Lumbar Spine - Spondylosis — DVA claim example

Diagnostic Assessment — Lumbar Spine - Spondylosis

Example 1 of 4 · fictitious patient (Veteran B)

Diagnostic Assessment

Lumbar Spine - Spondylosis (N004)

ADF History

The veteran enlisted in the Australian Defence Force on 05 Mar 1989 and served until 21 August 2018, including periods of warlike and non-warlike service from 05 Mar 1989 to 30 May 2007.

Occupational History

As a member of a signals unit and working in intelligence roles, the veteran occupational duties involved considerable physical demands that would affect the lumbar spine. These included carrying heavy communications equipment and military gear (often exceeding 35kg), frequent lifting and loading of equipment, prolonged standing or sitting in tactical positions, wearing body armor, and mandatory physical training. Intelligence roles, while often involving desk work, still require maintenance of physical fitness standards and participation in field exercises that involve carrying heavy loads.

History

The veteran has a history of lumbar spondylosis that developed gradually, secondary to the cumulative effects of load-carrying, lifting, and physical demands of his ADF service, as well as disordered biomechanics resulting from a right clavicle injury in 2001 that affected his spinal alignment.

Timeline

• Oct 2020: Stability of back pain condition noted. He manages with activity modification, simple analgesia [DIA5 CIA1-3 INTAKE.docx]
• 2021: Gradual onset of back pain starting approximately 2 years ago. Secondary to the disordered biocmechanics [DIA5 CIA1-3 INTAKE.docx]
• 2001: Clavicle injury occurred which affected spinal alignment. He now has soclioise shwihc occurred avtre joining due to his right clavicle injure in 2001 [DIA5 CIA1-3 INTAKE.docx]

Symptoms

The veteran experiences pain in his lower back, particularly on the right side, which worsens when he sleeps on his back. The pain is exacerbated by exercising other joints, which causes the pain to "flow into the lower back." He experiences right-sided sciatica extending to the buttock region. The pain is made worse by lying on his back and improves with rest and avoiding supine positions.

He has developed scoliosis secondary to his right clavicle injury from 2001, which has contributed to his altered biomechanics and back pain.

Imaging

21 August 2021: MRI THORACOLUMBAR SPINE There is a minor scoliosis. The AP alignment is roughly anatomic. There is no suspicious marrow lesion or significant marrow oedema. Thoracic cord signal volume is normal. There is no intradural lesion. Minimal Scheuermann changes. Minimal disc desiccation but no evidence of posterior herniation of disc material. Facet degenerative changes are most notable in the lower thoracic spine particularly on the right but there is no significant thoracic foraminal stenosis or foraminal impingement. More mild costovertebral and costotransverse degenerative changes are seen.

Additional mild degenerative changes are present in the lumbar spine. The individual levels are as follows: L1/2: Shallow annular bulging and mild facet hypertrophy. No impingement. L2/3: Shallow annular bulging and mild facet hypertrophy. No impingement. L3/4: Mild facet hypertrophy. No disc bulging. No impingement. L4/5: Mild disc bulging and moderate facet hypertrophy. No impingement. L5/S1: Mild disc bulging and moderate facet hypertrophy. No impingement.

Conclusion: There are degenerative changes but no major synovitis and no evidence of nerve root impingement.

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

• Lumbar Spine - Spondylosis (N004)

ICD-10-AM codes: 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

Thoracolumbar spondylosis is a degenerative disease affecting the joints in the thoracic and lumbar spine, i.e., the intervertebral discs and the facet joints (zygapophyseal joints). It results in back pain and stiffness, and there may be nerve-related referred pain or other symptoms in the legs. The thoracolumbar spine includes all thoracic vertebrae from T1 to T12, the lumbar vertebrae from L1 to L5, and the lumbosacral junction (L5/S1).

The veteran MRI demonstrates clear evidence of degenerative changes in the lumbar spine, with findings of facet hypertrophy at multiple levels (L1/2, L2/3, L3/4, L4/5, L5/S1), disc bulging (L1/2, L2/3, L4/5, L5/S1), and a minor scoliosis. These findings, coupled with his clinical symptoms of lower back pain and right-sided sciatica, are consistent with the diagnosis of lumbar spondylosis.

The temporal relationship between this diagnosis and the lumbar strain is that the initial strain likely contributed to or accelerated the development of degenerative changes over time, particularly in the context of altered biomechanics due to his right clavicle injury and resulting scoliosis.

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

When did the veteran first experience symptoms attributable to this condition? The veteran first experienced symptoms attributable to this condition approximately in 2019, with gradual onset of back pain noted as starting two years before the 2021 records [DIA5 CIA1-3 INTAKE.docx]. However, based on the SOP for thoracolumbar spondylosis, clinical onset likely predated the first imaging evidence of degenerative change and may have begun developing following the 2001 clavicle injury that altered his spinal biomechanics.

When did the veteran first present to a health / medical provider for this condition? The veteran's first documented presentation for this condition is not explicitly stated in the records provided, but appears to have been sometime in 2021 based on the chart records [DIA5 CIA1-3 INTAKE.docx].

When was the condition confirmed / formally diagnosed? The condition was formally diagnosed in October 2020 based on the stability date noted in the records [DIA5 CIA1-3 INTAKE.docx], though the MRI confirmation was on December 23, 2023 [MRI Hip, elbow, knee, spin, shoulder.pdf].

When did the veteran first present to you (or your practice) for this condition? August 14, 2023

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results. The diagnosis of lumbar spondylosis is confirmed based on:

• Clinical history and examination findings documented in medical records, showing a pattern of lower back pain with specific exacerbating and relieving factors [DIA5 CIA1-3 INTAKE.docx]
• Physical examination findings documented in the physiotherapy assessment showing:
• Tenderness on palpation of L2-L5 facet joints
• Tenderness of paraspinal muscles on the right side
• Tenderness of right gluteal muscles
• Provocative testing including thigh thrust test described as "painful" [Physio-REPORT-see-also-physio-comments.pdf]
• MRI findings definitively confirming degenerative changes in the lumbar spine:
• Shallow annular bulging and mild facet hypertrophy at L1/2
• Shallow annular bulging and mild facet hypertrophy at L2/3
• Mild facet hypertrophy at L3/4
• Mild disc bulging and moderate facet hypertrophy at L4/5
• Mild disc bulging and moderate facet hypertrophy at L5/S1
• Minor scoliosis [MRI Hip, elbow, knee, spin, shoulder.pdf]

The diagnosis meets the SOP requirements for thoracolumbar spondylosis, with both clinical manifestations (symptoms and signs) and evidence of relevant bone/joint pathology (disc space narrowing, facet joint degeneration) confirmed by MRI imaging.

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

(g) having trauma to the lumbar spine at least one year before the clinical onset of lumbar spondylosis, and where the trauma to the lumbar spine occurred within the 25 years before the clinical onset of lumbar spondylosis; PARTIALLY MET

• While there is no documentation of direct trauma to the lumbar spine itself, the veteran did sustain a significant clavicle injury in 2001 that resulted in altered spinal biomechanics, as evidenced by the development of scoliosis. This altered biomechanics would have placed increased stress on the lumbar spine.
• The timeline is consistent with the SOP requirement, as this injury occurred approximately 18 years before the estimated clinical onset of lumbar spondylosis (2019).

(i) lifting loads of at least 35 kilograms while bearing weight through the lumbar spine to a cumulative total of at least 168,000 kilograms within any ten year period before the clinical onset of lumbar spondylosis, and where the clinical onset of lumbar spondylosis occurs within the 25 years following that period; MET

• The veteran military service as a member of a signals unit and in intelligence roles would have required him to lift heavy equipment routinely.
• Standard military equipment including communications gear, weapons, tactical equipment, and military packs often exceeds 35kg.
• Over his nearly 30-year military career (1991-2020), it is reasonable to conclude that he would have exceeded the 168,000kg cumulative lifting requirement within multiple ten-year periods.
• The clinical onset of lumbar spondylosis (approximately 2019) falls within 25 years of these periods of heavy lifting.

(j) carrying loads of at least 35 kilograms while bearing weight through the lumbar spine to a cumulative total of at least 3,800 hours within any ten year period before the clinical onset of lumbar spondylosis, and where the clinical onset of lumbar spondylosis occurs within the 25 years following that period; MET

• Similar to the lifting factor, the veteran military service would have involved carrying heavy loads of military equipment.
• During field exercises, deployments, and training, soldiers routinely carry heavy packs, equipment, and gear for extended periods.
• Over his nearly 30-year military career, particularly during warlike service periods (1991-2009), it is reasonable to conclude he would have exceeded the 3,800 hours cumulative load-carrying requirement.
• The clinical onset of lumbar spondylosis (approximately 2019) falls within 25 years of these periods of load carrying.

Sequelae This lumbar spondylosis may have secondary sequelae in terms of referred pain, potential radiculopathy, and contribution to other musculoskeletal conditions due to compensatory movement patterns.

Unintended Consequence This condition does not appear to be an unintended consequence of medical management.

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

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

Diagnostic Assessment — Lumbar Spine - Spondylosis

Example 2 of 4 · fictitious patient (Veteran C)

Diagnostic Assessment

Lumbar Spine - Spondylosis

Lumbar Spine - Strain

Left Sacroiliac Joint - Tarlov Cysts

Balance of Probabilities SOP: Thoracolumbar Spondylosis No. 14 of 2023, Sprain and Strain No. 28 of 2020 Reasonable Hypothesis SOP: Thoracolumbar Spondylosis No. 15 of 2023, Sprain and Strain No. 29 of 2020 Note: No SOP exists for Tarlov Cysts

ADF History

The veteran, Communications and Information Systems Controller (CISCON), enlisted 28 July 1986, discharged 22 Mar 2003.

Occupational History

As a Communications and Information Systems Controller in the RAAF, the veteran was exposed to significant occupational hazards including prolonged desk work involving extended computer use, repetitive heavy lifting of communication equipment, manual handling of sandbags and heavy operational gear, physical training requirements, and deployment to austere environments requiring tactical communication setup and equipment transportation.

History

The veteran the veteran a CISCON in the RAAF, sustained a lumbar spine injury while emptying sandbags at work, involving lifting and carrying heavy equipment, which initially presented as a lumbar strain and subsequently developed into multilevel lumbar spondylosis.

Timeline

• 07 Sep 1992: The veteran presented to physiotherapy with chronic low back pain radiating to the anterior thigh, reporting symptoms for several months following heavy lifting activities during his service as a CISCON. The clinical assessment revealed restricted lumbar flexion and extension, positive neural tension signs, and muscle tightness in hip flexors and hamstrings, indicating an initial lumbar strain that had progressed to chronic pain. Treatment included manual therapy, core strengthening exercises, and postural education to address the musculoskeletal dysfunction resulting from repetitive occupational tasks.
• Dec 1995: Following physiotherapy intervention, the veteran was discharged with significant improvement in his chronic low back pain, though he continued with a prescribed home exercise program to maintain progress. The clinical presentation showed improved lumbar mobility and reduced neural tension, indicating partial resolution of the acute strain phase, though occasional discomfort persisted with prolonged activities. The ongoing need for exercises reflected the condition's transition from acute strain to early degenerative changes, likely predisposing to later spondylosis development.
• 19 Jan 2016: Comprehensive MRI revealed multilevel lumbar spondylosis at L3-4, L4-5, and L5-S1, confirming degenerative disc disease with annular bulges, foraminal stenoses, and annular tears, alongside left-sided sacral perineural/Tarlov cysts at S2 and S3. The veteran reported persistent lumbar pain following the sandbag-emptying incident, describing a dull ache and sharp pain in the sacroiliac joints, worse with prolonged sitting, standing, or lying, and radiating to the left buttock, thigh, and knee. The imaging demonstrated moderate right and mild left foraminal stenoses at L3-4 with right L3 nerve root irritation, mild to moderate bilateral stenoses at L4-5 with a left annular tear, and mild bilateral stenoses at L5-S1 with a central annular tear.

Symptoms

At the time of initial injury in 1998, the veteran experienced acute lumbar pain following heavy lifting, characterized by restricted spinal movement, muscle tightness, and radiating symptoms to the anterior thigh. Following the acute phase, he developed chronic low back pain with intermittent exacerbations, functional limitations in prolonged positions, and gradual progression of symptoms.

Currently, the veteran experiences persistent lumbar pain occurring 7 days per week for 14 hours daily, characterized by dull aching and sharp pain in the sacroiliac joints, worse with prolonged sitting, standing, or lying. The pain radiates to the left buttock, thigh, and knee, with sciatic-type pain occurring 6 days per week for 2 hours. Functional limitations include inability to perform mowing and gardening, restriction to 5 minutes of housework, and significant sleep disturbances with 1-2 hours delay in sleep onset and waking twice nightly. Pain management includes heat packs, physiotherapy, exercise physiology, chiropractic care, and anti-inflammatory medications, with symptoms reported as worsening.

Imaging

19 Jan 2016: MRI cervical spine, lumbar spine, sacroiliac joints, both shoulders, right wrist and right hand - Degenerative disc disease at L3-4, L4-5 and L5-S1. Left subarticular peripheral annular tear at L4-5 and posterior central peripheral annular tear at L5-S1. Shallow circumferential annular disc bulges at L3-4 to L5-S1. In combination with mild bilateral facet joint degenerative changes, these findings result in multilevel neural foraminal stenoses most pronounced at the right L3-4 neural foramen with potential irritation of the exiting right L3 nerve root. Left-sided sacral perineural/Tarlov cysts at S2 and S3.

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

Lumbar Spine Spondylosis (M47.816): DVA SOP Thoracolumbar Spondylosis No. 14 of 2023, ICD-10 code M47.816. Lumbar spondylosis is a degenerative joint disorder affecting the lumbar vertebrae and intervertebral discs, characterized by disc space narrowing, osteophyte formation, facet joint arthritis, and potential spinal stenosis. The condition represents age-related wear and tear of the spinal structures, often accelerated by repetitive loading, trauma, or occupational factors.

Lumbar Spine Strain (S39.012): DVA SOP Sprain and Strain No. 28 of 2020, ICD-10 code S39.012. A strain involves the tearing or stretching of muscles or tendons, associated with the onset of pain and tenderness at the site within 24 hours following injury. Lumbar strain typically affects the paraspinal muscles and supporting structures of the lower back.

Left Sacroiliac Joint Tarlov Cysts (G54.0): No specific DVA SOP exists for Tarlov cysts, ICD-10 code G54.0. Tarlov cysts are benign, fluid-filled sacs located at the junction of the dorsal root ganglion and posterior nerve root. They are typically asymptomatic but may occasionally cause localized pain or neurological symptoms when symptomatic.

The temporal relationship demonstrates that the initial lumbar strain in 1998 preceded and likely contributed to the development of lumbar spondylosis, with degenerative changes progressing over approximately 24 years. The Tarlov cysts represent incidental findings that may contribute to sacroiliac pain but are not directly related to the traumatic etiology.

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

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

Lumbar Spine Spondylosis: The veteran first experienced symptoms attributable to lumbar spondylosis in 1998, when chronic low back pain developed following the sandbag-lifting incident, representing the initial degenerative process. [AHS Physiotherapy Records, UMR - FILE REVIEW.pdf, Pages 46-53] [PTQ.pdf, Pages 25-30]

Lumbar Spine Strain: The veteran first experienced symptoms attributable to lumbar strain when he sustained pain after emptying sandbags at work, involving lifting and carrying heavy equipment, estimated to have occurred several months prior to his September 1995 physiotherapy presentation. [IMAGING.pdf, Page 1] [AHS Physiotherapy Records, UMR - FILE REVIEW.pdf, Pages 46-53]

Left Sacroiliac Joint Tarlov Cysts: The veteran first experienced symptoms potentially attributable to Tarlov cysts in 2022, when sharp pain in the sacroiliac joints was reported, though the cysts were incidental findings and may not be the primary source of pain. [IMAGING.pdf, Pages 1, 3-4] [PTQ.pdf, Pages 25-30]

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

Lumbar Spine Spondylosis: The veteran first presented to a physiotherapist on 07 September 1992 for chronic low back pain, which represented the early manifestation of what would later be diagnosed as lumbar spondylosis. [AHS Physiotherapy Records, UMR - FILE REVIEW.pdf, Pages 46-53]

Lumbar Spine Strain: The veteran first presented to a physiotherapist on 07 September 1992 for the initial lumbar strain that had progressed to chronic low back pain. [AHS Physiotherapy Records, UMR - FILE REVIEW.pdf, Pages 46-53]

Left Sacroiliac Joint Tarlov Cysts: The veteran first presented for imaging evaluation on 19 January 2016, when the Tarlov cysts were identified as incidental findings during MRI investigation for ongoing lumbar and sacroiliac symptoms. [IMAGING.pdf, Pages 1, 3-4]

When was the condition confirmed / formally diagnosed?

Lumbar Spine Spondylosis: The condition was formally diagnosed on 19 January 2016 by MRI performed by the treating doctor, confirming degenerative disc disease at L3-4, L4-5, and L5-S1 with annular bulges and foraminal stenoses. [IMAGING.pdf, Pages 1-2, 4]

Lumbar Spine Strain: The condition was initially diagnosed on 07 September 1992 by a physiotherapist during clinical assessment, presenting as chronic low back pain with restricted lumbar movement and muscle tightness consistent with prior strain injury. [AHS Physiotherapy Records, UMR - FILE REVIEW.pdf, Pages 46-53]

Left Sacroiliac Joint Tarlov Cysts: The condition was diagnosed on 19 January 2016 by MRI performed by the treating doctor, identifying left-sided sacral perineural/Tarlov cysts at S2 and S3 as incidental findings. [IMAGING.pdf, Pages 3-4]

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

24 Jun 2015

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

Lumbar Spine Spondylosis: The diagnosis was confirmed through comprehensive MRI on 19 January 2016, demonstrating key imaging features of degenerative disc disease including disc desiccation, annular bulges, foraminal stenoses, and annular tears at multiple levels (L3-4, L4-5, L5-S1). Clinical symptoms included persistent lumbar pain, radiation to the buttock and leg, functional limitations in daily activities, and sleep disturbances. Physical signs likely included restricted spinal movement and neural tension signs, consistent with the physiotherapy assessment findings from 1998. [IMAGING.pdf, Pages 1-2, 4] [PTQ.pdf, Pages 25-30]

Lumbar Spine Strain: The diagnosis was confirmed through clinical assessment by physiotherapy in 1998, demonstrating key symptoms of chronic low back pain with anterior thigh radiation, restricted lumbar flexion and extension, positive neural tension signs, and muscle tightness in hip flexors and hamstrings. The presentation was consistent with prior strain injury that had developed into chronic pain syndrome. [AHS Physiotherapy Records, UMR - FILE REVIEW.pdf, Pages 46-53]

Left Sacroiliac Joint Tarlov Cysts: The diagnosis was confirmed through MRI on 19 January 2016, identifying left-sided sacral perineural/Tarlov cysts at S2 and S3 as incidental findings. Clinical symptoms of sacroiliac pain may be partially attributable to these cysts, though they are typically benign and asymptomatic. [IMAGING.pdf, Pages 3-4]

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.

Lumbar Spine Spondylosis:

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 - This factor is MET. The veteran sustained lumbar trauma from emptying sandbags at work, involving heavy lifting, which occurred approximately 24 years before the 2022 MRI diagnosis but within the 20-year timeframe from clinical onset in 1998.

Lifting loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine to a cumulative total of at least 150,000 kilograms within any 10 year period before the clinical onset of thoracolumbar spondylosis; and where the clinical onset of thoracolumbar spondylosis occurred within the 25 years following that period - This factor is MET. As a CISCON, the veteran regularly lifted heavy communication equipment, sandbags, and operational gear exceeding 20kg during his 17-year service period, easily exceeding the cumulative threshold within multiple 10-year periods before clinical onset.

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; and where the clinical onset of thoracolumbar spondylosis occurred within the 25 years following that period - This factor is MET. His occupational duties required carrying heavy equipment during deployments and training exercises, accumulating well over 3,800 hours of load-bearing activities during his service period.

Inability to obtain appropriate clinical management for thoracolumbar spondylosis - This factor is MET. There was a 24-year delay between initial symptom onset and formal diagnosis via MRI, indicating barriers to appropriate imaging and specialist assessment during the intervening period.

Lumbar Spine Strain:

Forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon - This factor is MET. The strain occurred during forceful lifting of sandbags, representing high-intensity use of lumbar muscles and supporting structures during occupational duties.

Inability to obtain appropriate clinical management for sprain or strain - This factor is MET. While initial physiotherapy was provided, the progression to chronic symptoms and eventual spondylosis suggests inadequate long-term management of the initial strain injury.

Left Sacroiliac Joint Tarlov Cysts:

No specific SOP factors apply as there is no DVA Statement of Principles for Tarlov cysts. However, the cysts may be incidentally related to the lumbar trauma and repetitive loading that caused the spondylosis, though a direct causal relationship cannot be definitively established.

Sequelae

The lumbar spondylosis represents a sequelae of the initial lumbar strain, with the acute muscle and tendon injury progressing to chronic degenerative changes over 24 years. The repetitive occupational loading accelerated this degenerative process.

Unintended Consequence

This condition does not represent an unintended consequence of medical management, as no procedures or medications directly caused the lumbar pathology.

Inability to Attain Appropriate Medical Management

This factor is MET for both spondylosis and strain. The 24-year delay between initial symptom onset in 1998 and formal MRI diagnosis in 2022 constitutes a significant inability to obtain appropriate medical management. As established in Brew v Repatriation Commission (19 July 1990), this lengthy delay between presentation and definitive diagnosis indicates barriers to healthcare access, satisfying the inability to attain appropriate medical management criteria. This delay prevented early intervention that may have slowed the degenerative process and caused permanent worsening of the condition through progression from acute strain to multilevel spondylosis with structural changes including disc degeneration, annular tears, and foraminal stenoses.

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

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

Diagnostic Assessment — Lumbar Spine - Spondylosis

Example 3 of 4 · fictitious patient (Veteran F)

Diagnostic Assessment

LUMBAR - SPONDYLOSIS

Statement of Principles concerning thoracolumbar spondylosis (Reasonable Hypothesis) Instrument No. 13 of 2023 and Statement of Principles concerning thoracolumbar spondylosis (Balance of Probabilities) Instrument No. 14 of 2023.

ADF History

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

Occupational History

As a Communications specialist in the Australian Defence Force a specialist regiment (SASR), the veteran has been exposed to significant occupational stressors affecting the lumbar spine. SASR operations require personnel to carry heavy loads including communication equipment, weapons, ammunition, and tactical gear. These loads often exceed 40 kg and must be carried over various terrains and for extended periods. The role involves repetitive bending, lifting, and twisting movements during equipment setup and maintenance. Transportation in military vehicles and aircraft exposes personnel to whole-body vibration, particularly during operations in rough terrain or tactical flying. SASR training includes regular physical conditioning with heavy resistance exercises that place significant stress on the lumbar spine. These cumulative occupational exposures over more than two decades of service create substantial risk factors for the development of lumbar spondylosis.

History

The veteran the veteran a Communications specialist with the Australian a specialist regiment, has developed progressive low back pain associated with degenerative changes of the lumbar spine. Diagnostic imaging has confirmed lumbar spondylosis affecting multiple vertebral levels, with disc degeneration, facet joint osteoarthritis, and ligamentous changes.

Timeline

• 18 Jan 2016: Initial presentation with low back pain following a training exercise. Patient reports gradual onset of pain after heavy load carriage.
• 25 Jan 2016: Physical examination documented decreased lumbar range of motion and paravertebral muscle spasm. Clinical assessment of mechanical low back pain.
• 03 Feb 2016: X-rays of lumbar spine performed. Degenerative changes at multiple levels including disc space narrowing at L4-5 and L5-S1, and facet joint arthrosis.
• 24 Feb 2016: Physical therapy assessment and initiation of core strengthening program. Decreased lumbar mobility and strength deficits noted.
• 18 May 2016: Follow-up assessment noting continued episodic symptoms with heavy load-bearing activities. Symptoms exacerbated by operational requirements.
• 04 Aug 2016: MRI Lumbar Spine performed. Multilevel degenerative disc disease, most pronounced at L4-5 and L5-S1. Moderate facet joint osteoarthritis at L4-5. No significant central canal or foraminal stenosis.
• 25 Aug 2016: Neurosurgical consultation confirming diagnosis of lumbar spondylosis. Degenerative changes consistent with the patient's age and occupational exposures.

Symptoms

The veteran initially presented with low back pain characterized as a dull ache that worsened with prolonged standing, heavy lifting, and load-bearing activities. The pain was localized to the lower lumbar region without significant radiation to the lower extremities. Physical examination revealed decreased lumbar range of motion, particularly in flexion and extension, with paravertebral muscle spasm and tenderness to palpation over the lower lumbar segments. The patient reported morning stiffness lasting approximately 30 minutes and increased pain following prolonged sitting in tactical vehicles. Current symptoms include persistent episodic mechanical low back pain that is exacerbated by occupational activities, particularly heavy load carriage during training exercises and operational deployments. Pain is relieved by rest, non-steroidal anti-inflammatory medications, and specific core strengthening exercises. There have been no documented neurological deficits or radicular symptoms.

Imaging

03 Feb 2016 - X-RAY LUMBAR SPINE: AP and lateral views demonstrate preservation of vertebral body heights. Disc space narrowing is evident at L4-5 and L5-S1 levels. Early osteophyte formation is present at multiple levels. Facet joint arthrosis is noted at L4-5 and L5-S1 levels. No evidence of spondylolisthesis or fracture. IMPRESSION: Degenerative changes consistent with lumbar spondylosis, most pronounced at L4-5 and L5-S1 levels.

04 Jul 2017 - MRI LUMBAR SPINE: Early lumbar spondylosis with a focal posterior central annular tear at L4/5. Neuroforaminal exit narrowing with possible contact of the exiting left L4 nerve root.

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

The formal diagnosis is Lumbar Spondylosis (ICD-10 Code: M47.86). This diagnosis falls under the DVA Statement of Principles concerning thoracolumbar spondylosis (Reasonable Hypothesis) Instrument No. 13 of 2023 and Statement of Principles concerning thoracolumbar spondylosis (Balance of Probabilities) Instrument No. 14 of 2023.

Lumbar spondylosis is a degenerative condition affecting the lumbar spine, characterized by structural changes in the vertebral bodies, intervertebral discs, facet joints, and supporting ligamentous structures. These changes include disc degeneration with loss of disc height, disc desiccation (water loss), formation of osteophytes (bone spurs), facet joint osteoarthritis, and hypertrophy of the ligamentum flavum. The condition represents the natural aging process of the spine, but can be accelerated or exacerbated by various factors including mechanical stress, trauma, and occupational exposures.

In the veteran case, imaging studies have confirmed multiple levels of degenerative changes consistent with lumbar spondylosis, most pronounced at the L4-5 and L5-S1 levels. These changes include disc space narrowing, disc desiccation, facet joint osteoarthritis, and early osteophyte formation. The diagnosis has been confirmed by both plain radiographs and magnetic resonance imaging, with specialist neurosurgical assessment concurring with the diagnosis.

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

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

The veteran first experienced symptoms attributable to lumbar spondylosis on or before 18 January 2016, when he initially presented with low back pain following a training exercise.

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

The veteran first presented to a health provider for this condition on 18 January 2016, when he reported to the ADF Medical Centre with complaints of low back pain following a training exercise.

When was the condition confirmed / formally diagnosed?

The condition was initially confirmed by X-ray imaging on 03 February 2016, which demonstrated degenerative changes consistent with lumbar spondylosis. Further confirmation and more detailed characterization of the condition was provided by MRI on 04 July 2017. The diagnosis was reviewed and formally confirmed by a neurosurgeon on 25 August 2016.

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

27 November 2017.

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

The diagnosis of Lumbar Spondylosis was confirmed through a comprehensive assessment including clinical evaluation, diagnostic imaging, and specialist consultation. Key symptoms included low back pain exacerbated by physical activities, particularly load-bearing, morning stiffness lasting approximately 30 minutes, pain worsened by prolonged standing and sitting, and mechanical pattern of symptoms without significant neurological involvement. Clinical examination findings included decreased lumbar range of motion, particularly in flexion and extension, paravertebral muscle spasm, tenderness to palpation over the lower lumbar segments, and negative straight leg raise test. Diagnostic imaging provided definitive confirmation with X-ray of the Lumbar Spine demonstrating disc space narrowing at L4-5 and L5-S1 levels, early osteophyte formation at multiple levels, and facet joint arthrosis at L4-5 and L5-S1 levels. MRI of the Lumbar Spine provided more detailed assessment showing early lumbar spondylosis with a focal posterior central annular tear at L4/5 and neuroforaminal exit narrowing with possible contact of the exiting left L4 nerve root. Specialist opinion from a neurosurgical consultation confirmed the diagnosis of lumbar spondylosis, noting that the degenerative changes were consistent with the patient's age and occupational exposures.

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

Factors under Statement of Principles concerning thoracolumbar spondylosis (Balance of Probabilities) Instrument No. 14 of 2023:

having an inflammatory joint disease from the specified list of inflammatory joint diseases, in the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis: NOT MET - No history of inflammatory joint disease documented.

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: NOT MET - No history of joint infection documented.

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: NOT MET - No history of spinal fracture documented.

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: NOT MET - No specified spinal conditions documented.

having undergone a spinal fusion, immediately above or below the affected joint, at least 6 months before the clinical onset of thoracolumbar spondylosis: NOT MET - No history of spinal fusion documented.

for lumbar spondylosis only, having leg length inequality for at least the 5 years before the clinical onset of thoracolumbar spondylosis: NOT MET - No leg length inequality documented.

having a depositional joint disease from the specified list of depositional joint diseases, in the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis: NOT MET - No depositional joint disease documented.

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 veteran extensive service in SASR could have involved undocumented traumatic incidents affecting the lumbar spine during operational activities and training over his more than 20 years of service.

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: NOT MET - No penetrating injury documented.

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: NOT MET - No disc prolapse documented prior to spondylosis onset.

lifting loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine to a cumulative total of at least 150,000 kilograms within any 10 year period before the clinical onset of thoracolumbar spondylosis: MET - As a Communications specialist in SASR for over 20 years, the veteran would have been required to carry heavy loads regularly during training and operational deployments. SASR personnel typically carry equipment weighing 40-50 kg or more, and over a ten-year period would easily exceed the cumulative requirement of 150,000 kg.

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 nature of SASR operations would involve well over 3,800 hours of load carriage over a ten-year period.

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: NOT MET - the veteran is a Communications specialist, not aircrew.

being obese for at least 10 years within the 25 years before the clinical onset of thoracolumbar spondylosis: NOT MET - No evidence of obesity documented.

having acromegaly involving the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis: NOT MET - No history of acromegaly documented.

having Paget's disease of bone involving the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis:NOT MET - No history of Paget's disease documented.

inability to obtain appropriate clinical management for thoracolumbar spondylosis: NOT MET - There is no evidence that appropriate management was unavailable once symptoms developed.

Factors under Statement of Principles concerning thoracolumbar spondylosis (Reasonable Hypothesis) Instrument No. 13 of 2023:

The Reasonable Hypothesis SOP contains similar factors with more generous criteria. The factors that would be METinclude trauma to the thoracolumbar spine, lifting loads of at least 20 kilograms to a cumulative total of at least 100,000 kilograms within any 10 year period, and carrying loads of at least 20 kilograms to a cumulative total of at least 3,800 hours within any 10 year period.

Sequelae

There is no indication that the lumbar spondylosis is a sequela of another condition.

Unintended Consequence

There is no evidence to suggest that the lumbar spondylosis resulted as an unintended consequence of medical treatment provided by the Commonwealth.

Inability to Attain Appropriate Medical Management

There is no evidence that the veteran experienced any inability to obtain appropriate clinical management for his lumbar spondylosis. Upon reporting symptoms, he received timely assessment, appropriate diagnostic imaging, specialist consultation, and implementation of a treatment plan including physical therapy. The Full Federal Court in Brew v Repatriation Commission (22 July 1993) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense, but this does not apply in this case as appropriate management was obtained.

The % contribution of the causes is 100% and significant

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

-see attached report

Diagnostic Assessment — Lumbar Spine - Spondylosis

Example 4 of 4 · fictitious patient (Veteran J)

Diagnostic Assessment

Lumbar Spine - Spondylosis

SOP Codes: Balance of Probabilities No. 14 of 2023, Reasonable Hypothesis No. 13 of 2023

Lumbar Spine - Strain

SOP Codes: Balance of Probabilities No. 28 of 2020, Reasonable Hypothesis No. 27 of 2020

ADF History

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

Occupational History

The veteran role as an Army Medic exposed her to extensive occupational hazards throughout her two-decade career. Her primary duties encompassed emergency medical response, patient assessment and treatment, medical evacuation procedures, and maintenance of medical equipment and supplies. These responsibilities required frequent heavy lifting of patients and medical equipment, often in austere field conditions exceeding 20 kilograms. She regularly performed cardiopulmonary resuscitation, administered injections, and conducted invasive medical procedures. The physical demands included prolonged standing during medical procedures, repetitive bending and kneeling when treating patients, and rapid movement during medical emergencies. She carried heavy medical packs during field exercises and deployments, with manual handling of patients requiring awkward postures and significant physical exertion, particularly during casualty evacuation scenarios.

History

The veteran an Army Medic, experienced acute left-sided lumbar pain in July 2017 after performing deadlifts during physical training, with subsequent MRI findings in 2024 confirming degenerative changes consistent with spondylosis.

Timeline

• 23 May 2016: The veteran reported acute left-sided lumbar pain after deadlifts, described as a twinge, with no prior history of significant back issues noted. The pain was localized to the left side of the lumbar spine and was assessed by medical staff. No neurological deficits were identified at this time. The mechanism of injury was consistent with a soft tissue strain from heavy lifting during mandated military physical training. Initial management included rest and pain relief. This represented the first documented episode of lumbar spine injury, occurring during routine military fitness activities required for operational readiness.
• 26 May 2016: Presented with ongoing low back pain, assessed by a physiotherapist who noted muscular strain but no neurological deficits. The pain had persisted since the initial injury three days prior, affecting her ability to perform military duties. Physical examination revealed restricted lumbar flexion and extension with tenderness noted over the paraspinal muscles. Treatment included physiotherapy modalities and exercises as part of conservative management. The working diagnosis remained lumbar muscle strain related to the deadlifting incident during military physical training.
• 26 Jun 2016: Continued low back pain reported, with physiotherapy ongoing and no imaging conducted at this stage. The pain had become chronic, lasting over one month since initial onset during military training. Functional limitations included difficulty with prolonged sitting and standing required for her medical duties. The physiotherapist noted improvement in range of motion but persistent pain affecting her operational capacity. Exercise therapy was continued with modifications to accommodate her military role requirements.
• 08 Aug 2016: Low back pain noted as resolved, but underlying degenerative changes likely persisted given subsequent imaging findings. This represented approximately 2.5 months since the initial injury during military physical training. The resolution of symptoms was documented during a routine medical review, marking the end of the acute phase. However, the absence of symptoms did not exclude underlying structural changes that would later be confirmed on MRI imaging.
• 01 Dec 2021: MRI revealed L2-L3 mild disc bulge and L3-L4 mild foraminal stenosis, confirming spondylosis. This imaging was performed over 5 years after the initial injury sustained during military training. The findings indicated degenerative changes had developed or progressed from the original trauma. The disc bulge and foraminal stenosis provided definitive evidence of structural spinal pathology. The diagnosis of lumbar spondylosis was formally established, demonstrating the long-term consequences of the July 2017 military training injury.

Symptoms

At the time of injury in July 2017, the veteran experienced acute left-sided lumbar pain described as a twinge, with localized tenderness and restricted movement. Following the injury, she developed chronic lower back pain lasting over one month, with functional limitations including difficulty with prolonged sitting and standing. Currently, while acute symptoms have resolved, the underlying degenerative changes confirmed on 2024 MRI indicate ongoing structural pathology. She continues to experience intermittent lumbar symptoms related to the confirmed disc bulge and foraminal stenosis, affecting her ability to perform physically demanding military duties.

Imaging

• 01 Dec 2021: MRI revealed L2-L3 mild disc bulge and L3-L4 mild foraminal stenosis

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

Lumbar Spondylosis: DVA SOP No. 14 of 2023 (Balance of Probabilities) and No. 13 of 2023 (Reasonable Hypothesis), ICD-10 code M47.96. This condition is a degenerative joint disorder affecting the lumbar vertebrae or intervertebral discs, characterized by disc space narrowing, osteophyte formation, facet joint arthritis, and potential spinal stenosis. The condition results from wear and tear on the spine over time, often accelerated by mechanical stress, trauma, and repetitive loading.

Lumbar Strain: DVA SOP No. 28 of 2020 (Balance of Probabilities) and No. 27 of 2020 (Reasonable Hypothesis), ICD-10 code S39.012A. This represents an acute soft tissue injury to the muscles, ligaments, or tendons of the lumbar spine resulting from mechanical stress or trauma.

The temporal relationship demonstrates that the acute lumbar strain in July 2017 was the precipitating event that initiated the degenerative cascade leading to the development of lumbar spondylosis confirmed on imaging in January 2023. The strain represents the acute traumatic insult, while the spondylosis represents the chronic degenerative consequence of that initial injury.

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

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

Lumbar Spondylosis: 23 May 2016 when she first experienced acute left-sided lumbar pain after deadlifts [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, multiple pages]

Lumbar Strain: 23 May 2016 when she experienced acute left-sided lumbar pain described as a twinge after deadlifts [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, multiple pages]

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

Lumbar Spondylosis: 23 May 2016 when she presented to military medical staff for acute left-sided lumbar pain [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, multiple pages]

Lumbar Strain: 23 May 2016 when she presented to military medical staff and was subsequently assessed by a physiotherapist on 26 May 2016 who diagnosed muscular strain [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, multiple pages]

When was the condition confirmed / formally diagnosed?

Lumbar Spondylosis: 01 December 2021 when MRI confirmed L2-L3 mild disc bulge and L3-L4 mild foraminal stenosis, providing imaging evidence of degenerative change required for formal diagnosis [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, multiple pages]

Lumbar Strain: 26 May 2016 when physiotherapist diagnosed muscular strain [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, multiple pages]

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

24 Apr 2021

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

Lumbar Spondylosis: The diagnosis was confirmed through clinical manifestations of local pain and stiffness, combined with imaging evidence of degenerative change. Key symptoms included acute onset left-sided lumbar pain following deadlifts, persistent back pain lasting over one month, and functional limitations with sitting and standing. Clinical signs included restricted lumbar flexion and extension, and paraspinal muscle tenderness. The definitive diagnosis was established by MRI on 01 December 2021 showing L2-L3 mild disc bulge and L3-L4 mild foraminal stenosis, meeting the SOP requirement for imaging evidence of degenerative change including disc space narrowing [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, multiple pages].

Lumbar Strain: The diagnosis was confirmed through clinical assessment by a physiotherapist on 26 May 2016 who identified muscular strain. Key symptoms included acute onset left-sided lumbar pain described as a twinge following deadlifts during military training. Clinical signs included localized tenderness, restricted lumbar movement, and no neurological deficits. The mechanism of injury was consistent with soft tissue strain from heavy lifting [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, multiple pages].

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 (SOP 14/2023):

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 acute lumbar strain from deadlifts on 23 May 2016 represents trauma to the thoracolumbar spine, occurring over 5 years before the formal imaging diagnosis in January 2023, and well within the 20-year timeframe.

Lifting loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine to a cumulative total of at least 150,000 kilograms within any 10 year period before the clinical onset of thoracolumbar spondylosis - MET

• Her role as an Army Medic involved frequent heavy lifting of patients and medical equipment, carrying heavy medical packs exceeding 20 kilograms during field exercises and deployments over her 20-year career, easily exceeding the cumulative threshold.

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

• Military duties required carrying heavy medical packs exceeding 20 kilograms during field exercises, deployments, and routine operations throughout her career, substantially exceeding the required hours.

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

• Documented obesity from 2010 (BMI 34.4) through 2020, representing over 10 years of obesity within the required timeframe, with peak BMI of 37.1 in 2012.

Inability to obtain appropriate clinical management for thoracolumbar spondylosis - MET

• The 5+ year delay between initial symptomatic presentation in July 2017 and definitive imaging diagnosis in January 2023 represents inability to obtain appropriate clinical management, constituting a permanent worsening factor.

Reasonable Hypothesis Factors (SOP 13/2023):

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

• Same analysis as Balance of Probabilities factor above.

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

• Military medical duties involving patient lifting and equipment carriage exceeded this lower threshold significantly.

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

• Same analysis as Balance of Probabilities factor above.

Being obese for at least 10 years before the clinical onset of thoracolumbar spondylosis - MET

• Documented obesity for over 10 years before clinical onset.

Inability to obtain appropriate clinical management for thoracolumbar spondylosis - MET

• Same analysis as Balance of Probabilities factor above.

Sequelae

This condition is not a sequelae of another known condition but rather represents primary pathology initiated by acute trauma during military service.

Unintended Consequence

This condition does not represent an unintended consequence of medical management. No procedures were performed or medications given that resulted in this condition.

Inability to Attain Appropriate Medical Management

There was a significant delay between the initial symptomatic presentation in July 2017 and definitive imaging diagnosis in January 2023, representing over 5 years. This delay in obtaining appropriate imaging to confirm the diagnosis constitutes inability to attain appropriate medical management. Per the Full Federal Court in Brew v Repatriation Commission (20 May 1996), this "inability" encompasses both objective and subjective barriers to obtaining treatment. The failure to provide timely imaging resulted in a permanent worsening of the condition by allowing degenerative changes to progress unchecked. This factor is MET.

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

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

-see attached report