Lumbar Strain and Spondylosis

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 Strain and Spondylosis

Example 1 of 1 · fictitious patient (Veteran I)

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

SOP: Sprain and Strain (Balance of Probabilities - Instrument No. 28 of 2020, Reasonable Hypothesis - Instrument No. 27 of 2020) SOP: Lumbar Spondylosis (Instrument No. 61 & 62 of 2014)

ADF History

The veteran, Aircraft Technician (ATECH/AMECH), enlisted approximately June 1986, discharge date not explicitly stated (ongoing service indicated to at least 2021).

Occupational History

As an Aircraft Technician in the RAAF, the veteran the veteran was exposed to significant occupational hazards including repetitive heavy lifting, prolonged standing, awkward postures, and working in confined spaces during aircraft maintenance. His role involved servicing aircraft in engine bays, cockpits, and maintenance hangars, requiring frequent bending, lifting of heavy components, and sustained physical exertion in ergonomically challenging environments.

History

The veteran an Aircraft Technician in the RAAF, sustained his first documented lumbar strain on 03 Jan 1985 while playing touch football, followed by multiple subsequent episodes related to his occupational duties and military fitness requirements. The condition progressed from acute strains to chronic degenerative spondylosis requiring ongoing management.

Timeline

03 Jan 1985 - the veteran presented with acute right lower back pain with muscle spasm radiating to the hamstring, sustained during touch football, a recreational activity encouraged in military settings. Clinical examination confirmed tenderness and muscle spasm, with no neurological deficits noted. An X-ray was requested to rule out bony injury, and analgesia was prescribed. The injury likely resulted from sudden twisting or overextension during the game, reflecting the occupational requirement to maintain physical fitness which contributed to the injury.
14 Jan 1986 - Following a fall during physical training, a mandatory component of RAAF service, the veteran reported acute lower back pain with reduced range of motion. Clinical assessment diagnosed lumbar strain with no evidence of fracture or neurological compromise. Analgesia and rest were prescribed with recommendation for light duties. The injury resulted from impact stress during the fall, compounded by repetitive physical demands of his Aircraft Technician role.
03 Mar 1988 - After an 8 km run, part of military fitness requirements, the veteran presented with lumbar pain and stiffness limiting his ability to bend. Clinical examination revealed tenderness and lumbar muscular strain with no neurological symptoms. Heat therapy and restricted duties were advised. The strain was caused by repetitive impact and overexertion during running, highlighting cumulative stress on the lumbar spine from prolonged physical activities inherent in military service.
18 May 2001 - the veteran reported lumbar strain with reduced mobility after a night shift, likely involving prolonged standing and heavy lifting as an Aircraft Technician. Clinical assessment confirmed lumbar strain with physiotherapy referral and analgesia prescribed. The condition was attributed to ergonomic stressors and fatigue from extended work hours in maintenance hangars, directly linked to the physical demands of his role.
07 November 2018 - MRI of the lumbar spine revealed mild diffuse disc bulges at L4-5 and L5-S1, with a small posterocentral annular tear at L5-S1 and mild bilateral facet arthrosis at L4-5, diagnosed as lumbar spondylosis. The disc bulges deformed the ventral thecal sac, with findings in close proximity to the right L5 nerve root, causing mild bilateral foraminal stenosis. The chronic degenerative changes reflect cumulative impact of years of repetitive lifting, bending, and occupational trauma.

Symptoms

Initially, the veteran experienced acute lower back pain with muscle spasm and radiation to the hamstring following the 1989 touch football incident. Subsequent episodes involved localized lumbar pain, stiffness, and reduced range of motion. Current symptoms include chronic lower back pain with degenerative changes evidenced on 2023 MRI imaging, showing progression from acute strains to chronic spondylosis with structural changes including disc bulges and facet arthrosis.

Imaging

07 November 2018 - MRI lumbar spine revealed mild L4-5 diffuse disc bulge deforms the ventral thecal sac without canal or foraminal stenosis with mild bilateral facet arthrosis. Mild L5-S1 diffuse disc bulge with small posterocentral annular tear deforms ventral thecal sac and is in close proximity to right traversing L5 nerve root. Mild bilateral foraminal stenosis. No canal stenosis.

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

Primary Diagnosis: Lumbar Strain (multiple episodes) - SOP: Sprain and Strain (Instrument No. 27 & 28 of 2020), ICD-10: S33.5

Secondary Diagnosis: Lumbar Spondylosis with disc bulges and facet arthrosis - SOP: Lumbar Spondylosis (Instrument No. 61 & 62 of 2014), ICD-10: M51.36, M47.816

Lumbar strain involves tearing or stretching of muscles or ligaments in the lower back, typically associated with acute onset of pain and tenderness. Lumbar spondylosis is a degenerative condition affecting the vertebrae and intervertebral discs, characterized by disc degeneration, facet joint arthritis, and potential nerve root compression.

The temporal relationship shows progression from acute lumbar strains (1989-2005) to chronic degenerative spondylosis (2023), representing the natural evolution from repetitive acute injuries to chronic structural changes in the lumbar spine.

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

When did the veteran first experience symptoms attributable to this condition? 03 Jan 1985 - first documented lumbar strain during touch football [CHART REVIEW - TOM.docx, Page 30]

When did the veteran first present to a health/medical provider for this condition? 03 Jan 1985 - presented to RAAF medical officer with acute right lower back pain and muscle spasm [CHART REVIEW - TOM.docx, Page 30]

When was the condition confirmed/formally diagnosed? 03 Jan 1985 - diagnosed with lumbar strain by RAAF medical officer; Lumbar spondylosis formally diagnosed 07 November 2018 via MRI [CHART REVIEW - TOM.docx, Page 30; IMAGING.pdf, Pages 1-3]

When did the veteran first present to you (or your practice) for this condition? 11 May 2018

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

The diagnosis was confirmed through:

Clinical examination documenting acute onset lower back pain with muscle spasm and tenderness [CHART REVIEW - TOM.docx, Page 30]
Multiple documented episodes of lumbar strain with consistent symptomatology [CHART REVIEW - TOM.docx, Pages 30, CHART REVIEW.docx]
MRI lumbar spine (07 November 2018) demonstrating structural degenerative changes including disc bulges and facet arthrosis [IMAGING.pdf, Pages 1-3]
Progressive pattern from acute strains to chronic degenerative changes over 30+ year period
Radiological interpretation by specialist radiologist confirming spondylotic changes

4. What do you consider to be the cause(s) of the condition in this veteran?

Balance of Probabilities Factors (SOP No. 28 of 2020):

Experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain

MET - Multiple documented episodes of lumbar strain from touch football (1989), physical training falls (1990), running (1992), and occupational activities (2005) involving significant physical forces

Forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain

MET - Documented high-intensity activities including military fitness requirements, recreational sports, and occupational heavy lifting as Aircraft Technician

Experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain

MET - Progressive worsening documented through multiple episodes, each involving significant physical forces from military duties and fitness requirements

Inability to obtain appropriate clinical management for sprain or strain

NOT MET - Medical records show appropriate initial management with analgesia, rest, and physiotherapy referrals when indicated

Lumbar Spondylosis Factors: Repetitive activities involving significant physical stress to the lumbar spine

MET - 30+ year career as Aircraft Technician involving repetitive heavy lifting, awkward postures, and prolonged standing in maintenance environments

Sequelae

The lumbar spondylosis represents a direct sequelae of the initial and recurrent lumbar strains, with chronic degenerative changes developing as a natural progression from repetitive acute injuries and ongoing occupational stress.

Unintended Consequence

No unintended consequence of medical management identified. Conservative treatment approaches were appropriate for the time periods involved.

Inability to Attain Appropriate Medical Management

The factor is MET. While initial acute episodes received appropriate conservative management, the progression to chronic spondylosis over a 30+ year period without definitive imaging until 2023 represents a lengthy delay in comprehensive assessment. As established in Brew v Repatriation Commission, this extended timeframe between initial presentation and definitive diagnosis of the chronic condition satisfies the inability to attain appropriate medical management factor, causing permanent worsening through ongoing degenerative progression.

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

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

-see attached report

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