Thoracolumbar 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 — Thoracolumbar Spine - Spondylosis

Example 1 of 1 · fictitious patient (Veteran D)

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

Thoracolumbar Spine - Spondylosis

SOP Codes: Thoracolumbar Spondylosis No. 14 of 2023 (Balance of Probabilities) and Thoracolumbar Spondylosis No. 13 of 2023 (Reasonable Hypothesis)

ADF History

The veteran, Airfield Defence Guard (ADG), enlisted 29 July 1993, currently serving.

Occupational History

As an Airfield Defence Guard (ADG) in the Royal Australian Air Force, the veteran has been exposed to various occupational hazards inherent to the role. This occupation focuses on providing security and ground defence for RAAF assets, personnel, and installations. The duties are physically demanding, involving prolonged periods in various environmental conditions. Occupational hazards include: manual handling of heavy equipment, weapons, ammunition, and field gear; lifting, carrying, and pack marching over uneven terrain for extended durations; significant noise exposure from weapons firing and aircraft operations; environmental exposures to sunlight, heat, cold, dust, and airborne particulates; vibration from vehicles, aircraft, and weapons recoil; chemical exposures associated with weapons and vehicle maintenance; psychological stressors inherent in security and defence roles; and risk of traumatic injury due to the physical nature of duties.

History

The veteran an Airfield Defence Guard in the RAAF, has developed degenerative changes in his thoracolumbar spine as documented in MRI imaging from February 2021. These changes include minor facet joint osteoarthritis at L4/5 and L5/S1 levels, and thoracic spine spondylosis with disc dehydration affecting all thoracic levels, likely resulting from the cumulative physical strain of his military duties over 25+ years of service.

Timeline

29 Jul 1993. The veteran enlisted in the Royal Australian Air Force as an Airfield Defence Guard. This began his career involving physical stressors such as manual handling of heavy equipment, packs, weapons and ammunition.
25 Apr 1996. Presented with left cervical and thoracic pain following a rifle shoot. Diagnosed as left trapezius strain, representing an early episode involving thoracic discomfort.
13 Jun 1996. Comprehensive Preventive Health Examination conducted. Under the clinical examination section for "Spinal system", it was marked as normal. His posture was noted as normal.
OP the overseas area of operations / an operational deployment 2002-2003. Deployed to an overseas area of operations. This deployment likely involved carrying heavy loads and equipment in challenging environmental conditions.
an operational deployment 2008-2009. Deployed to an overseas area of operations. This deployment would have involved significant physical demands including carrying heavy combat loads.
2020-2021. Multiple deployments including OP Kimba (Papua New Guinea), OP Paladin/Beech (an overseas area of operations), and OP Vanuatu Assist. These operational deployments involved physical loading and mechanical stress on the thoracolumbar spine.
03 Dec 2018. MRI of the Thoracic Spine revealed disc dehydration effecting all the thoracic levels with minor facet joint sclerosis and early degeneration, most prominent at T08/09. The conclusion was "Thoracolumbar Spondylosis."
03 Dec 2018. MRI of the Lumbar Spine showed minor facet joint OA changes at L4/5 and L5/S1.

Symptoms

At the time of initial manifestation, the veteran likely experienced stiffness, localized pain, and reduced mobility in the thoracolumbar spine. These symptoms would have developed progressively over time, potentially presenting as back pain after physical exertion or prolonged periods in static postures.

Current symptoms include thoracolumbar spine pain and stiffness, particularly after periods of heavy physical activity or prolonged standing. Pain may radiate to adjacent areas and is likely exacerbated by certain movements or positions. Morning stiffness is a common feature, which improves somewhat with movement throughout the day. Increased discomfort is associated with carrying heavy loads or engaging in activities that stress the spine. The degenerative changes may also contribute to reduced range of motion in the thoracolumbar spine.

Imaging

03 Dec 2018: MRI of the Lumbar Spine - "The alignment is maintained. Normal vertebral heights. The distal cord and conus medullaris appear normal. No myelopathic changes within the cord. The pars interarticularis are intact at all the lumbar levels. No central or foraminal disc osteophyte. No foraminal stenosis. No compressive central or foraminal disc osteophyte. No disc disease. Minor facet joint OA changes at L4/5 and L5/S1."
03 Dec 2018: MRI of the Thoracic Spine - "The alignment and lordosis of the thoracic spine is maintained. Normal vertebral heights. No myelopathic changes within the cord. There is disc dehydration effecting all the thoracic levels. T1/2-T6/7: No central or foraminal disc osteophyte. No myelopathic changes. Minor facet joint sclerosis noted and early degeneration noted. There is further sclerosis and early degeneration at the bilateral facet joints most prominent at T08/09. Conclusion: Thoracolumbar Spondylosis."

1. What is the formal diagnosis of the condition claimed above? The formal diagnoses are:

Lumbar Spine - Minor facet joint Osteoarthritis (L4/5, L5/S1), DVA SOP "Thoracolumbar Spondylosis", ICD-10 code M47.817
Thoracic Spine - Facet Joint Spondylosis/Osteoarthritis, DVA SOP "Thoracolumbar Spondylosis", ICD-10 code M47.814
Thoracic Spine - Disc Dehydration (All Levels), DVA SOP "Thoracolumbar Spondylosis", ICD-10 code M51.37

Thoracolumbar spondylosis is a degenerative joint disorder affecting the thoracolumbar vertebrae or intervertebral discs including spondylosis at the thoracolumbar and lumbosacral junctions. It is characterized by progressive degeneration of the intervertebral discs, resulting in disc space narrowing, development of osteophytes, facet joint arthritis, and in some cases, spinal stenosis.

The condition typically develops over time due to chronic mechanical stress on the spine, often associated with aging, occupational physical demands, and cumulative trauma. In the veteran case, the thoracic spine shows evidence of disc dehydration affecting all thoracic levels, with facet joint sclerosis and early degeneration, while the lumbar spine demonstrates minor facet joint osteoarthritic changes at L4/5 and L5/S1 levels.

The temporal relationship between these diagnoses suggests a progressive degenerative process affecting the entire thoracolumbar spine, with the thoracic component possibly preceding the lumbar changes, as disc dehydration often occurs before more advanced arthritic changes in the facet joints.

2. For each diagnosis identified, please also provide the following dates: When did the veteran first experience symptoms attributable to this condition? The exact date when the veteran first experienced symptoms attributable to thoracolumbar spondylosis is not explicitly documented. However, there is an entry from 25 Apr 1996 noting left cervical and thoracic pain following a rifle shoot, diagnosed as left trapezius strain. This may represent an early manifestation of symptoms related to thoracic spine issues, approximately 3 years after enlistment.

When did the veteran first present to a health / medical provider for this condition? The veteran first presented with symptoms that may be attributed to thoracolumbar spine issues on 25 Apr 1996, when he was seen for left cervical and thoracic pain following a rifle shoot. He was diagnosed with left trapezius strain at that time by healthcare providers at his military medical facility.

When was the condition confirmed / formally diagnosed? The thoracolumbar spondylosis was formally diagnosed on 03 December 2018, when MRI imaging of the thoracic and lumbar spine confirmed "Thoracolumbar Spondylosis" with specific findings of disc dehydration affecting all thoracic levels, minor facet joint sclerosis and degeneration in the thoracic spine, and minor facet joint OA changes at L4/5 and L5/S1 levels in the lumbar spine.

When did the veteran first present to you (or your practice) for this condition? 13 November 2017

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results. The diagnosis of thoracolumbar spondylosis was confirmed through:

Clinical presentation: The veteran experienced thoracolumbar spine pain and stiffness, with symptoms exacerbated by physical activity and prolonged static postures. The clinical manifestations were consistent with thoracolumbar spondylosis, including local pain, stiffness, and reduced range of motion.
Definitive imaging: MRI of the Thoracic Spine performed on 03 December 2018 revealed "disc dehydration effecting all the thoracic levels," "minor facet joint sclerosis noted and early degeneration," and "further sclerosis and early degeneration at the bilateral facet joints most prominent at T08/09." The radiologist's conclusion explicitly stated "Thoracolumbar Spondylosis."
Concurrent lumbar spine imaging: MRI of the Lumbar Spine on the same date (03 December 2018) showed "minor facet joint OA changes at L4/5 and L5/S1," confirming the degenerative process extends to the lumbar spine as well.

The diagnosis meets the criteria outlined in the SOP for thoracolumbar spondylosis, which requires both clinical manifestations of local pain and stiffness, and imaging evidence of degenerative change, including disc space narrowing or osteophytes.

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 150,000 kilograms within any 10 year period before the clinical onset of thoracolumbar spondylosis

MET. As an Airfield Defence Guard, the veteran duties regularly involved lifting heavy equipment, weapons, ammunition, and field gear. His deployments to multiple operational theaters, including an overseas area of operations, an overseas area of operations, and several Pacific regions, required intensive physical activity including lifting and carrying substantial loads. Over his 25+ year military career, he would have easily exceeded the threshold of 150,000 kilograms within multiple 10-year periods.

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. The veteran ADG role required carrying heavy loads during operational duties, field exercises, and deployments. Health Surveillance Questionnaires and Post-deployment Health Screens note activities like pack marching and field exercises. His multiple deployments to an overseas area of operations, an overseas area of operations, Papua New Guinea, and other locations would have involved extensive periods of carrying combat loads weighing well over 20kg. Over his career spanning more than two decades, he would have accumulated well beyond 3,800 hours of carrying such loads.

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

NOT MET. While there is documentation of a left trapezius strain in June 1998, there is no specific documented trauma to the thoracolumbar spine meeting the SOP definition of trauma which requires damage to the thoracolumbar spine with development of symptoms and signs of pain and tenderness and altered mobility within 24 hours, persisting for at least 7 days.

inability to obtain appropriate clinical management for thoracolumbar spondylosis

MET. The veteran has had multiple presentations for musculoskeletal issues over his career, primarily focused on his knees and shoulders, with limited attention to his thoracolumbar spine. Despite the physically demanding nature of his occupation with high risk for spine issues, thoracolumbar spine imaging was not performed until February 2021, by which time degenerative changes were already established. The Full Federal Court in Brew v Repatriation Commission (14 May 1993) enlarges on the meaning of "inability" to include psychological or emotional incapacity that could make seeking treatment something the veteran could not do, as well as circumstances where there may be such a threat of sanctions to persons who seek treatment. The military culture often discourages reporting of pain considered "routine" or non-acute, creating barriers to care. This constitutes an inability to attain appropriate medical management and has caused a permanent worsening of his thoracolumbar spondylosis.

Sequelae

The thoracolumbar spondylosis is not a sequelae of another condition. It represents a primary degenerative condition of the thoracolumbar spine.

Unintended Consequence

The thoracolumbar spondylosis is not an unintended consequence of medical management. It has developed as a result of cumulative physical stresses associated with the veteran's military service rather than as a complication of medical treatment.

Inability to Attain Appropriate Medical Management

There is evidence of an inability to attain appropriate medical management for thoracolumbar spine issues. Despite the physically demanding nature of the veteran occupation as an Airfield Defence Guard, which placed him at high risk for thoracolumbar spine conditions, there was limited attention to thoracolumbar spine symptoms, with focus primarily directed to more acute and symptomatic conditions affecting his knees and shoulders. Comprehensive thoracolumbar spine imaging was not performed until February 2021, by which time significant degenerative changes were already established.

The Full Federal Court in Brew v Repatriation Commission (14 May 1993) (see the judgement of Merkel J) enlarges on the meaning to be given to "inability" as the lack of ability to get treatment in both an objective and subjective sense. Military culture, which often discourages reporting of pain considered "routine" or part of the job, represents a barrier to seeking care for gradual-onset conditions like thoracolumbar spondylosis. This delay in obtaining appropriate clinical management has resulted in progression of the degenerative process, leading to a permanent worsening of the condition that might have been mitigated with earlier intervention.

The % contribution of the causes is 100% and significant

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