Diagnostic Assessment — Thoracic Spondylosis
Example 1 of 1 · fictitious patient
Diagnostic Assessment Thoracic Spondylosis BOP Code: 14 of 2023 (Thoracolumbar Spondylosis) RH Code: 13 of 2023 (Thoracolumbar Spondylosis)
ADF History
The veteran, date of birth [withheld], served in the Australian Army as a Combat Engineer from 29 November 1988 to 15 September 1995
Occupational History
As a Combat Engineer in the Australian Army, the veteran performed physically demanding duties involving manual handling, heavy lifting, and exposure to high-impact sporting activities.
These duties placed sustained mechanical loading on the thoracic spine over the course of several years of service
History
The veteran has multilevel thoracic spondylosis with disc protrusions, facet arthropathy, costovertebral arthropathy, Scheuermann's disorder, and a mildly anteriorly wedged T11 vertebral body.
The condition has its origins in multiple acute injuries to the spine during ADF service, including a ligamentous back injury from rugby (May 1989), an upper back strain (February 1993), a car jack compressive injury (February 1993), and the cumulative effects of military occupational loading
Timeline
29 Apr 1989 — Combat Engineer the veteran sustained a ligamentous back injury from rugby at a field engineer regiment affecting the full spine including the thoracic region. "Ligamentous back injury" 25 Feb 1993 — ABSR the veteran presented with a left upper back strain sustained about three days earlier, a week after the car-jack incident of 18 February 1993; the pain had worsened going up and down stairs in ships, with tenderness over the left scapular region and upper back musculature.
Treated with Voltaren and Messal cream. "Strain musculature (upper back)" 18 Feb 1993 — ABSR the veteran was pinned under a car when a jack shifted at a field engineer regiment.
The compressive force through the shoulders directly loaded the thoracic spine. "Soft tissue injury" 28 May 2021 — X-ray chest and lumbar spine demonstrated multilevel degenerative disc disease at the distal thoracic spine and a mildly anteriorly wedged T11 vertebral body. "Minor degenerative changes" 05 Oct 2021 — MRI lumbosacral spine identified multiple endplate Schmorl's nodes in the lower thoracic and upper lumbar region consistent with Scheuermann's disorder, a developmental condition that would have been present during ADF service and would have predisposed the thoracic spine to accelerated degeneration under physical loading. "Scheuermann's disorder" 05 Nov 2021 — X-ray thoracic spine performed after the September 2021 workplace incident (struck in face and fell onto buttocks).
Multilevel thoracic spondylosis with prominent anterior claw-like osteophytosis at multiple levels was demonstrated.
No vertebral fracture. "Multilevel thoracic spondylosis" 13 Nov 2018 — MRI thoracic spine performed for thoracic spine pain.
Demonstrated moderate multilevel thoracic spondylosis with T4/5 2.5 3mm posterior disc- osteophyte complex, T5/6 2mm posterior disc osteophyte complex, T6/7 mild disc bulging with ventral thecal flattening, T7/8 2.5mm left paracentral protrusion abutting the ventral cord, and T8/9 3.5mm central disc protrusion with mild ventral cord indentation.
Moderately severe T4/5 facet arthropathy with reactive marrow oedema.
Moderate multilevel costovertebral arthropathy.
Normal thoracic spinal cord. "3.5mm central disc protrusion" 02 Jul 2020 — MRI lumbar spine demonstrated mild chronic T12 superior endplate depression with approximately 25% central vertebral body height loss, confirming progressive thoracolumbar degeneration. "Chronic endplate depression"
Symptoms
During service, the veteran experienced upper back pain and stiffness that interfered with activities including stair climbing and sleep.
Current symptoms include thoracic spine pain with disc protrusions approaching the spinal cord at T7/8 and T8/9 levels
Imaging
28 May 2021 — X-ray: "Multilevel degenerative disc disease at distal thoracic levels.
Mildly anteriorly wedged T11." 05 Oct 2021 — MRI: "Multiple endplate Schmorl's nodes in lower thoracic and upper lumbar region consistent with Scheuermann's disorder." 05 Nov 2021 — X-ray thoracic spine: "Multilevel thoracic spondylosis with prominent anterior claw-like osteophytosis." 6 January 2022 — Bone scan: "Mid to lower thoracic degenerative change." 13 Nov 2018 — MRI thoracic spine: "Moderate multilevel thoracic spondylosis.
T4/5 2.5 3mm posterior disc-osteophyte complex.
T5/6 2mm posterior disc osteophyte complex.
T6/7 mild disc bulging with ventral thecal flattening.
T7/8 2.5mm left paracentral protrusion abutting ventral cord.
T8/9 3.5mm central disc protrusion with mild ventral cord indentation.
Moderately severe T4/5 facet arthropathy with marrow oedema.
Moderate multilevel costovertebral arthropathy." 02 Jul 2020 — MRI lumbar spine: "Mild chronic T12 superior endplate depression with approximately 25% central vertebral body height loss."
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Thoracic Spondylosis (ICD-10: M47.814) encompassing multilevel disc degeneration, disc protrusions at T7/8 and T8/9 (M51.14), Scheuermann's disorder (M42.04), mildly anteriorly wedged T11 (M48.54), moderately severe T4/5 facet arthropathy, moderate multilevel costovertebral arthropathy, and chronic T12 endplate depression.
The relevant Statements of Principles are those concerning Thoracolumbar Spondylosis (Balance of Probabilities No.
14 of 2023; Reasonable Hypothesis No.
13 of 2023), applied by analogy as this is a DRCA claim.
Thoracic spondylosis is a degenerative condition of the thoracic spine characterised by progressive deterioration of the intervertebral discs, facet joints, costovertebral joints, and vertebral endplates.
In the veteran's case, the pre-existing Scheuermann's disorder provided a substrate of endplate irregularity that was further damaged by the in-service traumatic events and occupational loading, accelerating the degenerative process.
The disc protrusions at T7/8 and T8/9 with cord indentation represent clinically significant progression
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Approximately 29 April 1989 (ligamentous back injury) (ligamentous back injury with tenderness of the paravertebral muscles and left scapula); upper back strain 25 February 1993 [ [CHART REVIEW document], pages 16 17 and] When did the veteran first present to a health / medical provider for this condition? 29 April 1989 (ligamentous back injury, a field engineer regiment); upper back strain 25 February 1993 When was the condition confirmed / formally diagnosed? 28 May 2021 (first thoracic imaging) When did the veteran first present to you (or your practice) for this condition? 11 April 2020
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on imaging.
X-ray of the thoracic spine on 28 May 2021 demonstrated multilevel degenerative disc disease and a wedged T11.
MRI of the thoracic spine on 13 November 2018 provided comprehensive confirmation of moderate multilevel thoracic spondylosis with disc protrusions at T7/8 and T8/9 (the latter with cord indentation), severe T4/5 facet arthropathy, and multilevel costovertebral arthropathy
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 26 February 2009 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Definition: The Statement of Principles excludes Scheuermann disease from the definition of thoracolumbar spondylosis, so the veteran's Scheuermann's disorder is not itself the condition assessed and is considered below as a pre-existing vertebral deformity and predisposition.
His degenerative thoracic spondylosis meets the definition, with thoracic pain and imaging showing multilevel disc degeneration and osteophytes (x-rays of 28 May 2021 and 5 November 2021; MRI of 13 November 2018).
Causative Factors — Balance of Probabilities (Statement of Principles concerning Thoracolumbar Spondylosis, No.
14 of 2023) Factor 9(1): having an inflammatory joint disease from the specified list of inflammatory joint diseases, in the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis — NOT MET - There is no record of ankylosing spondylitis, psoriatic, reactive or rheumatoid arthritis, or arthritis associated with inflammatory bowel disease, and later MRI showed no sacroiliitis (11 September 2024 and 21 February 2026).
Factor 9(2): having non-viral infection of the affected joint, resulting in inflammation within that joint, at least 6 months before the clinical onset of thoracolumbar spondylosis — NOT MET - There is no record of a bacterial or other non-viral infection of a thoracic spinal joint, such as discitis, septic facet arthritis or vertebral osteomyelitis, and nothing in his history suggests it.
Factor 9(3): having an intra-articular fracture of the spine, at the level of, or adjacent to, the affected joint, at least 6 months before the clinical onset of thoracolumbar spondylosis — NOT MET - No spinal fracture is recorded before the estimated onset of 7 July 1992; the lumbosacral x-ray of 8 January 1991 showed no bone trauma, and the mild anterior wedging of T11 first noted on 28 May 2021 was not reported as a fracture.
Factor 9(4): having a spinal condition from the specified list of spinal conditions, affecting the thoracolumbar spine for at least the 6 months before the clinical onset of thoracolumbar spondylosis — MET - Two conditions on the specified list affected the veteran's thoracolumbar spine long before the estimated onset of 7 July 1992.
The lumbosacral x-ray of 8 January 1991 showed a very minor scoliosis at L4 5, convex to the left, and a left-convex lumbar curve was again reported on 28 May 2021 and 5 October 2021, so scoliosis was present about 18 months before onset.
Scheuermann's disorder is not itself on the list, but its sequelae, multilevel endplate irregularity with Schmorl's nodes in the lower thoracic and upper lumbar vertebrae (MRIs of 5 October 2021 and 13 November 2018), are deformities of vertebrae, as is the mildly wedged T11; as a disorder of adolescent growth, Scheuermann's disorder would have been present for years before onset.
Factor 9(5): having undergone a spinal fusion, immediately above or below the affected joint, at least 6 months before the clinical onset of thoracolumbar spondylosis — NOT MET - the veteran has never undergone spinal fusion surgery; his fusion operations were of the thumbs and toes, not the spine.
Factor 9(6): for lumbar spondylosis only, having leg length inequality for at least the 5 years before the clinical onset of thoracolumbar spondylosis — NOT MET - This factor applies only to lumbar spondylosis; the veteran's condition assessed here is spondylosis of the thoracic spine, and no leg length inequality of 2 cm or more is recorded.
Factor 9(7): having a depositional joint disease from the specified list of depositional joint diseases, in the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis — NOT MET - There is no record of gout, calcium pyrophosphate deposition disease (pseudogout), haemochromatosis, alkaptonuria or Wilson's disease, and nothing in his history suggests it.
Factor 9(8): having trauma to the thoracolumbar spine at least 6 months before the clinical onset of thoracolumbar spondylosis, and where the trauma to the thoracolumbar spine occurred within the 20 years before the clinical onset of thoracolumbar spondylosis — MET - the veteran sustained two qualifying traumas in service.
On 29 April 1989 a scrum collapsed on top of him in organised service rugby at a field engineer regiment, causing a ligamentous back injury with tenderness of the cervical and lumbar spine, paravertebral muscles and left scapular region; on 7 January 1991 he fell directly onto his back at work, bruising the right loin, with straight-leg raising reduced to 50 degrees and right L4 nerve-root irritation.
Each applied significant force to the thoracolumbar spine and caused damage, pain, tenderness and restricted duties, more than 6 months and within 20 years before the estimated onset of 7 July 1992; their duration is not recorded, but such injuries ordinarily persist beyond 7 days and his back complaints recurred.
The car-jack injury of 18 February 1993 and the upper- back strain of about 22 February 1993 occurred after the estimated onset and are considered under the worsening factors.
Factor 9(9): having a penetrating injury to an intervertebral disc before the clinical onset of thoracolumbar spondylosis at the level of, or adjacent to, the intervertebral disc injury — NOT MET - There is no record of a penetrating injury to a thoracic intervertebral disc from a bullet, fragment, knife or needle, and nothing in his history suggests it.
Factor 9(10): having a thoracolumbar intervertebral disc prolapse at least 6 months before the clinical onset of thoracolumbar spondylosis at the level of the intervertebral disc prolapse — NOT MET - No thoracic disc prolapse is recorded before the estimated onset of 7 July 1992; the leg symptoms of March 1990 and January 1991 arose from the lumbar spine, and the thoracic protrusions at T7/8 and T8/9 were first shown on 13 November 2018.
Factor 9(11): lifting loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine: (a) to a cumulative total of at least 150,000 kilograms within any 10 year period before the clinical onset of thoracolumbar spondylosis; and (b) where the clinical onset of thoracolumbar spondylosis occurred within the 25 years following that period — NOT MET - the veteran's duties as a Combat Engineer and Combat Engineer in a field engineer regiment, a field engineer regiment and a field engineer regiment involved repeated lifting through the thoracolumbar spine, including steel cables and cable drums at sea on 11 9 March 1990, survey equipment, ships' lines, boats and stores, and in November 1991 his orthopaedic surgeon expected him to be 'fully fit 100% for heavy manual work'.
However, only about 1.9 years of effective ship, survey and shore duty fall between February 1990 and the estimated onset of 7 July 1992, after excluding recruit training and the time off duty for thumb surgery between August 1991 and November 1991.
A conservative estimate of about 20 lifts of loads of at least 20 kg (averaging about 25 kg) on about 150 working days a year gives 25 20 150 1.9 142,500 kg, which falls short of the 150,000 kg required within a 10-year period before onset.
The lifting after onset is considered under the worsening factors.
Factor 9(12): carrying loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine: (a) to a cumulative total of at least 3,800 hours within any 10 year period before the clinical onset of thoracolumbar spondylosis; and (b) where the clinical onset of thoracolumbar spondylosis occurred within the 25 years following that period — NOT MET - Sustained load carrying of the kind this factor requires is not part of his documented duties; even one hour a day of carrying loads of at least 20 kg on about 150 working days a year over the 3.6 years of service before 7 July 1992 gives 1 150 3.6 540 hours, far below 3,800 hours.
Factor 9(13): for lumbar spondylosis only, flying in an engine powered aircraft as operational aircrew, for a cumulative total of at least 2,000 hours within the 25 years before the clinical onset of thoracolumbar spondylosis — NOT MET - This factor applies only to lumbar spondylosis; the veteran's condition assessed here is spondylosis of the thoracic spine, and he was never operational aircrew.
Factor 9(14): being obese for at least 10 years within the 25 years before the clinical onset of thoracolumbar spondylosis — NOT MET - the veteran was first recorded in the obese range on 15 January 1992 (BMI 32.9), less than 6 months before the estimated onset of 7 July 1992, having weighed 89 kg (BMI about 25.5) before enlistment in October 1988, so he was not obese for 10 years before onset.
Factor 9(15): having acromegaly involving the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis — NOT MET - There is no record of acromegaly or growth hormone excess, and nothing in his history suggests it; his large, thickset build was noted as his normal habitus before he enlisted.
Factor 9(16): having Paget's disease of bone involving the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis — NOT MET - There is no record of Paget's disease of bone, and the whole-body bone scan of 6 January 2022 showed only degenerative change in the thoracic spine.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Thoracolumbar Spondylosis, No.
13 of 2023) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): being a prisoner of war before the clinical onset of thoracolumbar spondylosis — NOT MET - the veteran was never a prisoner of war; he had no operational deployments and rendered no operational service.
Factor 9(2): having an inflammatory joint disease from the specified list of inflammatory joint diseases, in the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis — NOT MET - There is no record of ankylosing spondylitis, psoriatic, reactive or rheumatoid arthritis, or arthritis associated with inflammatory bowel disease, and later MRI showed no sacroiliitis (11 September 2024 and 21 February 2026).
Factor 9(3): having non-viral infection of the affected joint, resulting in inflammation within that joint, at least 6 months before the clinical onset of thoracolumbar spondylosis — NOT MET - There is no record of a bacterial or other non-viral infection of a thoracic spinal joint, such as discitis, septic facet arthritis or vertebral osteomyelitis, and nothing in his history suggests it.
Factor 9(4): having an intra-articular fracture of the spine, at the level of, or adjacent to, the affected joint, at least 6 months before the clinical onset of thoracolumbar spondylosis — NOT MET - No spinal fracture is recorded before the estimated onset of 7 July 1992; the lumbosacral x-ray of 8 January 1991 showed no bone trauma, and the mild anterior wedging of T11 first noted on 28 May 2021 was not reported as a fracture.
Factor 9(5): having a spinal condition from the specified list of spinal conditions, affecting the thoracolumbar spine for at least the 6 months before the clinical onset of thoracolumbar spondylosis — MET - A very minor left-convex scoliosis at L4 5 was shown on the lumbosacral x-ray of 8 January 1991 and persisted on the imaging of 28 May 2021 and 5 October 2021, affecting his thoracolumbar spine about 18 months before the estimated onset of 7 July 1992.
In addition, the sequelae of his adolescent Scheuermann's disorder (multilevel endplate irregularity with Schmorl's nodes in the lower thoracic and upper lumbar vertebrae) and the mildly anteriorly wedged T11 are deformities of vertebrae; Scheuermann's disorder is not itself named on the specified list, but as a developmental disorder its vertebral deformities would have been present for years before onset.
Factor 9(6): for lumbar spondylosis only, having a kyphotic abnormality or lordotic abnormality affecting the lumbar spine for at least the 6 months before the clinical onset of thoracolumbar spondylosis — NOT MET - This factor applies only to lumbar spondylosis; the veteran's condition assessed here is spondylosis of the thoracic spine, and his lumbar sagittal alignment was satisfactory on 28 May 2021.
Factor 9(7): having undergone a spinal fusion, immediately above or below the affected joint, at least 6 months before the clinical onset of thoracolumbar spondylosis — NOT MET - the veteran has never undergone spinal fusion surgery; his fusion operations were of the thumbs and toes, not the spine.
Factor 9(8): for lumbar spondylosis only, having leg length inequality for at least the 2 years before the clinical onset of thoracolumbar spondylosis — NOT MET - This factor applies only to lumbar spondylosis; the veteran's condition assessed here is spondylosis of the thoracic spine, and no leg length inequality of 2 cm or more is recorded.
Factor 9(9): having a depositional joint disease from the specified list of depositional joint diseases, in the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis — NOT MET - There is no record of gout, calcium pyrophosphate deposition disease (pseudogout), haemochromatosis, alkaptonuria or Wilson's disease, and nothing in his history suggests it.
Factor 9(10): having trauma to the thoracolumbar spine at least 6 months before the clinical onset of thoracolumbar spondylosis, and where the trauma to the thoracolumbar spine occurred within the 20 years before the clinical onset of thoracolumbar spondylosis — MET - On 29 April 1989 a scrum collapsed on top of the veteran in organised service rugby at a field engineer regiment, causing a ligamentous back injury with tenderness of the cervical and lumbar spine, paravertebral muscles and left scapular region, and on 7 January 1991 he fell directly onto his back at work, bruising the right loin, with straight-leg raising reduced to 50 degrees and right L4 nerve-root irritation.
Both applied significant force to the thoracolumbar spine and caused damage, pain, tenderness and restricted duties, more than 6 months and within 20 years before the estimated onset of 7 July 1992; although their duration is not recorded, such injuries ordinarily persist beyond 7 days, and his back complaints recurred.
The car-jack injury of 18 February 1993 and the upper-back strain of about 22 February 1993 occurred after the estimated onset and are considered under the worsening factors.
Factor 9(11): having a penetrating injury to an intervertebral disc before the clinical onset of thoracolumbar spondylosis at the level of, or adjacent to, the intervertebral disc injury — NOT MET - There is no record of a penetrating injury to a thoracic intervertebral disc from a bullet, fragment, knife or needle, and nothing in his history suggests it.
Factor 9(12): having a thoracolumbar intervertebral disc prolapse at least 6 months before the clinical onset of thoracolumbar spondylosis at the level of the intervertebral disc prolapse — NOT MET - No thoracic disc prolapse is recorded before the estimated onset of 7 July 1992; the leg symptoms of March 1990 and January 1991 arose from the lumbar spine, and the thoracic protrusions at T7/8 and T8/9 were first shown on 13 November 2018.
Factor 9(13): lifting loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine to a cumulative total of at least 100,000 kilograms within any 10 year period before the clinical onset of thoracolumbar spondylosis — MET - the veteran's documented duties as a Combat Engineer and Combat Engineer involved repeated lifting of loads of at least 20 kg through the thoracolumbar spine, such as the steel cables and cable drums he was lifting at sea in a field engineer regiment on 11 9 March 1990, survey equipment, ships' lines, boats and stores.
A conservative estimate from those duties of about 20 lifts averaging 25 kg on about 150 working days a year, over roughly 1.9 years of effective ship, survey and shore duty between February 1990 and the estimated onset of 7 July 1992 (excluding recruit training and the time off duty for thumb surgery between August 1991 and November 1991), gives 25 20 150 1.9 142,500 kg, exceeding 100,000 kg within a 10-year period before onset.
Factor 9(14): carrying loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine to a cumulative total of at least 3,800 hours within any 10 year period before the clinical onset of thoracolumbar spondylosis — NOT MET - Sustained load carrying of the kind this factor requires is not part of his documented duties; even one hour a day of carrying loads of at least 20 kg on about 150 working days a year over the 3.6 years of service before 7 July 1992 gives 1 150 3.6 540 hours, far below 3,800 hours.
Factor 9(15): for lumbar spondylosis only, flying in an engine powered aircraft as operational aircrew, for a cumulative total of at least 1,000 hours within the 25 years before the clinical onset of thoracolumbar spondylosis — NOT MET - This factor applies only to lumbar spondylosis; the veteran's condition assessed here is spondylosis of the thoracic spine, and he was never operational aircrew.
Factor 9(16): being obese for at least 10 years before the clinical onset of thoracolumbar spondylosis — NOT MET - the veteran was first recorded in the obese range on 15 January 1992 (BMI 32.9), less than 6 months before the estimated onset of 7 July 1992, having weighed 89 kg (BMI about 25.5) before enlistment in October 1988, so he was not obese for 10 years before onset.
Factor 9(17): having acromegaly involving the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis — NOT MET - There is no record of acromegaly or growth hormone excess, and nothing in his history suggests it; his large, thickset build was noted as his normal habitus before he enlisted.
Factor 9(18): having Paget's disease of bone involving the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis — NOT MET - There is no record of Paget's disease of bone, and the whole-body bone scan of 6 January 2022 showed only degenerative change in the thoracic spine.
Other Plausible Links to Service Under the DRCA, thoracic spondylosis is a disease, and the question is whether the veteran's employment contributed to it to a significant degree; it may also be accepted as a sequela of in-service spinal injuries.
Most of those injuries arose out of, or in the course of, his employment as a member: the collapsed scrum in organised service rugby on 29 April 1989, the lifting strain from steel cables at sea in a field engineer regiment on 8 March 1990, the fall onto his back at work on 7 January 1991, and the fall onto a floor polisher while scrubbing a deck on duty on 30 September 1993, which bruised the posterior right ribs 9 12.
Together with 6 years 8 months of heavy manual work as a Combat Engineer and Combat Engineer, these injuries loaded the lower thoracic and thoracolumbar segments where degeneration was later shown, and service contributed to the condition to a significant degree.
The veteran's Scheuermann's disorder, a developmental weakness of the vertebral endplates, was present but unrecognised when he enlisted at 16.
The axial loading of service, through repeated heavy lifting, collapsed scrums and falls onto his back, acted on these vulnerable endplates, and later imaging shows degeneration concentrated in the same mid and lower thoracic segments, with multiple Schmorl's nodes, endplate spurring, disc degeneration and costovertebral arthropathy.
Service thereby aggravated a pre-existing constitutional vulnerability and accelerated the development of spondylosis, a link that does not depend on the SOP factors.
The veteran's obesity began in service: he was first recorded in the obese range on 15 January 1992 (BMI 32.9), was placed on the Weight Surveillance Programme, and was heavier at discharge (BMI 35.7).
It persisted afterwards (BMI about 48.6 before bariatric surgery in 2024 and 41.5 on 22 May 2019) and has added to the load on his thoracic discs and facet joints as the spondylosis progressed.
If his obesity is accepted as related to service, its contribution to the progression of his thoracic spondylosis is a further link to service as a sequela.
Conclusion the veteran's thoracic spondylosis arose in a spine predisposed by adolescent Scheuermann's disorder and a mild scoliosis, from repeated in-service trauma to the thoracolumbar spine (the collapsed scrum of 29 April 1989 and the fall onto his back at work on 7 January 1991) and the heavy lifting of his duties as a Combat Engineer and Combat Engineer before its estimated clinical onset on 7 July 1992; that lifting meets the reasonable hypothesis threshold but falls just short of the balance of probabilities threshold.
The upper-back strain of February 1993, the on-duty fall of 30 September 1993, continued manual duties to discharge, obesity that began in service, the post-service fall of 3 September 2021 and about 28 years without investigation of the thoracic spine then contributed to its progression.
The trauma factors, the lifting factors under the reasonable hypothesis, and the aggravation of his pre-existing Scheuermann's disorder by service loading show that service contributed to the condition to a significant degree.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's thoracic spondylosis is found not to have arisen out of his service, the following factors address whether service rendered after its estimated clinical onset on 7 July 1992 (the date from which his symptoms are taken to have been persistently present) until his discharge on 15 September 1995, including the upper-back strain of February 1993, the on-duty fall of 30 September 1993 and continued manual duties, aggravated it or contributed to it in a material degree.
The car-jack injury of 18 February 1993 occurred off duty, and post-service events relevant to a factor are identified as such.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Thoracolumbar Spondylosis, No.
14 of 2023) Factor 9(17): having an inflammatory joint disease from the specified list of inflammatory joint diseases, in the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis — NOT MET - There is no record at any time of an inflammatory joint disease on the specified list (ankylosing spondylitis, psoriatic, reactive, rheumatoid or enteropathic arthritis), and MRI of 11 September 2024 and 21 February 2026 showed no sacroiliitis.
Factor 9(18): having non-viral infection of the affected joint, resulting in inflammation within that joint, at least 6 months before the clinical worsening of thoracolumbar spondylosis — NOT MET - There is no record, before or after the onset of his spondylosis, of a non-viral infection of a thoracic spinal joint such as discitis, septic facet arthritis or vertebral osteomyelitis, and nothing in his history suggests it.
Factor 9(19): having an intra-articular fracture of the spine, at the level of, or adjacent to, the affected joint, at least 6 months before the clinical worsening of thoracolumbar spondylosis — NOT MET - No intra-articular spinal fracture has been diagnosed: the x-ray of 5 November 2021 found no thoracic fracture, and the chronic T12 superior endplate depression first reported on 2 July 2020 was not described as a fracture and has not been followed by any later worsening.
Factor 9(20): having a spinal condition from the specified list of spinal conditions, affecting the thoracolumbar spine for at least the 6 months before the clinical worsening of thoracolumbar spondylosis — MET - The left-convex scoliosis documented from 8 January 1991 and the vertebral deformities of his Scheuermann's disorder (multilevel endplate irregularity with Schmorl's nodes in the lower thoracic and upper lumbar vertebrae, and a mildly wedged T11) affected his thoracolumbar spine for far longer than 6 months before each documented worsening, including the upper-back strain of February 1993, the aggravation after the fall of 30 September 1993 and the progression from minor disc degeneration on 28 May 2021 to moderate multilevel spondylosis on 13 November 2018.
Such deformities alter the loading of the thoracic discs and endplates, and his degeneration is most marked in the mid and lower thoracic segments.
This is a constitutional factor rather than a service exposure.
Factor 9(21): having undergone a spinal fusion, immediately above or below the affected joint, at least 6 months before the clinical worsening of thoracolumbar spondylosis — NOT MET - the veteran has never undergone spinal fusion surgery; his fusion operations were of the thumbs and toes, not the spine.
Factor 9(22): for lumbar spondylosis only, having leg length inequality for at least the 5 years before the clinical worsening of thoracolumbar spondylosis — NOT MET - This factor applies only to lumbar spondylosis; the veteran's condition assessed here is spondylosis of the thoracic spine, and no leg length inequality of 2 cm or more is recorded.
Factor 9(23): having trauma to the thoracolumbar spine at least 6 months before the clinical worsening of thoracolumbar spondylosis, and where the trauma to the thoracolumbar spine occurred within the 20 years before the clinical worsening of thoracolumbar spondylosis — MET - After the estimated onset of 7 July 1992, the veteran sustained further trauma to the thoracic spine.
On 18 February 1993, while off duty, he was injured in a car-jack incident, and he presented on 25 February 1993 with an upper-back strain sustained about 22 February 1993, with upper-back pain that worsened on ships' stairs.
On 30 September 1993 he slipped while scrubbing a deck on duty at FIMA, Alexandria, and landed on the floor polisher and his back, bruising the posterior right ribs 9 12, which articulate with the lower thoracic vertebrae; spinal movement was limited in all ranges and he needed light duties, physiotherapy and anti- inflammatory medication until at least 4 November 1993.
Each meets the definition of trauma; the February 1993 injuries occurred more than 6 months before the aggravation of October 1993, and the lower thoracic degeneration established by 2021 would have developed partly within 20 years of the fall of 30 September 1993.
The post-service fall onto his back at work on 3 September 2021 also qualifies: lower thoracic pain was 'not abating' on 5 November 2021, and more than 6 months later, within 20 years, the MRI of 13 November 2018 showed moderate multilevel spondylosis with disc protrusions abutting and indenting the cord at T7/8 and T8/9.
Factor 9(24): having a depositional joint disease from the specified list of depositional joint diseases, in the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis — NOT MET - There is no record of gout, calcium pyrophosphate deposition disease (pseudogout), haemochromatosis, alkaptonuria or Wilson's disease, and nothing in his history suggests it.
Factor 9(25): having a penetrating injury to an intervertebral disc before the clinical worsening of thoracolumbar spondylosis at the level of, or adjacent to, the intervertebral disc injury — NOT MET - There is no record of a penetrating injury to a thoracic intervertebral disc; his later spinal procedures (the facet joint injection of 20 January 2022 and the rhizotomies of 2020) targeted facet joints and their nerves, not a thoracic disc.
Factor 9(26): having a thoracolumbar intervertebral disc prolapse at least 6 months before the clinical worsening of thoracolumbar spondylosis at the level of the intervertebral disc prolapse — NOT MET - The disc protrusions at T7/8 and T8/9 were first shown on the MRI of 13 November 2018, and no later thoracic imaging or assessment has shown worsening at those levels; the new non- dermatomal right leg weakness of July 2020 has not been investigated at the thoracic level.
Factor 9(27): lifting loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine: (a) to a cumulative total of at least 150,000 kilograms within any 10 year period before the clinical worsening of thoracolumbar spondylosis; and (b) where the clinical worsening of thoracolumbar spondylosis occurred within the 25 years following that period — NOT MET - From the estimated onset of 7 July 1992 to discharge on 15 September 1995 the veteran continued manual duties at sea and ashore, and 20 lifts averaging 25 kg on 150 days a year over about 3.1 years gives 25 20 150 3.1 232,500 kg, exceeding 150,000 kg.
However, the documented worsening after discharge, from minor thoracic disc degeneration on 28 May 2021 to moderate multilevel spondylosis on 13 November 2018, occurred more than 25 years after that lifting ended in September 1995, and before the in-service aggravation of 30 September 1993 only about 1.2 years of such lifting had accrued (25 20 150 1.2 90,000 kg).
No post-service heavy lifting is documented beyond helping to load a truck in September 2021, so both limbs of the factor are not satisfied for the same worsening.
Factor 9(28): carrying loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine: (a) to a cumulative total of at least 3,800 hours within any 10 year period before the clinical worsening of thoracolumbar spondylosis; and (b) where the clinical worsening of thoracolumbar spondylosis occurred within the 25 years following that period — NOT MET - Even one hour a day of carrying loads of at least 20 kg on about 150 working days a year from the estimated onset of 7 July 1992 to discharge, about 3.1 years, gives 1 150 3.1 465 hours, and no heavy carrying work is documented after discharge, so 3,800 hours in a 10-year period is not approached.
Factor 9(29): for lumbar spondylosis only, flying in an engine powered aircraft as operational aircrew, for a cumulative total of at least 2,000 hours within the 25 years before the clinical worsening of thoracolumbar spondylosis — NOT MET - This factor applies only to lumbar spondylosis; the veteran's condition assessed here is spondylosis of the thoracic spine, and he was never operational aircrew.
Factor 9(30): being obese for at least 10 years within the 25 years before the clinical worsening of thoracolumbar spondylosis — MET - the veteran was obese from at least 15 January 1992 (BMI 32.9) to his discharge on 15 September 1995 (BMI 35.7), and he remained obese afterwards: his body habitus limited ultrasound in November 2021, he weighed about 168 kg (BMI about 48.6) before bariatric surgery in 2024, and 143.6 kg (BMI 41.5) on 22 May 2019.
On this trajectory he was obese for well over 10 years within the 25 years before the documented worsening, from minor thoracic disc degeneration on 28 May 2021 to moderate multilevel spondylosis with disc protrusions on 13 November 2018, and excess weight increases the load on the thoracic discs and facet joints.
This factor rests mainly on post-service facts, although his obesity began in service.
Factor 9(31): having acromegaly involving the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis — NOT MET - There is no record of acromegaly or growth hormone excess, and nothing in his history suggests it; his large, thickset build was noted as his normal habitus before he enlisted.
Factor 9(32): having Paget's disease of bone involving the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis — NOT MET - There is no record of Paget's disease of bone, and the whole-body bone scan of 6 January 2022 showed only degenerative change in the thoracic spine.
Factor 9(33): inability to obtain appropriate clinical management for thoracolumbar spondylosis — MET - the veteran presented repeatedly with back pain in service (1989, 1990, 1991, and after the estimated onset in February 1993 and February November 1993), including upper-back pain that worsened on ships' stairs, but was managed conservatively each time; his thoracic spine was never specifically imaged and the only specialist referral (October 1993) addressed the lumbar spine.
Thoracic spondylosis was not diagnosed until 28 May 2021, about 28 years after the upper-back strain of 25 February 1993.
Sea postings, the loss of his PM168 medical record in 1995 and the January 1992 command signal suspecting malingering were further barriers; under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is judged objectively and subjectively and includes psychological or emotional incapacity and the threat of sanctions that make seeking treatment unrealistic.
Unmanaged, the degeneration progressed to established multilevel spondylosis.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Thoracolumbar Spondylosis, No.
13 of 2023) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(19): being a prisoner of war before the clinical worsening of thoracolumbar spondylosis — NOT MET - the veteran was never a prisoner of war; he had no operational deployments and rendered no operational service.
Factor 9(20): having an inflammatory joint disease from the specified list of inflammatory joint diseases, in the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis — NOT MET - There is no record at any time of an inflammatory joint disease on the specified list (ankylosing spondylitis, psoriatic, reactive, rheumatoid or enteropathic arthritis), and MRI of 11 September 2024 and 21 February 2026 showed no sacroiliitis.
Factor 9(21): having non-viral infection of the affected joint, resulting in inflammation within that joint, at least 6 months before the clinical worsening of thoracolumbar spondylosis — NOT MET - There is no record, before or after the onset of his spondylosis, of a non-viral infection of a thoracic spinal joint such as discitis, septic facet arthritis or vertebral osteomyelitis, and nothing in his history suggests it.
Factor 9(22): having an intra-articular fracture of the spine, at the level of, or adjacent to, the affected joint, at least 6 months before the clinical worsening of thoracolumbar spondylosis — NOT MET - No intra-articular spinal fracture has been diagnosed: the x-ray of 5 November 2021 found no thoracic fracture, and the chronic T12 superior endplate depression first reported on 2 July 2020 was not described as a fracture and has not been followed by any later worsening.
Factor 9(23): having a spinal condition from the specified list of spinal conditions, affecting the thoracolumbar spine for at least the 6 months before the clinical worsening of thoracolumbar spondylosis — MET - The left-convex scoliosis documented from 8 January 1991 and the vertebral deformities of his Scheuermann's disorder (endplate irregularity with Schmorl's nodes in the lower thoracic and upper lumbar vertebrae, and a mildly wedged T11) were present for far longer than 6 months before each documented worsening, including the upper-back strain of February 1993, the aggravation after the fall of 30 September 1993 and the progression to moderate multilevel spondylosis shown on 13 November 2018.
These deformities alter the loading of the thoracic discs and endplates; this is a constitutional factor rather than a service exposure.
Factor 9(24): for lumbar spondylosis only, having a kyphotic abnormality or lordotic abnormality affecting the lumbar spine for at least the 6 months before the clinical worsening of thoracolumbar spondylosis — NOT MET - This factor applies only to lumbar spondylosis; the veteran's condition assessed here is spondylosis of the thoracic spine, and his lumbar sagittal alignment was satisfactory on 28 May 2021.
Factor 9(25): having undergone a spinal fusion, immediately above or below the affected joint, at least 6 months before the clinical worsening of thoracolumbar spondylosis — NOT MET - the veteran has never undergone spinal fusion surgery; his fusion operations were of the thumbs and toes, not the spine.
Factor 9(26): for lumbar spondylosis only, having leg length inequality for at least the 2 years before the clinical worsening of thoracolumbar spondylosis — NOT MET - This factor applies only to lumbar spondylosis; the veteran's condition assessed here is spondylosis of the thoracic spine, and no leg length inequality of 2 cm or more is recorded.
Factor 9(27): having a depositional joint disease from the specified list of depositional joint diseases, in the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis — NOT MET - There is no record of gout, calcium pyrophosphate deposition disease (pseudogout), haemochromatosis, alkaptonuria or Wilson's disease, and nothing in his history suggests it.
Factor 9(28): having trauma to the thoracolumbar spine at least 6 months before the clinical worsening of thoracolumbar spondylosis, and where the trauma to the thoracolumbar spine occurred within the 20 years before the clinical worsening of thoracolumbar spondylosis — MET - After the estimated onset of 7 July 1992, the veteran sustained further trauma to the thoracic spine.
On 18 February 1993, while off duty, he was injured in a car-jack incident, and he presented on 25 February 1993 with an upper-back strain sustained about 22 February 1993, with upper-back pain that worsened on ships' stairs.
On 30 September 1993 he slipped while scrubbing a deck on duty at FIMA, Alexandria, and landed on the floor polisher and his back, bruising the posterior right ribs 9 12, which articulate with the lower thoracic vertebrae; spinal movement was limited in all ranges and he needed light duties, physiotherapy and anti- inflammatory medication until at least 4 November 1993.
Each meets the definition of trauma; the February 1993 injuries occurred more than 6 months before the aggravation of October 1993, and the lower thoracic degeneration established by 2021 would have developed partly within 20 years of the fall of 30 September 1993.
The post-service fall onto his back at work on 3 September 2021 also qualifies: lower thoracic pain was 'not abating' on 5 November 2021, and more than 6 months later, within 20 years, the MRI of 13 November 2018 showed moderate multilevel spondylosis with disc protrusions abutting and indenting the cord at T7/8 and T8/9.
Factor 9(29): having a penetrating injury to an intervertebral disc before the clinical worsening of thoracolumbar spondylosis at the level of, or adjacent to, the intervertebral disc injury — NOT MET - There is no record of a penetrating injury to a thoracic intervertebral disc; his later spinal procedures (the facet joint injection of 20 January 2022 and the rhizotomies of 2020) targeted facet joints and their nerves, not a thoracic disc.
Factor 9(30): having a thoracolumbar intervertebral disc prolapse at least 6 months before the clinical worsening of thoracolumbar spondylosis at the level of the intervertebral disc prolapse — NOT MET - The disc protrusions at T7/8 and T8/9 were first shown on the MRI of 13 November 2018, and no later thoracic imaging or assessment has shown worsening at those levels; the new non- dermatomal right leg weakness of July 2020 has not been investigated at the thoracic level.
Factor 9(31): lifting loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine to a cumulative total of at least 100,000 kilograms within any 10 year period before the clinical worsening of thoracolumbar spondylosis — MET - After the estimated onset of 7 July 1992, the veteran continued manual duties until discharge, including ship and survey duties, the upper-back strain of February 1993 and scrubbing and polishing decks in ships' husbandry at FIMA, Alexandria, and then serving at a field engineer regiment, where 'heavy lifting' was recorded in March 1995.
A conservative estimate from these documented duties of about 20 lifts of loads averaging 25 kg on about 150 working days a year, over roughly 3.1 years of effective duty from onset to discharge on 15 September 1995, gives 25 20 150 3.1 232,500 kg, exceeding 100,000 kg within a 10-year period before the worsening shown by the progression from minor thoracic disc degeneration on 28 May 2021 to moderate multilevel spondylosis on 13 November 2018.
Factor 9(32): carrying loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine to a cumulative total of at least 3,800 hours within any 10 year period before the clinical worsening of thoracolumbar spondylosis — NOT MET - Even one hour a day of carrying loads of at least 20 kg on about 150 working days a year from the estimated onset of 7 July 1992 to discharge, about 3.1 years, gives 1 150 3.1 465 hours, and no heavy carrying work is documented after discharge, so 3,800 hours in a 10-year period is not approached.
Factor 9(33): for lumbar spondylosis only, flying in an engine powered aircraft as operational aircrew, for a cumulative total of at least 1,000 hours within the 25 years before the clinical worsening of thoracolumbar spondylosis — NOT MET - This factor applies only to lumbar spondylosis; the veteran's condition assessed here is spondylosis of the thoracic spine, and he was never operational aircrew.
Factor 9(34): being obese for at least 10 years before the clinical worsening of thoracolumbar spondylosis — MET - the veteran was obese from at least 15 January 1992 (BMI 32.9) through discharge (BMI 35.7 on 15 September 1995) and remained so afterwards, with body habitus limiting ultrasound in November 2021, a weight of about 168 kg (BMI about 48.6) before bariatric surgery in 2024 and 143.6 kg (BMI 41.5) on 22 May 2019.
He was therefore obese for well over 10 years before the documented worsening from 2021 to 2019, and excess weight adds load to the thoracic discs and facet joints; this rests mainly on post-service facts, although his obesity began in service.
Factor 9(35): having acromegaly involving the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis — NOT MET - There is no record of acromegaly or growth hormone excess, and nothing in his history suggests it; his large, thickset build was noted as his normal habitus before he enlisted.
Factor 9(36): having Paget's disease of bone involving the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis — NOT MET - There is no record of Paget's disease of bone, and the whole-body bone scan of 6 January 2022 showed only degenerative change in the thoracic spine.
Factor 9(37): inability to obtain appropriate clinical management for thoracolumbar spondylosis — MET - the veteran's recurrent in-service back presentations from 1989 to 1994, including upper- back pain in February 1993 and bruising of the posterior lower ribs in October 1993, were managed conservatively without thoracic imaging or thoracic specialist assessment, and the condition was not diagnosed until 28 May 2021, about 28 years later.
Sea postings, the loss of his PM168 medical record in 1995 and the January 1992 command signal suspecting malingering were further barriers; under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional incapacity and the threat of sanctions that make seeking treatment unrealistic.
Unmanaged, the degeneration progressed to established multilevel spondylosis with disc protrusions by 2019
Sequelae
Thoracic spondylosis is a sequela of the in-service thoracic strain (February 1993) and thoracic soft tissue injuries (May 1989, February 1993).
The pre-existing Scheuermann's disorder was aggravated by military service
Unintended Consequence
This condition is not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
This only applies to worsening factors.
No imaging of the thoracic spine was performed during service despite documented upper back pain presentations.
The first thoracic imaging was not performed until May 2021, approximately 25 years after discharge.
This represents a significant delay in diagnosis and treatment — MET
Date of Clinical Onset
Thoracic spondylosis is a chronic condition.
Its date of clinical onset is the date on which the condition first manifested clinically.
It is not the date on which the condition was first imaged or formally diagnosed
Imaging
And specialist diagnosis record when an established condition was confirmed; a chronic condition is present, and usually symptomatic, for a considerable period before it is investigated, so the date of imaging must not be taken as the date of clinical onset.
First documented presentation with pain in the thoracic spine: 29 April 1989 — scrum collapse playing rugby at a field engineer regiment, with tenderness of the paravertebral muscles and over the left scapula [CHART REVIEW document].
End of ADF service: 15 September 1995.
First imaging / formal diagnosis (confirmation, not onset): 28 May 2021 (first imaging of the thoracic spine).
The precise date of clinical onset cannot be determined from the records.
It is therefore estimated as the midpoint between the first documented presentation with pain in the thoracic spine (29 April 1989) and the end of the veteran's ADF service (15 September 1995).
Estimated date of clinical onset: 7 July 1992.
This date falls within the veteran's ADF service (29 November 1988 15 September 1995).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
