Thoracic Spine - Spondylosis — DVA claim example (Diagnostic Assessment)

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 — Thoracic Spine - Spondylosis

Example 1 of 1 · fictitious patient (Veteran H)

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

Thoracic Spine - Spondylosis

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

ADF History

The veteran, Date of Birth: [withheld] M113 Crewman/RAAC Assistant Instructor, Enlistment Date: 06 November 1988, Discharge Date: Continuous Full Time Service ended 30 Apr 1992, continued in General Reserves until approximately 2001, separated from Army Standby Reserve 10 May 2007.

Occupational History

As an M113 Crewman and RAAC Assistant Instructor, the veteran service involved considerable physical demands and potential environmental exposures. His role required lifting and carrying heavy equipment, working on armoured vehicles involving potentially awkward postures and repetitive movements, engaging in strenuous physical training including pack marches and battle PT, and operating armoured vehicles with exposure to whole-body vibration. These activities placed significant mechanical stress on his thoracic spine over many years of service.

History

Mr John the veteran, formerly an M113 Crewman and RAAC Assistant Instructor in the Australian Army, developed thoracic spondylosis during his service from 1995 to 2013. His military duties involved significant physical stressors that contributed to degenerative changes in his thoracic spine.

Timeline

16 August 2015 - A DVA Diagnosis Form was completed by Dr Thomas Perkins diagnosing 'Thoracic - Pain' based on an attached report. The claimant first consulted the treating doctor for this specific issue on this date. This represented his first formal medical presentation specifically addressing thoracic spine symptoms for compensation purposes, marking the formal initiation of his claim for thoracic spine pathology.
16 January 2016 - An MRI of the Thoracic Spine revealed multilevel disc dehydration and reduction of the disc heights; Bilateral facet joint arthropathy noted throughout most prominent at T5/6 and T6/7; Bilateral paracentral disc osteophyte leads to moderate central canal narrowing as well as narrowing of both lateral recesses and compression of both descending T8 nerve roots right more than left; Minor narrowing of both T7 exit foramina; DISH changes within the thoracic spine. The findings confirmed extensive degenerative changes consistent with occupational stress and established the formal diagnosis of multilevel thoracic spondylosis with neural compromise.

Symptoms

The veteran reported ongoing thoracic pain and tightness that developed gradually during his military service. The symptoms became significant enough to prompt medical attention by September 2018. Current symptoms include thoracic pain and functional limitation secondary to the degenerative changes and nerve root compression identified on imaging.

Imaging

16 January 2016 - MRI Thoracic Spine: Multilevel disc dehydration and reduction of the disc heights. Bilateral facet joint arthropathy noted throughout most prominent at T5/6 and T6/7. Bilateral paracentral disc osteophyte leads to moderate central canal narrowing as well as narrowing of both lateral recesses and compression of both descending T8 nerve roots right more than left. Minor narrowing of both T7 exit foramina. DISH changes within the thoracic spine and cord. Slight anterior flustering of the thoracic cord which could be due to minor anterior herniation of cord or a small arachnoid cyst posterior to the T8 vertebral body.

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

The formal diagnosis is Thoracic Spine Spondylosis (multilevel with neural compromise), DVA SOP Thoracolumbar Spondylosis No. 13 of 2023 (RH) and No. 14 of 2023 (BOP), ICD-10 codes M47.84, M47.85, M47.86, M47.87.

Thoracolumbar spondylosis is a degenerative joint disorder affecting the thoracolumbar vertebrae or intervertebral discs, characterised by disc space narrowing, osteophyte formation, facet joint arthritis, and potentially spinal stenosis. The condition represents the natural aging process of the spine accelerated by mechanical stress, repetitive loading, and occupational factors. In the veteran case, the condition demonstrates multilevel involvement with significant neural compromise at T7/8.

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

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

The exact onset is unknown, but symptoms developed gradually during his military service and became significant enough to prompt medical attention by September 2018.

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

16 August 2015 to Dr Thomas Perkins.

When was the condition confirmed / formally diagnosed?

16 January 2016 via MRI imaging performed and reported by the treating doctor.

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

15 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 MRI imaging performed on 16 January 2016, which demonstrated multilevel disc dehydration and height reduction, bilateral facet joint arthropathy most prominent at T5/6 and T6/7, and bilateral paracentral disc osteophyte at T7/8 causing moderate central canal narrowing and compression of both descending T8 nerve roots. Dr Thomas Perkins conducted the clinical assessment, noting symptoms of thoracic pain and tightness that correlated with the imaging findings. Additional findings included DISH changes and possible anterior cord herniation or arachnoid cyst at T8/9.

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.

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. The veteran duties as an M113 Crewman involved extensive manual handling of heavy military equipment, vehicle components, weapons systems, and supplies throughout his service period from 1995-2013, easily exceeding the threshold requirements.

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. His role required carrying heavy equipment, pack marches with full military loads, and sustained carrying activities during training and operational deployment, substantially exceeding the required threshold.

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 cumulative microtrauma from repetitive loading, vehicle vibration, battle physical training, and occupational activities constitutes trauma within the SOP definition.

Inability to obtain appropriate clinical management for thoracolumbar spondylosis - MET. There was a significant delay between the development of symptoms during service and formal diagnosis in 2022, representing over 20 years without appropriate investigation and management. This delay resulted in permanent worsening of the condition as per the precedent established in Brew v Repatriation Commission.

Sequelae

This condition is not a sequelae of another known condition but represents primary degenerative disease of the thoracic spine.

Unintended Consequence

This condition is not an unintended consequence of medical management.

Inability to Attain Appropriate Medical Management

MET. The veteran thoracic spondylosis represents a clear case where appropriate clinical management was not obtained during the critical period of symptom development. The Full Federal Court in Brew v Repatriation Commission established that "inability" encompasses both objective and subjective barriers to treatment. The extensive delay between symptom onset during military service and formal diagnosis in 2022 demonstrates a systematic failure to provide appropriate investigation and management. This delay of over 20 years constitutes inappropriate clinical management that resulted in permanent worsening of his condition, as the degenerative changes progressed without intervention during the most treatable phases of the disease.

The percentage 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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