Diagnostic Assessment — Thoracic Spine - Intervertebral Disc Prolapse
Example 1 of 1 · fictitious patient (Veteran AP)
Diagnostic Assessment
Thoracic Spine - Intervertebral Disc Prolapse
BOP Code: 69 of 2023 (Thoracolumbar Intervertebral Disc Prolapse)
RH Code: 68 of 2023 (Thoracolumbar Intervertebral Disc Prolapse)
ADF History
Veteran AP, date of birth 11 November 1978, Australian Army, Driver (Royal Australian Corps of Transport) from 1997 and Army Aviation Pilot (Captain) from 2007, enlisted 03 February 1997, medically discharged 28 November 2014. Operational service: East Timor, 20 September 1999 to 15 February 2000 (warlike); Iraq, 10 January 2005 to 30 June 2005 (warlike); Afghanistan, 01 March 2008 to 30 September 2008, 01 June 2010 to 15 December 2010, 10 January 2012 to 19 March 2012 (aeromedically evacuated) and 15 April 2013 to 20 June 2013 (all warlike).
Occupational History
As an Army driver the veteran drove heavy trucks and protected vehicles for long periods on convoys, exercises and deployments, exposed to whole-body vibration and jarring on unsealed roads, and manually loaded and unloaded stores, fuel and water. Drivers on operations are exposed to improvised explosive devices, indirect fire and vehicle accidents.
As a heavy-lift helicopter pilot he flew long sorties seated in a flexed posture with sustained whole-body vibration, wearing a helmet, body armour and survival equipment weighing about 18 kilograms. Operational flying involves hard and brownout landings, enemy fire and indirect fire attacks on airfields, with a risk of blast and fragment injury.
History
Veteran AP, an Army driver who later became a heavy-lift helicopter pilot, sustained blunt and fragment injuries to the thoracic spine in a rocket attack in Afghanistan on 18 March 2012 and developed a T8–T9 intervertebral disc prolapse with bacterial discitis. The prolapse worsened after a hard landing and a needle biopsy on a later Afghanistan deployment in June 2013.
Timeline
- 15 Mar 2001 — At a periodic health examination the veteran, then an Army driver, weighed 101 kg at a height of 1.80 m, BMI 31.2. He smoked 20 cigarettes a day, having started at age 16 in 1995. His BMI remained between 30 and 32 at each examination until December 2006, when he lost weight for pilot training. He stopped smoking on 30 June 2009. "BMI 31.2, smoker 20/day"
- 30 Jun 2005 — A transport unit summary recorded that from July 2003 to June 2005, including warlike service in Iraq, the veteran drove heavy trucks and protected vehicles for an average of 34 hours a week. He then commenced officer and pilot training and qualified as a heavy-lift helicopter pilot in December 2006. "driving average 34 hours weekly"
- 10 Dec 2011 — At his pre-deployment medical examination the veteran reported no back pain, and examination of the thoracic and lumbar spine was normal. His logbook recorded about 4,900 hours as pilot in command or co-pilot of heavy-lift helicopters since January 2007, including detachments to Afghanistan in 2008 and 2010. "spine normal, fit to deploy"
- 18 Mar 2012 — During warlike service in Afghanistan a rocket struck beside the veteran's accommodation at a coalition airfield. The blast threw him backwards into a concrete bunker wall, striking his mid-back, and a metal fragment entered the right side of his back. He had immediate severe mid-thoracic pain radiating around the chest wall in a band. CT at the role 3 hospital showed a fragment embedded in the T9 vertebral body adjacent to the T8–T9 disc. The fragment was removed and he was aeromedically evacuated. "rocket blast, fragment T9 body"
- 24 Mar 2012 — MRI showed a right paracentral T8–T9 disc prolapse indenting the thoracic cord without signal change, with end plate oedema. Cultures from the fragment track and a disc aspirate grew Staphylococcus aureus. A spinal surgeon and infectious diseases physician diagnosed a T8–T9 intervertebral disc prolapse with bacterial discitis introduced by the fragment, and he received eight weeks of intravenous antibiotics. "T8–9 prolapse, Staph discitis"
- 12 Nov 2012 — The veteran returned to flying with persisting intermittent band-like thoracic pain. A follow-up MRI planned for February 2013 to confirm resolution of the discitis was cancelled when he was assigned to the final helicopter detachment to Afghanistan. By then he had about 5,150 hours of helicopter pilot time since 2007. "follow-up MRI cancelled, deploying"
- 05 Jun 2013 — On warlike service in Afghanistan the veteran's helicopter made a heavy brownout landing, with a vertical impact that jarred his spine and caused immediate severe thoracic pain. He had had night pain for two weeks without access to imaging. At the role 3 hospital CRP was 86 mg/L and that evening a CT-guided needle biopsy of the T8–T9 disc was performed, which grew Staphylococcus aureus, confirming relapsed discitis. "heavy landing, disc biopsy, CRP 86"
- 06 Jun 2013 — The next morning he had numbness below the costal margin and unsteady gait, with brisk lower limb reflexes. MRI after aeromedical evacuation showed enlargement of the T8–T9 prolapse with cord compression and signal change. He underwent thoracic discectomy and debridement on 10 June 2013, and the surgeon recorded clinical worsening of the prolapse with myelopathy. "enlarged prolapse, cord compression"
Symptoms
At onset the veteran had severe constant mid-thoracic back pain with band-like pain radiating around the right chest wall at the level of the lower ribs, worse with coughing, twisting and sitting, and tenderness over T8 to T9. He could not sit in a cockpit seat for more than 20 minutes.
After onset the band pain persisted intermittently and was aggravated by flying. At the worsening in June 2013 he developed numbness below the costal margin, leg stiffness and unsteady gait. He now reports daily thoracic pain, chest wall dysaesthesia on the right, reduced walking tolerance and difficulty sitting or driving for more than 40 minutes.
Imaging
- 18 Mar 2012 — CT thoracic spine: "Metallic fragment embedded in the right posterolateral T9 vertebral body adjacent to the T8–T9 disc. No fracture displacement."
- 24 Mar 2012 — MRI thoracic spine: "Right paracentral T8–T9 disc prolapse indenting the cord without signal change. T8 and T9 end plate oedema with disc space fluid, consistent with discitis."
- 06 Jun 2013 — MRI thoracic spine: "Enlarged T8–T9 disc prolapse with cord compression and intramedullary T2 signal change. Recurrent end plate oedema and paravertebral inflammation."
Onset Date
The most likely date of onset of this condition is 18 Mar 2012.
At that date the veteran was a serving Army aviation pilot on warlike service in Afghanistan. A rocket attack threw him into a bunker wall and drove a fragment into the T9 vertebral body, and from that moment he had constant mid-thoracic and band-like chest wall pain.
This date is appropriate because his pre-deployment medical examination on 10 December 2011 recorded no back pain and a normal spinal examination, and he presented to the role 3 hospital on 18 March 2012 with symptoms that persisted from that time. MRI on 24 March 2012 confirmed the T8–T9 prolapse. Under the Statement of Principles, clinical onset is the point back from that imaging to when the symptoms were persistently present, which is 18 March 2012. It falls within continuous full-time service.
For the 24-hour factors, the 24 hours before onset run from 17 Mar 2012 to 18 Mar 2012 and contain the blast trauma and the fragment penetration of the adjacent vertebral body. For the bacterial infection factor, Staphylococcus aureus introduced by the fragment was present in the disc on 18 Mar 2012. For the load factors, the 5 years before onset run from 18 Mar 2007 to 18 Mar 2012 and the 10 years from 18 Mar 2002 to 18 Mar 2012; in that time he wore about 18 kilograms of flight equipment for about 3,800 hours, a Load-Factor of about 1,230,000. For driving, the 10 years before onset contain July 2003 to June 2005, two years at an average of 34 hours a week. For flying, the same 10 years contain about 5,150 hours as helicopter pilot from January 2007. For smoking, he smoked 14 pack-years and stopped on 30 Jun 2009, so the 5 years after cessation run to 30 Jun 2014 and include the onset. For obesity, the 25 years before onset run from 18 Mar 1987 and contain six years with a BMI above 30, from 2001 to 2006.
For the worsening factors, the documented worsening was on 06 Jun 2013. The 24 hours before it run from 05 Jun 2013 to 06 Jun 2013 and contain the heavy landing and the CT-guided needle biopsy of the T8–T9 disc, and relapsed Staphylococcus aureus infection was present. The 5 years before it run from 06 Jun 2008 and the 10 years from 06 Jun 2003; both contain the equipment Load-Factor, the 10 years contain the 2003 to 2005 driving and all the helicopter hours, and the worsening fell within 5 years of stopping smoking.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Thoracic Spine - Intervertebral Disc Prolapse, being a right paracentral T8–T9 intervertebral disc prolapse (ICD-10-AM M51.24), under the Statements of Principles concerning thoracolumbar intervertebral disc prolapse, Balance of Probabilities No. 69 of 2023 and Reasonable Hypothesis No. 68 of 2023.
Thoracic intervertebral disc prolapse is the displacement of nucleus pulposus or annulus material beyond the margins of the disc space in the thoracic spine. Because the thoracic canal is narrow, a prolapse may compress the spinal cord as well as the nerve roots, producing band-like chest wall pain along the intercostal nerve, mid-back pain and, with cord compression, numbness, leg stiffness and gait disturbance. It is typically provoked by significant force applied to the spine, and a disc weakened by infection, penetrating injury, smoking or chronic vibration and loading is more prone to prolapse and to further displacement.
The diagnosis followed blast trauma and a fragment injury to the T9 vertebral body in Afghanistan, with bacterial discitis, on a background of years of driving, helicopter flying and load-bearing. It began on 18 March 2012, was confirmed on MRI on 24 March 2012 and worsened in June 2013.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
18 March 2012.
When did the veteran first present to a health / medical provider for this condition?
18 March 2012.
When was the condition confirmed / formally diagnosed?
24 March 2012.
When did the veteran first present to you (or your practice) for this condition?
21 May 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on MRI of 24 March 2012, which showed a right paracentral T8–T9 disc prolapse indenting the thoracic cord, with end plate oedema and disc space fluid from discitis. This is imaging evidence of thoracolumbar intervertebral disc prolapse, and with the clinical symptoms and signs it meets the Statement of Principles definition.
The clinical picture was consistent: sudden severe mid-thoracic pain with band-like right chest wall radiation at the T8 to T9 dermatomes after significant force to the spine, local tenderness and painful restriction of thoracic rotation. A spinal surgeon confirmed the diagnosis. The worsening was confirmed on 06 June 2013 by MRI showing enlargement of the prolapse with cord compression and signal change, by new myelopathic signs, and at surgery on 10 June 2013.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 18 March 2012, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service, including the veteran's driving and helicopter flying in Australia. The Reasonable Hypothesis instrument applies to his warlike service in Afghanistan, where the rocket attack of 18 March 2012 caused the prolapse and the heavy landing and biopsy of 05 June 2013 preceded the worsening, and to his warlike service in Iraq in 2005, where much of the driving took place.
Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Balance of Probabilities — Statement of Principles concerning Thoracolumbar Intervertebral Disc Prolapse, No. 69 of 2023
Causative factors
Factor 9(1): having trauma to the affected intervertebral disc within the 24 hours before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET
- On 18 March 2012 a rocket blast threw the veteran backwards into a concrete wall, applying significant force to the mid-thoracic spine. He had immediate pain and tenderness at T8 to T9, the symptoms persisted, and the prolapse was present from that day. The trauma and the onset occurred on the same day.
Factor 9(2): having a penetrating injury to the affected intervertebral disc or adjacent vertebral body, within the 24 hours before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET
- In the same attack on 18 March 2012 a metal fragment pierced the T9 vertebral body, adjacent to the affected T8–T9 disc, as shown on CT that day. This was within the 24 hours before onset.
Factor 9(3): physically carrying or lifting loads of at least 10 kilograms, to a cumulative total Load-Factor of at least 300,000 within the 5 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET
- From 18 March 2007 to 18 March 2012 the veteran carried about 18 kilograms of helmet, body armour and survival equipment for about 3,800 hours of flying and ground duties. The Load-Factor is 18 squared multiplied by 3,800, about 1,230,000.
Factor 9(4): driving a motor vehicle for an average of at least 30 hours per week, for a period of at least 2 years within the 10 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET
- From July 2003 to June 2005 the veteran drove heavy trucks and protected vehicles for an average of 34 hours a week, as recorded by his transport unit. This two-year period falls within the 10 years before onset, from 18 March 2002 to 18 March 2012.
Factor 9(5): piloting an engine powered aircraft for a cumulative total of at least 5,000 hours within the 10 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET
- His logbook records about 5,150 hours piloting heavy-lift helicopters, which are engine powered aircraft, from January 2007 to March 2012, within the 10 years before onset.
Factor 9(6): flying in a helicopter as operational aircrew, for a cumulative total of at least 5,000 hours within the 10 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET
- The same 5,150 hours were flown as operational aircrew in heavy-lift helicopters between January 2007 and March 2012, within the 10 years before onset.
Factor 9(7): having smoked tobacco products in an amount of at least 10 pack-years before the clinical onset of thoracolumbar intervertebral disc prolapse, and if smoking has ceased before the clinical onset of thoracolumbar intervertebral disc prolapse, then that onset occurred within 5 years of cessation; — MET
- The veteran smoked 20 cigarettes a day from 1995 until 30 June 2009, 14 pack-years, much of it in service. Onset on 18 March 2012 occurred less than three years after he stopped.
Factor 9(8): having bacterial infection of the affected disc at the time of the clinical onset of thoracolumbar intervertebral disc prolapse; — MET
- Cultures from the fragment track and a T8–T9 disc aspirate grew Staphylococcus aureus, and MRI on 24 March 2012 showed discitis. The infection was introduced into the disc by the fragment on 18 March 2012 and was present at onset.
Factor 9(9): being obese for at least 5 years within the 25 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET
- The veteran's BMI was 31.2 on 15 March 2001 and remained between 30 and 32 until December 2006, about six years, within the 25 years before onset.
Worsening factors
Factor 9(10): having trauma to the affected intervertebral disc within the 24 hours before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET
- On 05 June 2013 a heavy brownout landing applied a vertical impact to his spine, with immediate severe thoracic pain and tenderness. The worsening, with an enlarged prolapse and cord compression, was documented the next day, 06 June 2013.
Factor 9(11): having a penetrating injury to the affected intervertebral disc or adjacent vertebral body, within the 24 hours before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET
- On the evening of 05 June 2013 a biopsy needle was passed into the T8–T9 disc under CT guidance. This piercing of the affected disc by a needle occurred within the 24 hours before the worsening on 06 June 2013.
Factor 9(12): physically carrying or lifting loads of at least 10 kilograms, to a cumulative total Load-Factor of at least 300,000 within the 5 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET
- From 06 June 2008 to 06 June 2013 he wore about 18 kilograms of flight equipment for about 3,600 hours, a Load-Factor of about 1,170,000.
Factor 9(13): driving a motor vehicle for an average of at least 30 hours per week, for a period of at least 2 years within the 10 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET
- The driving from July 2003 to June 2005, averaging 34 hours a week, falls within the 10 years before the worsening, from 06 June 2003 to 06 June 2013.
Factor 9(14): piloting an engine powered aircraft for a cumulative total of at least 5,000 hours within the 10 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET
- He had piloted helicopters for about 5,400 hours from January 2007 to June 2013, within the 10 years before the worsening.
Factor 9(15): flying in a helicopter as operational aircrew, for a cumulative total of at least 5,000 hours within the 10 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET
- The same 5,400 hours were flown as operational helicopter aircrew within the 10 years before the worsening.
Factor 9(16): having smoked tobacco products in an amount of at least 10 pack-years before the clinical worsening of thoracolumbar intervertebral disc prolapse, and if smoking has ceased before the clinical worsening of thoracolumbar intervertebral disc prolapse, then that worsening occurred within 5 years of cessation; — MET
- He had smoked 14 pack-years, and the worsening on 06 June 2013 occurred less than four years after he stopped on 30 June 2009.
Factor 9(17): having bacterial infection of the affected disc at the time of the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET
- The biopsy of 05 June 2013 grew Staphylococcus aureus, with a CRP of 86 mg/L and recurrent end plate oedema on MRI, confirming relapsed bacterial discitis at the time of the worsening.
Factor 9(18): being obese for at least 5 years within the 25 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET
- The six years with a BMI above 30, from 2001 to 2006, fall within the 25 years before the worsening.
Factor 9(19): inability to obtain appropriate clinical management for thoracolumbar intervertebral disc prolapse before the clinical worsening of thoracolumbar intervertebral disc prolapse. — MET
- The follow-up MRI planned for February 2013 to confirm resolution of the discitis was cancelled when he deployed, and during two weeks of night pain before the worsening no imaging or specialist review was available at his location. The relapse went undetected until the prolapse enlarged with cord compression. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Thoracolumbar Intervertebral Disc Prolapse, No. 68 of 2023
Causative factors
Factor 9(1): having trauma to the affected intervertebral disc within the 24 hours before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET
- On warlike service in Afghanistan on 18 March 2012 a rocket blast threw the veteran into a concrete wall, striking his mid-thoracic spine, with immediate persisting pain at T8 to T9. Onset was the same day.
Factor 9(2): having a penetrating injury to the affected intervertebral disc or adjacent vertebral body, within the 24 hours before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET
- In the same rocket attack on warlike service on 18 March 2012 a fragment pierced the T9 vertebral body adjacent to the affected disc, within the 24 hours before onset.
Factor 9(3): physically carrying or lifting loads of at least 10 kilograms, to a cumulative total Load-Factor of at least 150,000 within the 10 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET
- Within the 10 years before onset the veteran wore about 18 kilograms of flight equipment for about 3,800 hours, including on warlike service in Afghanistan in 2008, 2010 and 2012, and lifted fuel and water jerry cans of about 20 kilograms on warlike service in Iraq in 2005. The Load-Factor from the flight equipment alone is about 1,230,000.
Factor 9(4): driving a motor vehicle for an average of at least 25 hours per week, for a period of at least 2 years within the 10 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET
- From July 2003 to June 2005 he drove heavy trucks and protected vehicles for an average of 34 hours a week, including convoy driving on warlike service in Iraq from January to June 2005, within the 10 years before onset.
Factor 9(5): flying in an engine powered aircraft as operational crew, for a cumulative total of at least 2,500 hours within the 10 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET
- He flew about 5,150 hours as operational crew of heavy-lift helicopters from January 2007 to March 2012, including about 1,300 hours on warlike service in Afghanistan.
Factor 9(6): flying in a helicopter as operational aircrew, for a cumulative total of at least 2,500 hours within the 10 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET
- The same 5,150 helicopter hours, including warlike service in Afghanistan, fall within the 10 years before onset.
Factor 9(7): having smoked tobacco products in an amount of at least 5 pack-years before the clinical onset of thoracolumbar intervertebral disc prolapse, and if smoking has ceased before the clinical onset of thoracolumbar intervertebral disc prolapse, then that onset occurred within 5 years of cessation; — MET
- The veteran smoked 14 pack-years, including through his warlike service in East Timor and Iraq, and onset occurred less than three years after he stopped on 30 June 2009.
Factor 9(8): having bacterial infection of the affected disc at the time of the clinical onset of thoracolumbar intervertebral disc prolapse; — MET
- Staphylococcus aureus introduced into the T8–T9 disc by the fragment on warlike service on 18 March 2012 was present at onset and grew from the disc aspirate.
Factor 9(9): being obese for at least 5 years within the 25 years before the clinical onset of thoracolumbar intervertebral disc prolapse; — MET
- His BMI was above 30 from 2001 to 2006, about six years, a period that included his warlike service in Iraq in 2005.
Worsening factors
Factor 9(10): having trauma to the affected intervertebral disc within the 24 hours before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET
- The heavy brownout landing on warlike service in Afghanistan on 05 June 2013 jarred his thoracic spine within the 24 hours before the worsening on 06 June 2013.
Factor 9(11): having a penetrating injury to the affected intervertebral disc or adjacent vertebral body, within the 24 hours before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET
- The CT-guided biopsy needle pierced the T8–T9 disc at the role 3 hospital during warlike service on 05 June 2013, within the 24 hours before the worsening.
Factor 9(12): physically carrying or lifting loads of at least 10 kilograms, to a cumulative total Load-Factor of at least 150,000 within the 10 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET
- Within the 10 years before the worsening he wore 18 kilograms of flight equipment for over 3,800 hours, including warlike service in Afghanistan in 2013, a Load-Factor above 1,200,000.
Factor 9(13): driving a motor vehicle for an average of at least 25 hours per week, for a period of at least 2 years within the 10 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET
- The driving from July 2003 to June 2005, including warlike service in Iraq, falls within the 10 years before the worsening.
Factor 9(14): flying in an engine powered aircraft as operational crew, for a cumulative total of at least 2,500 hours within the 10 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET
- About 5,400 hours as operational helicopter crew, including warlike service in Afghanistan in 2013, fall within the 10 years before the worsening.
Factor 9(15): flying in a helicopter as operational aircrew, for a cumulative total of at least 2,500 hours within the 10 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET
- The same 5,400 helicopter hours fall within the 10 years before the worsening.
Factor 9(16): having smoked tobacco products in an amount of at least 5 pack-years before the clinical worsening of thoracolumbar intervertebral disc prolapse, and if smoking has ceased before the clinical worsening of thoracolumbar intervertebral disc prolapse, then that worsening occurred within 5 years of cessation; — MET
- He had smoked 14 pack-years, including on warlike service, and the worsening occurred within four years of cessation.
Factor 9(17): having bacterial infection of the affected disc at the time of the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET
- Relapsed Staphylococcus aureus discitis, from the infection introduced by the fragment on warlike service, was confirmed on biopsy on 05 June 2013 and present at the worsening.
Factor 9(18): being obese for at least 5 years within the 25 years before the clinical worsening of thoracolumbar intervertebral disc prolapse; — MET
- The six years of obesity from 2001 to 2006, including warlike service in Iraq, fall within the 25 years before the worsening.
Factor 9(19): inability to obtain appropriate clinical management for thoracolumbar intervertebral disc prolapse before the clinical worsening of thoracolumbar intervertebral disc prolapse. — MET
- On warlike service in Afghanistan in 2013 the veteran could not obtain the surveillance MRI or specialist review needed to detect relapse of the discitis, and the prolapse enlarged with cord compression before treatment was possible.
The % contribution of the causes is 100% and significant.
Sequelae
The thoracic disc prolapse is a sequela of the blast and fragment injuries sustained in the rocket attack in Afghanistan on 18 March 2012 and of the bacterial discitis introduced by the fragment. It has in turn led to thoracic myelopathy, right T8 intercostal neuropathic pain and post-surgical thoracic pain, which should be considered as sequelae.
Unintended Consequence
Met. The CT-guided needle biopsy of the T8–T9 disc on 05 June 2013, provided by the Commonwealth while the veteran was serving, pierced the affected disc within 24 hours of the worsening and contributed to it as an unintended consequence of medical treatment (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. The surveillance MRI planned for February 2013 to confirm that the discitis had resolved was cancelled because of the veteran's deployment, and during two weeks of night pain in Afghanistan before the worsening no imaging or specialist review was available. The relapse of infection went undetected until the prolapse enlarged with cord compression and myelopathy. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the unavailability of indicated surveillance and treatment because of operational circumstances amounts to an inability to obtain appropriate clinical management before the clinical worsening.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 15 Mar 2001, Periodic health examination, Medical Officer, Garrison health centre
- 30 Jun 2005, Transport unit driving summary, Officer Commanding
- 10 Dec 2011, Pre-deployment medical examination, Medical Officer
- 18 Mar 2012, Trauma admission and CT thoracic spine, Role 3 hospital, Afghanistan
- 24 Mar 2012, MRI thoracic spine and spinal surgical consultation, Spinal surgeon
- 24 Mar 2012, Microbiology report and infectious diseases consultation, Infectious diseases physician
- 12 Nov 2012, Aviation medicine review, Aviation Medical Officer
- 05 Jun 2013, Emergency record and CT-guided disc biopsy, Role 3 hospital, Afghanistan
- 06 Jun 2013, MRI thoracic spine, Radiologist
- 10 Jun 2013, Operation report, Spinal surgeon
- Pilot flying logbook summary, 2007 to 2013, Army aviation
- Statement of Principles concerning Thoracolumbar Intervertebral Disc Prolapse (Balance of Probabilities) No. 69 of 2023, Repatriation Medical Authority
- Statement of Principles concerning Thoracolumbar Intervertebral Disc Prolapse (Reasonable Hypothesis) No. 68 of 2023, Repatriation Medical Authority
