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Diagnostic Assessment — Lumbar Spondylosis
Example 4 of 4 · fictitious patient
Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.
Diagnostic Assessment Lumbar Spondylosis BOP Code: 14 of 2023 (Thoracolumbar Spondylosis) RH Code: 13 of 2023 (Thoracolumbar Spondylosis)
ADF History
The veteran, date of birth [withheld], served in the Royal Australian Navy as a Marine Technician from 28 June 1978 to 13 April 1985
Occupational History
As a Marine Technician in the Royal Australian Navy, the veteran was employed in duties that placed sustained and repetitive mechanical loading on the lumbar spine.
These duties included lifting heavy equipment such as steel cables and survey instruments, performing manual labour aboard naval vessels in a moving maritime environment, and operating in confined spaces that required awkward postures.
He also played rugby during service, including organised sport recorded as duty at a frigate on 26 November 1978, when a scrum collapsed on top of him; rugby is a high-impact activity with a significant risk of spinal injury.
His later account of representing the Defence Force in rugby union, rugby league and boxing is not documented in the service records
History
The veteran has lumbar spondylosis with multilevel degenerative disc disease, bilateral facet arthropathy, disc herniation, synovial cyst formation, paraspinal denervation, and retrolisthesis.
The condition has its origins in multiple acute lumbar injuries sustained during ADF service between 1978 and 1985, including a lumbar strain after a heavy rugby tackle (October 1978), a ligamentous back injury from rugby (December 1978), a lumbar strain from lifting steel cables (October 1979), a direct fall onto his back at work with right L4 nerve root irritation (August 1980), a motor vehicle accident (1980), a soft tissue injury from a car falling off a jack (September 1982), and a slip on a wet deck (May 1983).
In May 1983 he was referred to Consultant Orthopaedic Surgeon the treating doctor further assessment; at review on 3 June 1983, X-rays of 30 April 1983 were reported as showing query spondylolysis at L5 with no spondylolisthesis
Timeline
04 Oct 1978 — Marine Technician the veteran, as a young adult, presented at a frigate with aching of the back on parade after being tackled heavily at rugby three days earlier.
Examination showed slight tenderness of the lumbar spine with full range of movement and normal straight leg raising, and he was treated with Brufen. "Lumbar back strain" 26 Nov 1978 — Marine Technician the veteran, as a young adult, sustained a ligamentous back injury affecting the cervical and lumbar spine when a scrum collapsed on top of him in organised sport (rugby) while serving at a frigate.
Tenderness over the cervical and lumbar spine with paraspinal muscles was documented, with reduced range of motion.
It followed a lumbar back strain recorded on 4 October 1978. "Ligamentous back injury" 05 Oct 1979 — ABSR the veteran strained the lumbar area whilst lifting steel cables during Marine Technician duties at a frigate.
Range of motion painful on flexion and extension.
Paraesthesia queried.
Treated with Indocid and placed on light duty for 4 days. "Strain to lumbar area" 5 August 1980 — ABSR the veteran fell directly onto his back at work, with mild back pain radiating to the right buttock and knee.
Examination the next day showed bruising of the right loin, tenderness over the sacrum and straight leg raising reduced to 50 degrees on the right, with full range of movement and normal reflexes; the diagnosis was a soft tissue injury with mild irritation of the right L4 nerve root, and he was excused duty for two days.
An X-ray of the lumbosacral spine on 6 August 1980 showed no bone trauma and normal disc spaces, with a very minor scoliosis at L4 and L5 convex to the left. "Soft tissue injury to back" 24 Jan 1981 — ABSR the veteran was admitted to Cooktown Hospital, and then Calvary Hospital, a frigate, after a four-wheel-drive accident over the weekend at Cooktown, with a dislocated left thumb and abrasions to the hand; no back injury was recorded at the time.
In May 1983 his doctors recorded low back pain since this accident and back trouble "on and off" since it. "MVA 1980" 17 Sep 1982 — ABSR the veteran, then serving in a frigate, was pinned by the shoulders under his car when the jack shifted while he was changing a flat tyre on his way home from work at the start of weekend leave (the injury record ticks "No" for duty and for travelling to or from duty), sustaining soft tissue injury to the right shoulder and lower back with pain radiating down the left leg.
SLR was 70 degrees with hamstring tightness.
Brufen 400mg TDS and local heat were prescribed, with seven days' light duty. "Soft tissue injury" 27 Sep 1982 — Hospital admission at RANH a frigate formally records "CHRONIC LOW BACK PAIN (ICD 724.2)" as a recognised secondary diagnosis.
Voltaren 50mg twice daily was being taken on an ongoing basis, confirming chronic NSAID use for lumbar pain. "Chronic low back pain" 29 Apr 1983 — ABSR the veteran, as a young adult, slipped on a wet polished floor at FIMA Alexandria/a frigate whilst deck polishing, landing on the polisher and striking his back.
He also sustained bruising of the right posterior ribs (ribs 9 to 12).
The medical officer documented a significant additional history: chronic low back pain since a motor vehicle accident in 1980, with referred pain to the upper legs after diving and prolonged standing, occasional paraesthesiae under the posterior right thigh, and an inability to lie in any position other than on his stomach due to pain.
Examination demonstrated tenderness at L4 5 S1 vertebral levels and a possible old fracture at L5 was queried.
Full range of motion was preserved and reflexes were normal.
X-rays of the ribs and lumbosacral spine were requested.
A right L4 nerve root irritation had already been recorded after a fall onto his back in August 1980. "Low back pain since MVA 1980" 03 May 1983 — ABSR the veteran presented with recurrent low back pain aggravated by the fall four days earlier.
He was currently receiving physiotherapy and Naprosyn for his back, and reported pain following a physiotherapy session earlier that day.
Examination demonstrated tenderness over the L4/5 region with limited movement in all ranges and normal reflexes.
The attending medical officer used the term "recurrent L.B.P." explicitly, confirming a chronic, recurring pattern of lumbar symptoms during service.
He was prescribed Panadol QID PRN in addition to his existing medications and placed on light duty for 5 days. "Recurrent L.B.P." 03 Jun 1983 — At orthopaedic review by Consultant Orthopaedic Surgeon the treating doctor, X-rays of 30 Apr 1983 were reported as showing query spondylolysis at L5 with no spondylolisthesis.
ABSR the veteran reported that his pain was improving and he was having daily physiotherapy.
Examination showed good range of motion and no neurological deficit.
Feldene was continued and physiotherapy was reduced to twice weekly. "L5 ? spondylolysis.
No spondylolisthesis." 5 August 2003 — CT lumbosacral spine performed for acute right L5/S1 nerve root pain.
Demonstrated right posterolateral and paramedian L5/S1 disc bulging with soft tissue density impinging on the right L5 nerve root, anterior and posterior disc bulging at L4/5 with focal posterocentral disc protrusion, and L5/S1 facet arthropathy with vacuum phenomenon on the left.
This was the first imaging of the lumbar spine after discharge and demonstrated established degeneration, most marked at L5/S1 (minor disc space narrowing and facet arthropathy with vacuum phenomenon), consistent with longstanding pathology originating years prior. "Disc herniation with nerve impingement" 02 Apr 2011 — While helping to load a truck at work in the transport industry, the veteran was struck in the face by a strut that fell from the truck roof, with loss of consciousness, and fell to the ground, landing on his back
Imaging
Requests recorded that he had injured his back, with lower thoracic pain "not abating" in June 2011 and increasing right leg symptoms consistent with L5 radiculopathy by August 2011. "Fall to ground.
Injured back." 04 May 2011 — MRI lumbosacral spine identified multilevel disc degeneration with moderate left L5/S1 facet arthropathy and Scheuermann's disorder with multiple endplate Schmorl's nodes. "Multilevel disc degeneration" 5 August 2011 — Whole body bone scan demonstrated moderate focal uptake in right L4/5 facet joint confirming active degenerative disease at this level.
A CT-guided injection of the right L4/5 facet joint with Celestone and bupivacaine was performed on 19 August 2011. "Active facet arthropathy" 10 Apr 2014 — MRI lumbosacral spine showed development of a new left L5/S1 facet joint synovial cyst causing mild thecal indentation, representing a new complication of the progressive facet arthropathy. "New synovial cyst" 20 Sep 2015 — MRI lumbosacral spine demonstrated progressive left L5/S1 facet arthropathy with a 9mm synovial cyst and new diffuse denervation oedema and fatty atrophy in the left sacral paraspinal musculature, indicating nerve root damage from the progressive spinal pathology. "Denervation oedema and fatty atrophy" 17 Apr 2018 — Localised bone scan confirmed active right L4/5 and left L5/S1 facet arthropathy and bilateral hip osteoarthritis more prominent on the right. "Active facet arthropathy" 29 Jan 2020 — MRI lumbar spine for new onset right leg pain and weakness.
Demonstrated high-grade right L4/5 and left L5/S1 facet degeneration, persistent left L5/S1 synovial cyst, L5/S1 4mm retrolisthesis, and left L5 nerve root contact with mild indentation.
Multiple levels showed STIR high signal possibly representing post- rhizotomy change. "High-grade facet degeneration"
Symptoms
During service, the veteran experienced recurrent lumbar pain with referred symptoms to the lower limbs, paraesthesiae under the right thigh, and functional limitation requiring repeated light duty periods, physiotherapy and chronic NSAID use (Voltaren, Naprosyn, Indocid, Brufen, Feldene).
Current symptoms include chronic lumbar pain with bilateral sciatica, right leg pain and weakness, reduced mobility, and neurological deficit as evidenced by left paraspinal denervation on MRI.
He has required CT-guided facet joint injection and rhizotomy for pain management
Imaging
6 August 1980 — X-ray lumbosacral spine: "No bone trauma has been demonstrated about the lumbar vertebral bodies, the disc spaces and neural foramina all have a normal appearance.
A very minor scoliosis at L.4 & 5 is convex to the left." 30 Apr 1983 — X-rays (reported at orthopaedic review on 03 Jun 1983): "L5 ? spondylolysis.
No spondylolisthesis." 5 August 2003 — CT lumbosacral spine for acute right L5/S1 nerve root pain: "Right posterolateral and paramedian L5/S1 disc bulging with soft tissue density impinging on the right L5 nerve root.
L4/5 focal posterocentral disc protrusion.
L5/S1 facet arthropathy with vacuum phenomenon on the left." 25 Dec 2010 — X-ray lumbar spine: "Multilevel degenerative disc disease particularly at lower lumbar levels.
Mild facet osteoarthropathy.
Gentle scoliosis convex to the left.
Mildly anteriorly wedged T11." 04 May 2011 — MRI lumbosacral spine: "Multilevel disc degeneration with moderate left L5/S1 facet arthropathy.
Multiple endplate Schmorl's nodes consistent with Scheuermann's disorder." 5 August 2011 — Bone scan: "Moderate focal uptake in right L4/5 facet joint." 19 August 2011 — CT-guided facet joint injection: "Under CT guidance, an injection was performed into the right L4/5 facet joint with a mixture of 1 mL of Celestone and 1 mL of bupivacaine." 10 Apr 2014 — MRI lumbosacral spine: "New left L5/S1 facet joint synovial cyst.
Progression of facet arthropathy." 20 Sep 2015 — MRI lumbosacral spine: "Progressive left L5/S1 facet arthropathy with 9mm synovial cyst.
New denervation oedema and fatty atrophy in left sacral paraspinal musculature." 14 Jan 2016 — Bone scan: "Low-grade activity at L5/S1 disc/endplate complex with left facet uptake." 27 Sep 2016 — MRI lumbosacral spine: "Moderately severe left facet arthritis with 9mm synovial cyst deviating left S1 root.
Left L5 foraminal neural impingement." 09 Jun 2017 — MRI lumbar spine: "Multilevel facet degenerative change most prominent at L5/S1.
Left facet synovial cyst displacing left S1 nerve root.
Left L5/S1 foraminal narrowing with abutment of left L5 nerve root." 17 Apr 2018 — Bone scan: "Active right L4/5 and left L5/S1 facet arthropathy.
Bilateral hip OA." 29 Jan 2020 — MRI lumbar spine: "High-grade right L4/5 and left L5/S1 facet degeneration.
Left L5/S1 synovial cyst persistent ( 5mm).
L5/S1 4mm retrolisthesis.
Left L5 nerve root contact/mild indentation.
Post-rhizotomy changes."
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Lumbar Spondylosis (ICD-10: M47.816) encompassing multilevel degenerative disc disease (M51.16), bilateral facet arthropathy, left L5/S1 facet joint synovial cyst (M71.38), left paraspinal denervation (M62.50), lumbar scoliosis (M41.26), and L5/S1 retrolisthesis (M43.16).
The relevant Statements of Principles are those concerning Thoracolumbar Spondylosis (Balance of Probabilities No.
14 of 2023; Reasonable Hypothesis No.
13 of 2023), applied by analogy as this is a DRCA claim.
Lumbar spondylosis is a degenerative condition of the lumbar spine characterised by progressive deterioration of the intervertebral discs, facet joints, and surrounding bony and soft tissue structures.
The condition is characterised by disc desiccation, loss of disc height, annular bulging and herniation, osteophyte formation, facet hypertrophy and arthropathy, and secondary complications including synovial cyst formation, spinal stenosis, nerve root compression, and segmental instability.
It is a chronic, progressive condition that once established is permanent and does not resolve.
The temporal relationship between the multiple diagnoses is sequential.
The lumbar strain and ligamentous injury of 1978 and the musculotendinous strain of 1979 destabilised the lumbar motion segments.
The fall onto his back and the MVA in 1980, and the car jack injury in 1982, caused further cumulative damage.
By 1982, the condition was formally classified as chronic.
The first post-discharge imaging in 2003 demonstrated established degeneration, most marked at L5/S1.
Serial imaging from 2010 to 2019 shows relentless progression with development of synovial cyst (2014), paraspinal denervation (2015), and retrolisthesis (2019)
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Approximately 1 October 1978 (a lumbar back strain after he was tackled heavily at rugby, recorded at a frigate on 4 October 1978) [CHART REVIEW document].
The degenerative process was initiated by the acute injuries during service and became established by 2003 when post-discharge imaging was first performed.
When did the veteran first present to a health / medical provider for this condition? 4 October 1978 (lumbar back strain, a frigate) [CHART REVIEW document].
First formal documentation of chronic low back pain: 27 September 1982.
First imaging confirming spondylosis: 5 August 2003.
When was the condition confirmed / formally diagnosed? 5 August 2003 (CT lumbosacral spine) When did the veteran first present to you (or your practice) for this condition? 8 November 2019
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis of lumbar spondylosis was confirmed on imaging.
During service, a X-ray of the lumbosacral spine on 6 August 1980, after a fall onto his back at work, showed no bone trauma and normal disc spaces, with a very minor scoliosis at L4 and L5 convex to the left [CHART REVIEW document], and X-rays of 30 April 1983 were reported at orthopaedic review on 3 June 1983 as showing query spondylolysis at L5 with no spondylolisthesis, with good range of motion and no neurological deficit on examination [CHART REVIEW document].
The earliest post-discharge imaging of the lumbar spine was a CT lumbosacral spine on 5 August 2003, which demonstrated right posterolateral disc herniation at L5/S1 with L5 nerve root impingement and multilevel degenerative changes.
The level of degeneration on this first post-discharge imaging was consistent with longstanding pathology originating years prior.
Subsequent serial MRI scans from 2011 through 2019 and bone scans in 2011, 2015, and 2018 have confirmed progressive multilevel degenerative disc disease, facet arthropathy, synovial cyst formation, paraspinal denervation, and retrolisthesis.
The clinical symptoms of chronic low back pain with radiculopathy were documented throughout the latter years of service from 1982 onwards [ [CHART REVIEW document], pages 8 9, 12 13, 33, 112 113]
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 25 September 1998 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Definition: Subsection 7(4) of the Statement of Principles excludes Scheuermann disease, but the veteran's diagnosis rests on degenerative change rather than his Scheuermann endplate changes: disc space narrowing and facet arthropathy with vacuum phenomenon at L5/S1 on the CT of 5 August 2003, and multilevel lumbar disc degeneration and facet arthropathy on later imaging, so the definition is met.
The dictionary counts clinical onset back from that first confirming imaging to when symptoms became persistent; his back trouble after the 1980 injuries and chronic low back pain on Voltaren by October 1982 are consistent with the estimated onset of 7 January 1982.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Thoracolumbar Spondylosis, No.
14 of 2023) 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 — NOT MET - There is no record of ankylosing spondylitis, rheumatoid, psoriatic or reactive arthritis, or arthritis associated with inflammatory bowel disease; his sacroiliac joints were normal on the lumbosacral X-ray of 6 August 1980, and later imaging showed no sacroiliitis.
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 — NOT MET - There is no record of infection of a lumbar facet joint or intervertebral disc before the estimated onset of 7 January 1982, and nothing in his history suggests it.
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 — NOT MET - The lumbosacral X-ray of 6 August 1980 showed no bone trauma, and the 1983 query of L5 spondylolysis, a pars interarticularis defect rather than an intra-articular fracture, was not confirmed; later MRI showed the partes intact.
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 - The specified list includes scoliosis and deformity of a vertebra.
The lumbosacral X-ray of 6 August 1980, 17 months before the estimated onset of 7 January 1982, showed a very minor scoliosis at L4 and L5 convex to the left, and a left-convex lumbar curve was again reported on the X-ray of 25 December 2010 and the MRI of 4 May 2011.
Scheuermann's disorder is not itself on the list, but its recorded sequelae, multiple endplate Schmorl's nodes in the lower thoracic and upper lumbar vertebrae, are deformities of vertebrae, and because the disorder develops during adolescent growth they were present well before onset.
These are constitutional factors, not related to service.
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 — NOT MET - the veteran has never undergone spinal fusion; his only fusion operations were of the thumb and toe joints between 1980 and 1982.
Factor 9(6): for lumbar spondylosis only, having leg length inequality for at least the 5 years before the clinical onset of thoracolumbar spondylosis — NOT MET - There is no record of a leg length inequality of at least 2 centimetres on examination or imaging, and nothing in his history suggests one.
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 — NOT MET - There is no record of gout, pseudogout, haemochromatosis, alkaptonuria or Wilson's disease, and nothing in his history suggests any of them.
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 veteran sustained repeated discrete trauma to the lumbar spine more than six months before the estimated onset of 7 January 1982 and within the 20 years before it: a rugby scrum collapsed on top of him in organised sport on 26 November 1978 (tender lumbar spine, reduced range of movement); he strained his lower back lifting steel cables and cable drums at sea on 5 October 1979 (painful flexion and extension, then leg numbness); he fell directly onto his back at work on 5 August 1980 (sacral tenderness, straight leg raising limited to 50 degrees, right L4 root irritation); and a four-wheel-drive accident at Cooktown in late January 1981 was followed by back trouble 'on and off', as recorded in May 1983.
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 — NOT MET - There is no record of a bullet, fragment, knife or needle piercing a lumbar intervertebral disc before the estimated onset, and nothing in his history suggests it.
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 — NOT MET - No disc prolapse was diagnosed before the estimated onset; the transient leg numbness of October 1979 and mild right L4 root irritation of August 1980 did not establish one, and herniation was first imaged on 5 August 2003.
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 - Load weights are not recorded, but heavy lifting was inherent in his duties as a Marine Technician and Marine Technician: working ships' lines and rope work, handling survey equipment, storing ship and, on 5 October 1979 in a frigate, lifting steel cables and cable drums, which strained his back.
Excluding his first year of recruit and category training, about 2.5 years of such duties preceded the estimated onset.
At a conservative 20 lifts of at least 25 kg on each of 150 heavy working days a year (allowing for leave, watchkeeping and post- operative light duties), the total estimated from his documented duties is about 187,500 kg (2.5 150 20 25), all within the 10 years immediately before onset.
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 — NOT MET - Carrying loads of at least 20 kg was intermittent in his duties; even at 30 minutes a day on 150 working days a year, his 3.5 years of service before onset give about 265 hours, far short of 3,800 hours.
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 — NOT MET - the veteran served as a Marine Technician and Marine Technician and never flew as operational aircrew in any aircraft.
Factor 9(14): being obese for at least 10 years within the 25 years before the clinical onset of thoracolumbar spondylosis — NOT MET - the veteran was first recorded as obese (BMI 32.9) on 13 August 1981; even if he had been obese from soon after enlistment in July 1978, he could not have been obese for 10 years before the estimated onset of 7 January 1982.
Factor 9(15): having acromegaly involving the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis — NOT MET - There is no record of acromegaly or growth hormone excess at any time, and nothing in his history suggests it.
Factor 9(16): having Paget's disease of bone involving the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis — NOT MET - There is no record of Paget's disease of bone, and the later bone scans of 2011, 2015 and 2018 showed only degenerative facet and endplate uptake in the lumbar spine.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Thoracolumbar Spondylosis, No.
13 of 2023) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): being a prisoner of war before the clinical onset of thoracolumbar spondylosis — NOT MET - the veteran was never a prisoner of war; he rendered peacetime naval service with no operational deployments.
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 — NOT MET - No inflammatory joint disease on the specified list (ankylosing spondylitis, rheumatoid, psoriatic, reactive or enteropathic arthritis) is recorded, and his sacroiliac joints were normal on the lumbosacral X-ray of 6 August 1980.
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 — NOT MET - There is no record of infection of a lumbar facet joint or disc before the estimated onset of 7 January 1982, and nothing in his history suggests it.
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 — NOT MET - No intra-articular spinal fracture is recorded: the X-ray of 6 August 1980 showed no bone trauma, and the 1983 query of L5 spondylolysis, a pars defect rather than an intra-articular fracture, was not confirmed on later MRI.
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 specified list includes scoliosis and deformity of a vertebra.
A very minor left-convex scoliosis at L4 and L5 was shown on the lumbosacral X-ray of 6 August 1980, 17 months before the estimated onset of 7 January 1982, and persisted on imaging in 2010 and 2011.
The multiple endplate Schmorl's nodes of Scheuermann's disorder, which develops during adolescent growth, are deformities of vertebrae that were present well before onset.
These are constitutional factors, not related to service.
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 — NOT MET - No abnormal lumbar kyphosis or lordosis is recorded; the X-ray of 25 December 2010 reported satisfactory sagittal alignment and the MRI of 10 April 2014 normal alignment, his scoliosis being a lateral rather than sagittal curve.
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 — NOT MET - the veteran has never undergone spinal fusion; his fusion operations were confined to the thumb and toe joints.
Factor 9(8): for lumbar spondylosis only, having leg length inequality for at least the 2 years before the clinical onset of thoracolumbar spondylosis — NOT MET - There is no record of a leg length inequality of at least 2 centimetres, and nothing in his history suggests one.
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 — NOT MET - There is no record of gout, pseudogout, haemochromatosis, alkaptonuria or Wilson's disease, and nothing in his history suggests any of them.
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 - More than six months before the estimated onset of 7 January 1982, and within 20 years of it, the veteran sustained repeated discrete lumbar trauma: a rugby scrum collapse in organised sport on 26 November 1978 (tender lumbar spine, reduced movement); a strain lifting steel cables and cable drums at sea on 5 October 1979 (painful movement, leg numbness); a direct fall onto his back at work on 5 August 1980 (sacral tenderness, straight leg raising limited to 50 degrees, right L4 root irritation); and a four-wheel-drive accident at Cooktown in late January 1981, after which he had back trouble on and off.
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 — NOT MET - There is no record of any object piercing a lumbar intervertebral disc before the estimated onset, and nothing in his history suggests it.
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 — NOT MET - No disc prolapse was diagnosed before the estimated onset; the transient leg numbness of October 1979 and right L4 root irritation of August 1980 did not establish one, and herniation was first imaged in August 2003.
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 - Heavy lifting was inherent in his documented duties as a Marine Technician and Marine Technician, including rope work, survey equipment and, on 5 October 1979, steel cables and cable drums that strained his back.
Estimated from those duties, about 2.5 years of such work before the estimated onset (excluding recruit and category training), at a conservative 20 lifts of at least 25 kg on 150 heavy working days a year, totals about 187,500 kg (2.5 150 20 25), well above 100,000 kg within the 10 years before onset.
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 — NOT MET - Carrying loads of at least 20 kg was intermittent; even 30 minutes a day on 150 working days a year over his 3.5 years of service before onset gives about 265 hours, far short of 3,800 hours.
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 — NOT MET - the veteran served as a Marine Technician and Marine Technician and never flew as operational aircrew in any aircraft.
Factor 9(16): being obese for at least 10 years before the clinical onset of thoracolumbar spondylosis — NOT MET - the veteran was first recorded as obese (BMI 32.9) on 13 August 1981, less than five months before the estimated onset of 7 January 1982, so he had not been obese for 10 years before it.
Factor 9(17): having acromegaly involving the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis — NOT MET - There is no record of acromegaly or growth hormone excess at any time, and nothing in his history suggests it.
Factor 9(18): having Paget's disease of bone involving the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis — NOT MET - There is no record of Paget's disease of bone, and later bone scans showed only degenerative uptake in the lumbar spine.
Other Plausible Links to Service Independently of the Statement of Principles, the veteran's lumbar symptoms began with injuries that arose out of, or in the course of, his employment as a member.
At a frigate, as a young adult, he strained his lower back after a heavy rugby tackle in October 1978, and on 26 November 1978 a scrum collapsed on top of him during organised sport on duty; on 5 October 1979 he strained his back lifting steel cables and cable drums during survey work at sea in a frigate; on 5 August 1980 he fell directly onto his back at work, with right L4 nerve root irritation; and on 29 April 1983 he slipped on soapy water while scrubbing a deck on duty and landed on the floor polisher, injuring his back.
The spondylosis can also be regarded as a sequela of these in-service lumbar injuries.
The records show continuity: back trouble 'on and off' after the 1980 injuries, chronic low back pain treated with Voltaren by October 1982, and 'recurrent' low back pain with tenderness from L4 to S1 requiring physiotherapy and orthopaedic review in February and June 1983.
The first post-service imaging, the CT of 5 August 2003, showed established degeneration at the same segments: disc space narrowing, disc herniation and facet arthropathy with vacuum phenomenon at L5/S1, and a disc protrusion at L4/5.
Under the DRCA, a disease is compensable where employment contributed to it to a significant degree, and repeated injury to these segments in service is such a contribution.
Service also aggravated a constitutional predisposition.
His minor left-convex lumbar scoliosis (first recorded on 6 August 1980) and Scheuermann's endplate changes are not due to service, but they leave the spine more vulnerable to trauma and loading.
After his back pain became chronic he continued Marine Technician and ships' husbandry duties; in May 1983 he was restricted to light duties with no lifting or driving, yet heavy lifting is again recorded at a frigate in October 1984, and his back was never investigated beyond plain X-rays before discharge.
Continued heavy loading of a symptomatic, uninvestigated spine is an aggravation of the condition by his employment.
Conclusion the veteran's lumbar spondylosis arose from repeated trauma to the lumbar spine and cumulative heavy lifting during his naval service, acting on a spine with a minor constitutional scoliosis and Scheuermann's endplate changes.
The in-service injuries of 1978 to 1980 and an estimated 187,500 kg of heavy lifting before onset meet the trauma and lifting factors, and the progression to chronic low back pain treated with anti-inflammatory medication by 1982 shows the condition developing in service; the scoliosis and vertebral deformity are a background factor unrelated to service.
After onset, further in-service trauma, continued heavy duties and the absence of investigation worsened the condition, which was later aggravated by long-standing obesity and the post-service fall of April 2011.
Service contributed to its onset and progression to a significant degree.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's lumbar spondylosis is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset (estimated 7 January 1982) aggravated it or contributed to it in a material degree.
He served for a further three years and three months after that date, during which he was injured when a car slid off its jack (September 1982) and in a fall onto a floor polisher on duty (May 1983), and continued heavy duties while taking anti-inflammatory medication for chronic low back pain; post-service factors are also addressed.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Thoracolumbar Spondylosis, No.
14 of 2023) 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 — NOT MET - No inflammatory joint disease on the specified list has been diagnosed at any time, and imaging from 2014 to 2018 showed no sacroiliitis or erosive arthropathy.
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 — NOT MET - No infection of a lumbar facet joint or disc has been recorded at any time, including after the facet joint injection of 19 August 2011 and the rhizotomies of 2019.
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 — NOT MET - No intra-articular fracture at or adjacent to the affected lumbar levels preceded the recorded worsening: the 1983 query of L5 spondylolysis was not confirmed, no fracture was found after the 2011 fall, and a chronic T12 endplate depression was first reported only in February 2020.
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 veteran's constitutional spinal deformities from the specified list persisted after onset: a left-convex lumbar scoliosis was recorded in 1980 and again in 2010 and 2011, the multiple endplate Schmorl's nodes of Scheuermann's disorder are permanent deformities of the vertebrae, and developmentally asymmetrical posterior elements at L5/S1 were described in 2016.
These affected the thoracolumbar spine for decades before the measurable worsening from the CT of 5 August 2003 (L5/S1 disc herniation and facet arthropathy) to the MRI of 29 January 2020 (high-grade L5/S1 facet degeneration, synovial cyst and retrolisthesis).
They are not related to service.
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 — NOT MET - the veteran has never undergone spinal fusion; his fusion operations were confined to the thumb and toe joints between 1980 and 1982.
Factor 9(22): for lumbar spondylosis only, having leg length inequality for at least the 5 years before the clinical worsening of thoracolumbar spondylosis — NOT MET - There is no record of a leg length inequality of at least 2 centimetres at any time, and nothing in his history suggests one.
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 - After onset, on 17 September 1982, a car slid off its jack and pinned him, causing low back pain radiating down the left leg with straight leg raising limited to 70 degrees; more than six months later, in February and June 1983, his 'recurrent' low back pain with limited movement required lumbar X-rays, physiotherapy, orthopaedic referral and light duties with no lifting, following a further fall onto a floor polisher on duty on 29 April 1983.
After service, a workplace fall onto his back on 2 April 2011, with months of pain and a right L4/5 facet injection, preceded by over six months the new left L5/S1 synovial cyst of April 2014 and later denervation and retrolisthesis, all within 20 years.
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 — NOT MET - There is no record of gout, pseudogout, haemochromatosis, alkaptonuria or Wilson's disease at any time, and nothing in his history suggests any of them.
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 — NOT MET - No lumbar disc has been pierced by a needle or other object: the CT-guided injection of 19 August 2011 was into the right L4/5 facet joint, the 2019 rhizotomies targeted the facet joints, and no discography is recorded.
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 CT of 5 August 2003, performed for acute right L5/S1 nerve root pain, showed a right posterolateral L5/S1 disc herniation impinging on the right L5 nerve root (a sequestrated fragment could not be excluded) and a L4/5 disc protrusion.
More than six months later those levels worsened measurably: moderate L5/S1 disc degeneration with a disc-osteophyte complex and left facet arthropathy (2011), a new left L5/S1 facet synovial cyst (2014), left sacral paraspinal denervation (2015), left L5 foraminal impingement (2016 and 2017), and a 4 mm L5/S1 retrolisthesis with a shallow L4/5 disc extrusion (2019).
This factor is met on post-service facts.
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 - After onset the veteran served a further three years and three months: at sea in a frigate, in ships' husbandry at the Fleet Intermediate Maintenance Activity, Sydney (including scrubbing and polishing decks), and at a frigate, where 'heavy lifting' is recorded in October 1984.
Allowing for about four months of ineffective or restricted duty, about 2.9 years at a conservative 20 lifts of at least 25 kg on 150 heavy working days a year gives an estimated 217,500 kg (2.9 150 20 25) from his documented duties, and about 400,000 kg over his whole service, all within one 10-year period.
The worsening shown on the CT of 5 August 2003 and on imaging in 2010 and 2011 followed within 25 years of that period.
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 — NOT MET - Carrying loads of at least 20 kg was intermittent; even 30 minutes a day on 150 working days a year over his whole 6.8 years of service gives about 510 hours, and no heavy post- service carrying is recorded.
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 — NOT MET - the veteran served as a Marine Technician and Marine Technician and never flew as operational aircrew in any aircraft.
Factor 9(30): being obese for at least 10 years within the 25 years before the clinical worsening of thoracolumbar spondylosis — MET - the veteran was obese through most of 1981 to 1985 (BMI 32.9 in August 1981 and 35.7 at discharge in April 1985), and the later records indicate that he remained so: his body habitus made ultrasound technically very difficult in 2011, he weighed about 168 kg (BMI about 48.6) before bariatric surgery in 2013, and his BMI was 41.5 on 19 December 2018.
He was therefore obese for well over 10 years within the 25 years before the worsening documented from 2003 to 2019, including the new synovial cyst (2014), denervation (2015) and retrolisthesis (2019).
This factor is met largely on post-service facts, although the obesity began during service.
Factor 9(31): having acromegaly involving the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis — NOT MET - There is no record of acromegaly or growth hormone excess at any time, and nothing in his history suggests it.
Factor 9(32): having Paget's disease of bone involving the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis — NOT MET - There is no record of Paget's disease of bone; the bone scans of 2011, 2015 and 2018 showed only degenerative facet and endplate uptake.
Factor 9(33): inability to obtain appropriate clinical management for thoracolumbar spondylosis — MET - the veteran presented repeatedly with lumbar symptoms from 1978, with nerve root signs and chronic low back pain on Voltaren by 1982, yet had only anti-inflammatories, brief light duties and one plain X-ray before May 1983; the queried L5 spondylolysis was then not pursued, and his discharge examination did not mention his back.
Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional incapacity and the threat of sanctions; his barriers included treatment at sea without a medical officer (1979), remote care at Cooktown (1980), the August 1981 signal suspecting him of malingering and the loss of his medical record (1984).
Diagnosis came only with the CT of 5 August 2003, almost 25 years after first presentation, when disc herniation was established.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Thoracolumbar Spondylosis, No.
13 of 2023) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(19): being a prisoner of war before the clinical worsening of thoracolumbar spondylosis — NOT MET - the veteran was never a prisoner of war at any time; he rendered peacetime naval service with no operational deployments.
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 — NOT MET - No inflammatory joint disease on the specified list has been diagnosed at any time, and imaging from 2014 to 2018 showed no sacroiliitis.
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 — NOT MET - No infection of a lumbar facet joint or disc has been recorded, including after the facet joint injection of 19 August 2011 and the 2019 rhizotomies.
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 — NOT MET - No intra-articular fracture at or adjacent to the affected lumbar levels preceded the recorded worsening; the 1983 query of L5 spondylolysis was not confirmed, no fracture was found after the 2011 fall, and a T12 endplate depression was first reported only in February 2020.
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 specified list includes scoliosis and deformity of a vertebra.
The veteran's left-convex lumbar scoliosis (recorded in 1980, 2010 and 2011), the permanent endplate deformities of Scheuermann's disorder with multiple Schmorl's nodes, and the developmentally asymmetrical L5/S1 posterior elements described in 2016 affected his thoracolumbar spine for decades before the worsening documented from the CT of 5 August 2003 to the MRI of 29 January 2020.
These constitutional factors are not related to service.
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 — NOT MET - No abnormal lumbar kyphosis or lordosis is recorded; the X-ray of 25 December 2010 reported satisfactory sagittal alignment and the MRI of 10 April 2014 normal vertebral alignment.
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 — NOT MET - the veteran has never undergone spinal fusion; his fusion operations were confined to the thumb and toe joints.
Factor 9(26): for lumbar spondylosis only, having leg length inequality for at least the 2 years before the clinical worsening of thoracolumbar spondylosis — NOT MET - There is no record of a leg length inequality of at least 2 centimetres at any time, and nothing in his history suggests one.
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 — NOT MET - There is no record of gout, pseudogout, haemochromatosis, alkaptonuria or Wilson's disease, and nothing in his history suggests any of them.
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 - On 17 September 1982, after onset, a car slid off its jack and pinned him, causing low back pain radiating down the left leg with limited straight leg raising; more than six months later, in February and June 1983, his recurrent low back pain with limited movement required X- rays, physiotherapy, orthopaedic referral and light duties with no lifting.
After service, a workplace fall onto his back on 2 April 2011, with months of pain and a right L4/5 facet injection, preceded the new left L5/S1 synovial cyst of April 2014 and the later denervation and retrolisthesis by more than six months, all within 20 years.
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 — NOT MET - No lumbar disc has been pierced by a needle or other object; the 2011 injection was into the right L4/5 facet joint, the 2019 rhizotomies targeted the facet joints, and no discography is recorded.
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 CT of 5 August 2003 showed a right L5/S1 disc herniation impinging on the right L5 nerve root and a L4/5 disc protrusion.
More than six months later those levels worsened measurably, with a new left L5/S1 facet synovial cyst (2014), left sacral paraspinal denervation (2015), left L5 foraminal impingement (2016 and 2017), and a 4 mm L5/S1 retrolisthesis with a shallow L4/5 disc extrusion (2019).
This factor is met on post-service facts.
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 - After onset the veteran served a further three years and three months in a frigate, in ships' husbandry at the Fleet Intermediate Maintenance Activity, Sydney, and at a frigate, where heavy lifting is recorded in October 1984.
Estimated from those duties, about 2.9 effective years at a conservative 20 lifts of at least 25 kg on 150 heavy working days a year gives about 217,500 kg (2.9 150 20 25), and about 400,000 kg over his whole service, well above 100,000 kg within a 10-year period before the worsening documented from 2003.
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 — NOT MET - Carrying loads of at least 20 kg was intermittent; even 30 minutes a day on 150 working days a year over his 6.8 years of service gives about 510 hours, far short of 3,800 hours.
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 — NOT MET - the veteran served as a Marine Technician and Marine Technician and never flew as operational aircrew in any aircraft.
Factor 9(34): being obese for at least 10 years before the clinical worsening of thoracolumbar spondylosis — MET - the veteran was obese through most of 1981 to 1985 (BMI 32.9 in August 1981 and 35.7 at discharge in April 1985), and later records indicate that he remained so, weighing about 168 kg (BMI about 48.6) before bariatric surgery in 2013 and with a BMI of 41.5 in December 2018.
He was therefore obese for well over 10 years before the worsening documented from 2003 to 2019.
This factor is met largely on post-service facts, although the obesity began during service.
Factor 9(35): having acromegaly involving the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis — NOT MET - There is no record of acromegaly or growth hormone excess at any time, and nothing in his history suggests it.
Factor 9(36): having Paget's disease of bone involving the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis — NOT MET - There is no record of Paget's disease of bone; the bone scans of 2011, 2015 and 2018 showed only degenerative uptake.
Factor 9(37): inability to obtain appropriate clinical management for thoracolumbar spondylosis — MET - the veteran's recurrent in-service lumbar presentations from 1978, including nerve root signs and chronic low back pain on Voltaren by 1982, were managed with anti-inflammatories and light duties, without specialist referral until May 1983 or investigation beyond plain X- rays, and the condition was not diagnosed until the CT of 5 August 2003, almost 25 years later.
Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional incapacity and the threat of sanctions; his barriers included sea and remote postings, the August 1981 signal suspecting him of malingering and the loss of his medical record in 1984
Sequelae
Lumbar spondylosis is in part a sequela of the veteran's in-service lumbar injuries: the lumbar strains of October 1978 and October 1979, the lumbar sprain of December 1978 and the lumbar soft tissue injuries of 1980, 1982 and 1983.
These injuries, together with cumulative heavy lifting in service, initiated and accelerated a degenerative process in a spine that also had a minor constitutional scoliosis and Scheuermann's endplate changes, and it has progressed to the current advanced multilevel lumbar degeneration
Unintended Consequence
This condition is not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
This only applies to worsening factors.
The veteran presented repeatedly with lumbar symptoms from October 1978, including leg numbness (October 1979), right L4 nerve root irritation (August 1980) and chronic low back pain treated with Voltaren (October 1982), but was managed with anti-inflammatory medication, brief periods of light duty and a single plain X-ray (August 1980) until physiotherapy, further X-rays and orthopaedic referral in May 1983.
The queried L5 spondylolysis was not investigated further, his discharge examination made no mention of his back, and the condition was not diagnosed until the CT of 5 August 2003, almost 25 years after his first presentation, when a disc herniation impinging on the right L5 nerve root was already established — MET.
Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability to obtain appropriate clinical management is assessed objectively and subjectively and includes psychological or emotional incapacity and the threat of sanctions that make seeking treatment unrealistic.
The veteran's documented barriers included treatment at sea by a Marine Technician medical assistant in October 1979, with review by a medical officer deferred until the ship returned to a frigate, remote care at Cooktown after the 1980 accident, the command signal of 18 August 1981 suspecting him of malingering, and the loss of his PM168 medical record at a frigate in May 1984
Date of Clinical Onset
Lumbar spondylosis is a chronic condition.
Its date of clinical onset is the date on which the condition first manifested clinically.
It is not the date on which the condition was first imaged or formally diagnosed
Imaging
And specialist diagnosis record when an established condition was confirmed; a chronic condition is present, and usually symptomatic, for a considerable period before it is investigated, so the date of imaging must not be taken as the date of clinical onset.
First documented presentation with pain in the lumbar spine: 4 October 1978 — lumbar back strain at a frigate, with aching of the back on parade three days after a heavy rugby tackle and lumbar tenderness on examination [CHART REVIEW document].
End of ADF service: 13 April 1985.
First imaging / formal diagnosis (confirmation, not onset): 5 August 2003 (CT of the lumbosacral spine).
The precise date of clinical onset cannot be determined from the records.
It is therefore estimated as the midpoint between the first documented presentation with pain in the lumbar spine (4 October 1978) and the end of the veteran's ADF service (13 April 1985).
Estimated date of clinical onset: 7 January 1982.
This date falls within the veteran's ADF service (28 June 1978 13 April 1985).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
