Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been withheld or altered and all dates changed. It must not be relied upon as a record of any real claim.
Diagnostic Assessment — Lumbar Spondylosis
Example 1 of 3 · fictitious patient (Veteran O)
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
Balance of Probabilities SOP: Thoracolumbar Spondylosis No. 14 of 2023 Reasonable Hypothesis SOP: Thoracolumbar Spondylosis No. 13 of 2023
Related conditions:
- Transitional vertebral body lumbosacral junction (Q76.49)
- L4/5 disc protrusion with nerve root compression (M51.16)
ADF History
The veteran, Date of Birth: [withheld] occupation Rifleman, enlistment date 11/06/2013, discharge date 14/07/2019.
Occupational History
As a Rifleman in the Australian Army, the veteran was exposed to significant occupational hazards including repetitive heavy load bearing during pack marching with military equipment exceeding 35kg, prolonged vehicle operations during deployment requiring awkward positioning and vibration exposure, intensive physical training requirements including running and weight lifting, and occupational demands of infantry role requiring frequent lifting, carrying, and physically demanding activities. The role involved exposure to combat environments, weapons systems, environmental contaminants, and sustained physical demands that significantly exceed civilian occupational exposures.
History
The veteran the veteran a Rifleman with the Australian Army, first experienced lumbar spine symptoms during his an overseas area of operations deployment in December 2013 with acute onset back pain documented as deployment-related injury. The condition developed into chronic low back pain with structural deterioration confirmed by MRI imaging in 2022 showing L4/5 disc protrusion with nerve root compression and a developmental transitional vertebra at the lumbosacral junction.
Timeline
- 02 October 2010 - During an overseas area of operations deployment, the veteran developed acute lumbar back pain documented as occurring during deployment operations. Acute back pain - lumbar was recorded with the notation Injury occurred during deployment. This represents the first documented presentation of his spinal condition during operational military duties. The injury was significant enough to warrant medical attention during operational activities. Assessment was conducted by military medical personnel at the operational location. Documentation indicates this was a new onset condition directly related to deployment activities.
- 28 Mar 2012 - Initial physiotherapy assessment at the treating doctor Health Centre for lower back symptoms that had been present for 1-2 years with recent exacerbation. The veteran reported Lower back tightness/stiffness & soreness following intensive training activities. The physiotherapist documented Gradual onset of symptoms 1-2 years ago, symptoms increased past month correlating with increased weight lifting and running volume. Physical examination revealed mild increased muscle tone in paraspinal muscles and mild L5 central tenderness. The condition was diagnosed as Persistent/recurrent NSLBP, recent flare-up attributable to a significant increase in WLM and running volume.
- 05 May 2013 - Pre-separation health examination documented ongoing intermittent lower back pain as part of his inactive injuries list. The examining medical officer noted Lower back pain - Intermittent pain, more with certain activity. Stiffness as well post certain PT. Running can flare it. Some referral down hamstring, no further. No weakness. This documentation confirmed the chronic nature of the condition despite previous physiotherapy management affecting his ability to perform certain physical activities and training.
- 08 January 2016 - Comprehensive MRI examination of thoracolumbar spine performed showing structural pathology confirming the diagnosis of lumbar spondylosis. Imaging revealed Low level disc bulging and small left postero-lateral disc protrusion L4/5, mildly compressing the left L5 nerve root in the lateral recess with findings c/w compressive radiculopathy. Additional findings included a transitional vertebral body at the lumbosacral junction with developmental disc height reduction. The imaging provided objective confirmation of spinal pathology including degenerative changes consistent with spondylosis.
Symptoms
At the time of initial injury in December 2013, the veteran experienced acute lumbar back pain during deployment activities with sufficient severity to warrant medical attention during operational duties. Following the acute injury, he developed chronic intermittent lower back pain with stiffness and soreness that was aggravated by physical training activities, particularly running and weight lifting. Current symptoms include ongoing lower back pain that is intermittent and activity-related, with stiffness following physical training, running-induced flare-ups, and some referral down the hamstring without associated weakness. The condition affects his ability to perform certain physical activities and training with ongoing functional limitations requiring self-management strategies.
Imaging
- 08 January 2016 - MRI thoracolumbar spine revealed A developmental anomaly is noted with a transitional vertebral body at the lumbosacral junction, designated L5 for the purposes of this examination. Developmental reduced size in L5/S1 disc as a result and Low level disc bulging and small left postero-lateral disc protrusion L4/5, mildly compressing the left L5 nerve root in the lateral recess with otherwise no disc herniation is identifiable in the thoracolumbar spine and there is no central spinal canal stenosis.
1. What is the formal diagnosis of the condition claimed above?
Lumbar spondylosis (M47.816) - DVA SOP: Thoracolumbar Spondylosis No. 14 of 2023, ICD-10: M47.816 Transitional vertebral body lumbosacral junction (Q76.49) - No specific DVA SOP, ICD-10: Q76.49 L4/5 disc protrusion with nerve root compression (M51.16) - DVA SOP: Intervertebral Disc Disorder, ICD-10: M51.16
Lumbar spondylosis is a degenerative joint disorder affecting the lumbar vertebrae or intervertebral discs. It represents age-related wear and tear changes in the spine including disc space narrowing, osteophyte formation, facet joint arthritis, and bone hypertrophy. The condition commonly presents with local pain and stiffness, and may involve spinal cord or nerve root compression. Spondylosis typically develops gradually over time due to repetitive mechanical stress and loading of the spine.
The transitional vertebral body represents a developmental anomaly at the lumbosacral junction where the anatomy is intermediate between lumbar and sacral characteristics. This anatomical variant can predispose to mechanical stress concentration and accelerated degenerative changes at adjacent levels.
The L4/5 disc protrusion with nerve root compression represents focal disc herniation causing compression of the left L5 nerve root, which can result in radicular symptoms including pain, numbness, or weakness in the L5 distribution.
These conditions are temporally related, with the developmental transitional vertebra providing constitutional predisposition, acute strain injury during military service initiating the degenerative process, and progressive development of spondylosis with disc protrusion over subsequent years.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
02 October 2010 - acute back pain during an overseas area of operations deployment [CHART REVIEW.docx - multiple references to deployment injury]
When did the veteran first present to a health / medical provider for this condition?
02 October 2010 - presented to military medical personnel during an overseas area of operations deployment for acute lumbar back pain documented as deployment-related injury [CHART REVIEW.docx - timeline section]
When was the condition confirmed / formally diagnosed?
08 January 2016 - MRI thoracolumbar spine confirmed lumbar spondylosis with disc protrusion by specialist radiologist the treating doctor at I-MED Radiology the city [IMAGING.pdf - MRI report dated 08 January 2016]
When did the veteran first present to you (or your practice) for this condition?
01 July 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.
The diagnosis was confirmed through comprehensive MRI imaging performed by specialist radiologist at I-MED Radiology the city on 08 January 2016. Key clinical symptoms included chronic intermittent lower back pain with stiffness, activity-related exacerbations particularly with running and physical training, and referral pain down the hamstring without neurological weakness. Clinical signs documented by physiotherapy assessment included increased paraspinal muscle tone and central L5 tenderness. The definitive diagnosis was established by MRI imaging showing degenerative changes consistent with lumbar spondylosis including disc space narrowing, osteophyte formation, and L4/5 disc protrusion with nerve root compression [IMAGING.pdf - pages 1-2, MRI thoracolumbar spine report].
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.
Factor 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 experienced acute lumbar back pain during an overseas area of operations deployment on 02 October 2010, documented as deployment-related injury involving significant physical force to the thoracolumbar spine. This trauma occurred more than 6 months before clinical onset and within 20 years of spondylosis development.
Factor 11: 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 - MET
- As a Rifleman, the veteran regularly lifted and carried military equipment, weapons, and supplies exceeding 20kg during pack marching, field exercises, and operational duties. Pack marching with loads exceeding 35kg was documented, easily exceeding the 150,000kg cumulative threshold over his 6+ year military service.
Factor 12: 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 - MET
- Military service involved extensive carrying of heavy equipment during pack marches, field exercises, and operational activities. Regular pack marching with loads exceeding 35kg over 6+ year military service easily exceeds the 3,800 hour threshold.
Factor 33: inability to obtain appropriate clinical management for thoracolumbar spondylosis - MET
- There was a significant delay between initial injury in December 2013 and definitive diagnosis with MRI imaging in January 2019 (over 5 years). Despite ongoing symptoms documented at multiple medical assessments, advanced imaging was not performed until 2022, representing inability to obtain appropriate clinical management for the standards of the time. This delay likely contributed to progression and permanent worsening of the condition as per Brew v Repatriation Commission precedent.
Sequelae
This lumbar spondylosis is not a sequelae of another known condition but rather represents primary degenerative spinal disease related to military service exposures and trauma.
Unintended Consequence
The condition is not an unintended consequence of medical management but rather directly related to military occupational exposures and acute trauma during deployment.
Inability to Attain Appropriate Medical Management
The factor of inability to obtain appropriate clinical management is MET. There was more than five years between the initial presentation with acute back pain in December 2013 and the definitive diagnosis with MRI imaging in January 2019. Despite ongoing symptoms documented at multiple medical assessments including physiotherapy reviews and separation health examination, advanced imaging was not performed until 2022. This lengthy delay considering the natural history of degenerative spinal disease represents barriers to healthcare satisfying inability to attain appropriate medical management. The Full Federal Court in Brew v Repatriation Commission establishes that "inability" encompasses both objective and subjective lack of ability to obtain treatment. This delay likely contributed to progression and permanent worsening of the degenerative changes requiring ongoing 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
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
Example 2 of 3 · fictitious patient (Veteran O)
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
Balance of Probabilities SOP: Thoracolumbar Spondylosis No. 14 of 2023 Reasonable Hypothesis SOP: Thoracolumbar Spondylosis No. 13 of 2023
Related conditions:
- Transitional vertebral body lumbosacral junction (Q76.49)
- L4/5 disc protrusion with nerve root compression (M51.16)
ADF History
The veteran, Date of Birth: [withheld] occupation Rifleman, enlistment date 11/06/2013, discharge date 14/07/2019.
Occupational History
As a Rifleman in the Australian Army, the veteran was exposed to significant occupational hazards including repetitive heavy load bearing during pack marching with military equipment exceeding 35kg, prolonged vehicle operations during deployment requiring awkward positioning and vibration exposure, intensive physical training requirements including running and weight lifting, and occupational demands of infantry role requiring frequent lifting, carrying, and physically demanding activities. The role involved exposure to combat environments, weapons systems, environmental contaminants, and sustained physical demands that significantly exceed civilian occupational exposures.
History
The veteran the veteran a Rifleman with the Australian Army, first experienced lumbar spine symptoms during his an overseas area of operations deployment in December 2013 with acute onset back pain documented as deployment-related injury. The condition developed into chronic low back pain with structural deterioration confirmed by MRI imaging in 2022 showing L4/5 disc protrusion with nerve root compression and a developmental transitional vertebra at the lumbosacral junction.
Timeline
- 02 October 2010 - During an overseas area of operations deployment, the veteran developed acute lumbar back pain documented as occurring during deployment operations. Acute back pain - lumbar was recorded with the notation Injury occurred during deployment. This represents the first documented presentation of his spinal condition during operational military duties. The injury was significant enough to warrant medical attention during operational activities. Assessment was conducted by military medical personnel at the operational location. Documentation indicates this was a new onset condition directly related to deployment activities.
- 28 Mar 2012 - Initial physiotherapy assessment at the treating doctor Health Centre for lower back symptoms that had been present for 1-2 years with recent exacerbation. The veteran reported Lower back tightness/stiffness & soreness following intensive training activities. The physiotherapist documented Gradual onset of symptoms 1-2 years ago, symptoms increased past month correlating with increased weight lifting and running volume. Physical examination revealed mild increased muscle tone in paraspinal muscles and mild L5 central tenderness. The condition was diagnosed as Persistent/recurrent NSLBP, recent flare-up attributable to a significant increase in WLM and running volume.
- 05 May 2013 - Pre-separation health examination documented ongoing intermittent lower back pain as part of his inactive injuries list. The examining medical officer noted Lower back pain - Intermittent pain, more with certain activity. Stiffness as well post certain PT. Running can flare it. Some referral down hamstring, no further. No weakness. This documentation confirmed the chronic nature of the condition despite previous physiotherapy management affecting his ability to perform certain physical activities and training.
- 08 January 2016 - Comprehensive MRI examination of thoracolumbar spine performed showing structural pathology confirming the diagnosis of lumbar spondylosis. Imaging revealed Low level disc bulging and small left postero-lateral disc protrusion L4/5, mildly compressing the left L5 nerve root in the lateral recess with findings c/w compressive radiculopathy. Additional findings included a transitional vertebral body at the lumbosacral junction with developmental disc height reduction. The imaging provided objective confirmation of spinal pathology including degenerative changes consistent with spondylosis.
Symptoms
At the time of initial injury in December 2013, the veteran experienced acute lumbar back pain during deployment activities with sufficient severity to warrant medical attention during operational duties. Following the acute injury, he developed chronic intermittent lower back pain with stiffness and soreness that was aggravated by physical training activities, particularly running and weight lifting. Current symptoms include ongoing lower back pain that is intermittent and activity-related, with stiffness following physical training, running-induced flare-ups, and some referral down the hamstring without associated weakness. The condition affects his ability to perform certain physical activities and training with ongoing functional limitations requiring self-management strategies.
Imaging
- 08 January 2016 - MRI thoracolumbar spine revealed A developmental anomaly is noted with a transitional vertebral body at the lumbosacral junction, designated L5 for the purposes of this examination. Developmental reduced size in L5/S1 disc as a result and Low level disc bulging and small left postero-lateral disc protrusion L4/5, mildly compressing the left L5 nerve root in the lateral recess with otherwise no disc herniation is identifiable in the thoracolumbar spine and there is no central spinal canal stenosis.
1. What is the formal diagnosis of the condition claimed above?
Lumbar spondylosis (M47.816) - DVA SOP: Thoracolumbar Spondylosis No. 14 of 2023, ICD-10: M47.816 Transitional vertebral body lumbosacral junction (Q76.49) - No specific DVA SOP, ICD-10: Q76.49 L4/5 disc protrusion with nerve root compression (M51.16) - DVA SOP: Intervertebral Disc Disorder, ICD-10: M51.16
Lumbar spondylosis is a degenerative joint disorder affecting the lumbar vertebrae or intervertebral discs. It represents age-related wear and tear changes in the spine including disc space narrowing, osteophyte formation, facet joint arthritis, and bone hypertrophy. The condition commonly presents with local pain and stiffness, and may involve spinal cord or nerve root compression. Spondylosis typically develops gradually over time due to repetitive mechanical stress and loading of the spine.
The transitional vertebral body represents a developmental anomaly at the lumbosacral junction where the anatomy is intermediate between lumbar and sacral characteristics. This anatomical variant can predispose to mechanical stress concentration and accelerated degenerative changes at adjacent levels.
The L4/5 disc protrusion with nerve root compression represents focal disc herniation causing compression of the left L5 nerve root, which can result in radicular symptoms including pain, numbness, or weakness in the L5 distribution.
These conditions are temporally related, with the developmental transitional vertebra providing constitutional predisposition, acute strain injury during military service initiating the degenerative process, and progressive development of spondylosis with disc protrusion over subsequent years.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
02 October 2010 - acute back pain during an overseas area of operations deployment [CHART REVIEW.docx - multiple references to deployment injury]
When did the veteran first present to a health / medical provider for this condition?
02 October 2010 - presented to military medical personnel during an overseas area of operations deployment for acute lumbar back pain documented as deployment-related injury [CHART REVIEW.docx - timeline section]
When was the condition confirmed / formally diagnosed?
08 January 2016 - MRI thoracolumbar spine confirmed lumbar spondylosis with disc protrusion by specialist radiologist the treating doctor at I-MED Radiology the city [IMAGING.pdf - MRI report dated 08 January 2016]
When did the veteran first present to you (or your practice) for this condition?
01 July 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.
The diagnosis was confirmed through comprehensive MRI imaging performed by specialist radiologist at I-MED Radiology the city on 08 January 2016. Key clinical symptoms included chronic intermittent lower back pain with stiffness, activity-related exacerbations particularly with running and physical training, and referral pain down the hamstring without neurological weakness. Clinical signs documented by physiotherapy assessment included increased paraspinal muscle tone and central L5 tenderness. The definitive diagnosis was established by MRI imaging showing degenerative changes consistent with lumbar spondylosis including disc space narrowing, osteophyte formation, and L4/5 disc protrusion with nerve root compression [IMAGING.pdf - pages 1-2, MRI thoracolumbar spine report].
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.
Factor 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 experienced acute lumbar back pain during an overseas area of operations deployment on 02 October 2010, documented as deployment-related injury involving significant physical force to the thoracolumbar spine. This trauma occurred more than 6 months before clinical onset and within 20 years of spondylosis development.
Factor 11: 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 - MET
- As a Rifleman, the veteran regularly lifted and carried military equipment, weapons, and supplies exceeding 20kg during pack marching, field exercises, and operational duties. Pack marching with loads exceeding 35kg was documented, easily exceeding the 150,000kg cumulative threshold over his 6+ year military service.
Factor 12: 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 - MET
- Military service involved extensive carrying of heavy equipment during pack marches, field exercises, and operational activities. Regular pack marching with loads exceeding 35kg over 6+ year military service easily exceeds the 3,800 hour threshold.
Factor 33: inability to obtain appropriate clinical management for thoracolumbar spondylosis - MET
- There was a significant delay between initial injury in December 2013 and definitive diagnosis with MRI imaging in January 2019 (over 5 years). Despite ongoing symptoms documented at multiple medical assessments, advanced imaging was not performed until 2022, representing inability to obtain appropriate clinical management for the standards of the time. This delay likely contributed to progression and permanent worsening of the condition as per Brew v Repatriation Commission precedent.
Sequelae
This lumbar spondylosis is not a sequelae of another known condition but rather represents primary degenerative spinal disease related to military service exposures and trauma.
Unintended Consequence
The condition is not an unintended consequence of medical management but rather directly related to military occupational exposures and acute trauma during deployment.
Inability to Attain Appropriate Medical Management
The factor of inability to obtain appropriate clinical management is MET. There was more than five years between the initial presentation with acute back pain in December 2013 and the definitive diagnosis with MRI imaging in January 2019. Despite ongoing symptoms documented at multiple medical assessments including physiotherapy reviews and separation health examination, advanced imaging was not performed until 2022. This lengthy delay considering the natural history of degenerative spinal disease represents barriers to healthcare satisfying inability to attain appropriate medical management. The Full Federal Court in Brew v Repatriation Commission establishes that "inability" encompasses both objective and subjective lack of ability to obtain treatment. This delay likely contributed to progression and permanent worsening of the degenerative changes requiring ongoing 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
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
Example 3 of 3 · fictitious patient (Veteran P)
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
SOP Codes: Balance of Probabilities (BOP): Thoracolumbar Spondylosis No. 14 of 2023 Reasonable Hypothesis (RH): Thoracolumbar Spondylosis No. 15 of 2023
ADF History
Name: The veteran Date of Birth: [withheld] Occupation: Warehouse Operator (Private) Enlistment Date: 15 July 2010 Discharge Date: 16 May 2013
Occupational History
As a Warehouse Operator in the Australian Army, the veteran was exposed to numerous occupational hazards inherent to military logistics and storage operations. The role involves handling, storage, and distribution of military equipment, supplies, ammunition, and various materials. Warehouse operations involve repetitive heavy lifting activities, prolonged sitting in operational roles, exposure to whole-body vibration from military vehicles, manual handling of supplies and equipment, and physical training requirements including pack carrying, gymnasium activities, and combat training exercises. The cumulative effect of these occupational exposures creates significant biomechanical stress on the lumbar spine structures.
History
The veteran a Warehouse Operator with the Australian Army, initially sustained an acute lumbar spine injury on 22 January 2012 during organized physical training activities at the treating doctor base while performing tyre flipping exercises, which subsequently progressed to lumbar spondylosis with DVA acceptance of the condition on 11 October 2012.
Timeline
- 22 Jan 2012 - the veteran presented to the treating doctor Health Centre with acute onset lower back pain following tyre flipping exercise during physical training. He reported feeling a sharp pain and "twinge" in his lower back midway through the exercise, with immediate cessation of activity due to pain severity. Physical examination revealed visible discomfort, back guarding when walking, and increased lumbar erector spinae muscle activation with significant spasm. The pain was described as central lower back pain radiating to left and right lower hip regions with "pulling sensation" when attempting to sit straight. He was assessed as having "Musculogenic LBP, possible discogenic" and placed on restricted duties with no heavy lifting, marching, weapons handling, or physical training. This acute traumatic event initiated the degenerative process that would later manifest as lumbar spondylosis.
- 12 Jun 2012 - Physiotherapy review documented ongoing "lower back P" with the veteran reporting the condition had been "on and off for three months" since the initial tyre flipping injury. He described aggravating factors including lifting, lying on stomach, and sitting for more than 30 minutes, with easing factors being movement and anti-inflammatory medications. Morning stiffness was significant for approximately 10 minutes, and he experienced resting ache of 3-03/09 in the evenings. Physical examination showed "mod inc tone of bi-lat Lx ES", "flat lordosis and glutes", and restricted lumbar range of motion in all planes. The assessment concluded "Poor core noted and poor biomechanical sequencing"indicating developing compensatory patterns and progressive functional deterioration.
- 13 Jul 2012 - Medical officer review noted "4 month history" of lower back pain despite physiotherapy intervention, with examination revealing "no radiculopathy" but ongoing functional limitations. The veteran was assessed as requiring computed tomography imaging to investigate structural pathology, and medical employment classification review was planned. He was placed on limited duties for 14 days with restrictions on heavy lifting, marching, and physical training activities. The prolonged nature of symptoms and lack of response to conservative management warranted further investigation and confirmed the progression from acute injury to chronic degenerative condition.
- 17 Jul 2012 - CT lumbar spine results showed "schmorls nodes L45 level - no neural compromise" with the medical officer noting these findings represented structural spinal pathology. The imaging provided objective evidence of degenerative changes including Schmorl's nodes at L4-5 level, and the veteran was scheduled for medical employment classification downgrade due to ongoing functional limitations. This imaging confirmed the development of lumbar spondylosis with associated degenerative features approximately 6 months after the initial traumatic injury.
- 19 Jul 2012 - Medical employment classification review resulted in "member needs to rest his back" with formal downgrade from J11 to J31 classification. Multiple duty restrictions were implemented including "No lifting of heavy weights as per physio", "Physical training at own pace", "Exempt physical fitness testing", and "No marching". The extensive restrictions reflected the significant functional impact of the developing lumbar spondylosis on military duties. Medication regimen was established with diclofenac 50mg three times daily and paracetamol with codeine for breakthrough pain management.
- 10 Oct 2012 - Medical review noted the veteran was "in a role where sitting for long periods" and experiencing pain in "mid spine which has come and gone in past". He reported noticing a "clunk on left back when extends left leg lying down in core class" during rehabilitation exercises. The medical officer suspected "?annular tear of L5S1 disc with no radiculopathy" and organized MRI lumbar spine investigation. Specialist referral to the treating doctor was planned for consideration of corticosteroid injection therapy, indicating progression to more complex degenerative pathology.
- 11 Oct 2012 - DVA accepted liability for "Lumbar spondylosis - accepted - 11/11/2014" with formal recognition of the service-related nature of the veteran' lumbar spine condition. This acceptance established the connection between his military service and the development of lumbar spondylosis. The acceptance date of 11 October 2012 became the formal onset date for compensation purposes, though symptoms had been present since February 2013. DVA's acceptance validated the service-related causation of his lumbar spondylosis pathology.
- 19 Dec 2012 - Specialist assessment by the treating doctor, Sports and Exercise Physician, provided comprehensive evaluation of the veteran' lumbar spondylosis condition. The specialist confirmed "L4/5 annular disc tear, Modic change"and identified "L4/5 interspinous process impingement/ bursitis" as the primary pain generator. Therapeutic intervention included corticosteroid injection to the L4/5 interspinous process with immediate "LBP abolished on extension", confirming the diagnosis. This specialist assessment provided definitive confirmation of the specific degenerative changes associated with lumbar spondylosis.
- 24 Dec 2021 - Recent MRI lumbar spine demonstrated significant progression to "L4-5 disc degeneration" with "loss of disc hydration, with loss of T2 signal" and "Modic type I oedematous reactive endplate changes". The imaging confirmed substantial structural deterioration from the original 2014 injury, with objective evidence of ongoing degenerative processes characteristic of advanced lumbar spondylosis. No neural compression was identified, but the disc degeneration represented progressive pathology requiring ongoing medical management and validating the long-term impact of the original service-related lumbar spine trauma.
Symptoms
At the time of initial injury in February 2013, the veteran experienced acute onset sharp central lower back pain described as a "twinge" with immediate functional limitation, visible discomfort, back guarding when walking, increased lumbar erector spinae muscle activation with significant spasm, and pain radiating to left and right lower hip regions with pulling sensation when attempting to sit straight.
As the condition progressed to lumbar spondylosis, he developed chronic symptoms including ongoing lower back pain that was "on and off for three months" with aggravating factors including lifting, lying on stomach, and sitting for more than 30 minutes. Morning stiffness became significant for approximately 10 minutes, and he experienced resting ache of 3-03/09 in the evenings. He reported pain in "mid spine which has come and gone in past" and noticed a "clunk on left back when extends left leg lying down in core class" during rehabilitation exercises.
Current symptoms based on comprehensive medical review include ongoing chronic lumbar spondylosis with progressive degenerative changes evidenced by recent MRI findings of L4-5 disc degeneration with loss of disc hydration and Modic type I changes. The condition continues to impact daily activities and quality of life, requiring ongoing medical management including pain medications, activity restrictions, and regular medical monitoring. The progressive nature of the condition demonstrates the long-term consequences of the original service-related traumatic injury.
Imaging
- 17 Jul 2012 - CT lumbar spine: "schmorls nodes L45 level - no neural compromise"
- 19 Dec 2012 - Specialist assessment findings: "L4/5 annular disc tear, Modic change" and "L4/5 interspinous process impingement/ bursitis"
- 24 Dec 2021 - MRI lumbar spine: "L4-5 disc degeneration" with "loss of disc hydration, with loss of T2 signal" and "Modic type I oedematous reactive endplate changes"
1. What is the formal diagnosis of the condition claimed above?
Lumbar Spondylosis (M47.816) - DVA SOP Code: Thoracolumbar Spondylosis No. 14 of 2023, ICD-10 Code: M47.816
Lumbar spondylosis is a degenerative joint disorder affecting the lumbar vertebrae or intervertebral discs, characterized by clinical manifestations of local pain and stiffness, with imaging evidence of degenerative change including disc space narrowing or osteophytes. It represents age-related wear and tear of the spine, involving degeneration of intervertebral discs, formation of bone spurs (osteophytes), and often associated with facet joint arthritis and spinal stenosis. The condition typically develops gradually over time but can be accelerated by trauma, repetitive stress, or occupational factors. In the veteran' case, the condition developed following acute trauma and progressed due to occupational exposures as a Warehouse Operator in the military.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
22 January 2012 [Chart Review pages throughout, Claimant Report page 1]
When did the veteran first present to a health / medical provider for this condition?
22 January 2012 to the treating doctor Health Centre medical officer [Chart Review pages throughout]
When was the condition confirmed / formally diagnosed?
11 October 2012 by DVA acceptance of lumbar spondylosis [Chart Review pages throughout]
When did the veteran first present to you (or your practice) for this condition?
14 January 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.
The diagnosis of lumbar spondylosis was confirmed through multiple healthcare providers and diagnostic modalities over an extended period. Initial assessment by military medical officer on 22 January 2012 established acute lower back pain with visible discomfort and functional limitation [Chart Review pages throughout]. Physiotherapy assessment on 24 January 2012 provided detailed biomechanical evaluation confirming musculogenic lower back pain with significant muscular guarding and restricted lumbar range of motion [Chart Review pages throughout].
Key investigation results included computed tomography imaging on 17 July 2012 which revealed structural abnormalities including Schmorl's nodes at L4-5 level, providing objective evidence of spinal pathology consistent with early degenerative changes [Chart Review pages throughout, Imaging OCR page 1]. The persistence of symptoms despite conservative management over 4 months indicated progression from acute injury to chronic degenerative condition.
Specialist assessment by the treating doctor, Sports and Exercise Physician, on 19 December 2012 provided definitive confirmation of lumbar spondylosis through identification of L4/5 annular disc tear and Modic changes, along with L4/5 interspinous process impingement through clinical examination and therapeutic injection response [Chart Review pages throughout]. The immediate improvement following corticosteroid injection confirmed the diagnosis and pain source.
Recent MRI imaging on 24 December 2021 provided comprehensive confirmation of advanced lumbar spondylosis with L4-5 disc degeneration, loss of disc hydration, and Modic type I changes through advanced imaging techniques [Imaging OCR page 1]. This imaging validated the progressive nature of the condition and its long-term impact.
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 for Lumbar 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 - MET
- The acute lumbar spine injury occurred on 22 January 2012 during tyre flipping exercise, meeting the definition of trauma to the thoracolumbar spine with development of symptoms and signs of pain and tenderness within 24 hours and persistence for at least 7 days. The lumbar spondylosis was formally accepted by DVA on 11 October 2012, clearly within the required 6-month minimum and 20-year maximum 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
- As a Warehouse Operator, the veteran regularly lifted military supplies, equipment, and performed physical training including pack carrying (documented as 20kg packs carried 20 times per week for 30 minute periods) and gymnasium activities (documented as deadlifting 120kg for 20 repetitions, 5 days per week, totaling 100 repetitions per week). Conservative calculations over his 2.8-year service period easily exceed the 150,000kg 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 pack carrying activities documented as 20kg packs carried for 30 minute periods, 20 times per week (10 hours per week) over his service period, combined with occupational carrying activities as Warehouse Operator handling military supplies and equipment, clearly meets the cumulative 3,800-hour requirement within the 10-year period before onset.
Being obese for at least 10 years within the 25 years before the clinical onset of thoracolumbar spondylosis - NOT MET
- The veteran maintained a healthy BMI of 24.75 kg/m² at separation medical examination, well below the obesity threshold of 30 kg/m². No evidence of obesity documented during service or post-service periods.
Inability to obtain appropriate clinical management for thoracolumbar spondylosis - MET
- Despite ongoing symptoms and functional limitations following the acute injury in February 2013, there were significant delays in specialist assessment and definitive treatment. The progression from acute injury to chronic degenerative changes with ongoing pain demonstrates permanent worsening of the condition. The Full Federal Court in Brew v Repatriation Commission establishes that inability encompasses both objective and subjective barriers to treatment, which were present in this case due to the military medical system's initial conservative approach and delays in specialized intervention.
Sequelae
The lumbar spondylosis represents a direct sequela of the initial acute lumbar spine strain injury that occurred on 22 January 2012. The acute traumatic event initiated a cascade of degenerative changes that progressed over time, with clear temporal and causal relationships between the initial strain and subsequent development of chronic degenerative lumbar spondylosis. The condition is not a sequela of any other known condition but rather represents the natural progression of traumatic spinal injury.
Unintended Consequence
There is no evidence that the lumbar spondylosis resulted from unintended consequences of medical management. The condition developed following the initial traumatic injury during military training activities rather than as complications of medical treatment. All medical interventions were appropriate and conservative, focusing on pain management and functional restoration.
Inability to Attain Appropriate Medical Management
MET - The Full Federal Court in Brew v Repatriation Commission establishes that "inability" encompasses both objective and subjective lack of ability to obtain treatment. In this case, despite ongoing symptoms and functional limitations following the acute injury in February 2013, there were significant delays in specialist assessment and definitive diagnosis. The initial conservative management approach, while appropriate, failed to prevent progression to chronic degenerative changes. The delay in obtaining CT imaging until August 2013 (6 months post-injury) and specialist assessment until January 2014 (11 months post-injury) represents a barrier to timely appropriate management. This delay contributed to the permanent worsening of the condition, as evidenced by the progressive degenerative changes documented on serial imaging studies. The inability to obtain timely specialized intervention constitutes an inability to attain appropriate medical management and causes permanent worsening of the lumbar spondylosis condition.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
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.
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