating injury to an intervertebral disc before the clinical worsening of thoracolumbar spondylosis at the level of, or adjacent to, the intervertebral disc injury; — MET
- The fragment penetration of the L4–L5 disc on warlike service in East Timor preceded the worsening at that level.
Factor 9(30): having a thoracolumbar intervertebral disc prolapse at least 6 months before the clinical worsening of thoracolumbar spondylosis at the level of the intervertebral disc prolapse; — MET
- The 2013 L4–L5 prolapse, in the disc damaged on warlike service, preceded the worsening by more than four years.
Factor 9(31): lifting loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine to a cumulative total of at least 100,000 kilograms within any 10 year period before the clinical worsening of thoracolumbar spondylosis; — MET
- The 190,000 kilograms lifted from 1990 to 1999, including on warlike service in East Timor, fell within a 10-year period before the worsening.
Factor 9(32): carrying loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine to a cumulative total of at least 3,800 hours within any 10 year period before the clinical worsening of thoracolumbar spondylosis; — MET
- The 4,600 hours of load carriage from 1987 to 1996, including warlike service in Somalia, fell within a 10-year period before the worsening.
Factor 9(33): for lumbar spondylosis only, flying in an engine powered aircraft as operational aircrew, for a cumulative total of at least 1,000 hours within the 25 years before the clinical worsening of thoracolumbar spondylosis; — MET
- The 2,650 hours as operational aircrew, including warlike service in Afghanistan, fell within the 25 years before the worsening.
Factor 9(34): being obese for at least 10 years before the clinical worsening of thoracolumbar spondylosis; — MET
- His BMI was above 30 for more than 14 years before the worsening, including throughout his warlike service in the Middle East in 2017.
Factor 9(35): having acromegaly involving the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis; — MET
- Acromegalic spondylopathy preceded the worsening.
Factor 9(36): having Paget's disease of bone involving the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis; — MET
- Paget's disease of L3 preceded the worsening.
Factor 9(37): inability to obtain appropriate clinical management for thoracolumbar spondylosis. — MET
- On warlike service in the Middle East from April to October 2017 the veteran could not obtain physiotherapy, imaging, surgical review or a continuous supply of pregabalin, and the radiculopathy progressed to severe stenosis with motor weakness.
The % contribution of the causes is 100% and significant.
Sequelae
The lumbar radiculopathy is a sequela of the veteran's accepted conditions: the fragment injury, facet fracture and discitis of L4–L5 sustained in East Timor, the L5–S1 spondylolisthesis and its fusion, which transferred load to the L4–L5 segment above, and the right femoral malunion with leg length inequality from his captivity in Somalia.
Unintended Consequence
Met. The adjacent segment degeneration at L4–L5 is in part an unintended consequence of the instrumented L5–S1 fusion performed on 18 February 2014, which was provided and paid for by the Commonwealth while the veteran was serving (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. On deployment to the Middle East from April to October 2017 the veteran, already diagnosed with L4–L5 spondylosis and radiculopathy, could not obtain physiotherapy, repeat imaging or spinal surgical review, and his pregabalin supply lapsed for five weeks. On return, MRI showed progression to severe foraminal and lateral recess stenosis, and great toe extension had weakened to 3/5. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational circumstances that prevent indicated treatment amount to an inability to obtain appropriate clinical management. A further 14-month wait for decompression surgery after his return also reflects barriers to care.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 02 Apr 1993, Post-release medical assessment and orthopaedic record, Medical Officer, Somalia
- 14 Dec 1999, Trauma admission and CT lumbar spine, Field hospital, East Timor
- 02 Feb 2000, MRI lumbar spine and infectious diseases consultation, Infectious diseases physician
- 12 Jul 2001, X-ray lumbar spine, Radiologist
- 28 May 2003, Rheumatology consultation and MRI, Rheumatologist
- 16 Oct 2012, Endocrinology consultation, Endocrinologist
- 10 Jun 2013, MRI lumbar spine and bone scan, Radiologist
- 18 Feb 2014, Operation report, Spinal surgeon
- 21 Oct 2015, Post-operative review, Spinal surgeon
- 15 Mar 2016, Outpatient health record, Medical Officer, Garrison health centre
- 04 Apr 2016, MRI lumbar spine and spinal surgical consultation, Spinal surgeon
- 22 Nov 2017, MRI lumbar spine and nerve conduction studies, Neurologist
- Flying logbook summary, 2004 to 2015, Army aviation
- Statement of Principles concerning Thoracolumbar Spondylosis (Balance of Probabilities) No. 14 of 2023, Repatriation Medical Authority
- Statement of Principles concerning Thoracolumbar Spondylosis (Reasonable Hypothesis) No. 13 of 2023, Repatriation Medical Authority
