Reference Determination Content
Suggested draft · fictitious patient
Cervical Spine - Pain, Disc Narrowing at C5/6 and Perineural Cyst
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 17 February 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 17 February 2025;
- A periodic health examination by the medical officer, Garrison health centre, dated 3 March 2009;
- A field casualty record by the patrol medic, Afghanistan, dated 19 June 2010;
- A clinical record and cervical X-ray by the medical officer, Role 2 facility, Afghanistan, dated 21 June 2010;
- An outpatient record and physiotherapy notes by the medical officer and physiotherapist, dated 15 November 2010;
- A periodic health examination by the medical officer, Garrison health centre, dated 9 April 2013;
- A casualty record by the unit medic, Iraq, dated 14 February 2016;
- A clinical record by the medical officer, Deployed health facility, Iraq, dated 2 March 2016;
- An MRI cervical spine by the radiologist, dated 7 July 2016;
- A specialist consultation by the sports physician, dated 19 July 2016;
- An occupational medicine assessment by the occupational physician, dated 22 November 2018.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
21 January 2006 and 18 March 2019
Cervical Spine - Pain, Disc Narrowing at C5/6 and Perineural Cyst
You have stated that your condition was caused by:
- experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament
- forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon
Diagnosis: Pain, Disc Narrowing at C5/6 and Perineural Cyst
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 17 February 2025, and is supported by a clinical record and cervical X-ray by the medical officer, Role 2 facility, Afghanistan, dated 21 June 2010.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Sprain and Strain (Reasonable Hypothesis) (No. 27 of 2020)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament
- forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with severe posterior neck pain with muscle spasm, tenderness over the C5/6 spinous processes and right paraspinal and trapezius muscles, and loss of rotation and side bending on 21 June 2010.
The diagnosis was made clinically by the medical officer on 21 June 2010, two days after the fall: midline tenderness at C5/6, right paraspinal and trapezius spasm, reduced and painful rotation and side bending, pain on resisted movement, and a normal neurological examination, with radiographs excluding fracture. Pain and tenderness began within an hour of the injury, meeting the Statement of Principles definitions of both sprain and strain.
This has then led to further investigations and the diagnosis of your condition of Pain, Disc Narrowing at C5/6 and Perineural Cyst. I have accepted your condition of Pain, Disc Narrowing at C5/6 and Perineural Cyst.
Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that this condition is related to your wartime service.
I have therefore accepted that this condition is related to your service with effect from 19 June 2010.
Cervical Spine - Pain, Disc Narrowing at C5/6 and Perineural Cyst (Worsening)
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 17 February 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 17 February 2025;
- A periodic health examination by the medical officer, Garrison health centre, dated 3 March 2009;
- A field casualty record by the patrol medic, Afghanistan, dated 19 June 2010;
- A clinical record and cervical X-ray by the medical officer, Role 2 facility, Afghanistan, dated 21 June 2010;
- An outpatient record and physiotherapy notes by the medical officer and physiotherapist, dated 15 November 2010;
- A periodic health examination by the medical officer, Garrison health centre, dated 9 April 2013;
- A casualty record by the unit medic, Iraq, dated 14 February 2016;
- A clinical record by the medical officer, Deployed health facility, Iraq, dated 2 March 2016;
- An MRI cervical spine by the radiologist, dated 7 July 2016;
- A specialist consultation by the sports physician, dated 19 July 2016;
- An occupational medicine assessment by the occupational physician, dated 22 November 2018.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
21 January 2006 and 18 March 2019
Cervical Spine - Pain, Disc Narrowing at C5/6 and Perineural Cyst (Worsening)
You have stated that the worsening of your condition was caused by:
- experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament
- forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon
- inability to obtain appropriate clinical management for sprain or strain
Diagnosis: Pain, Disc Narrowing at C5/6 and Perineural Cyst (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 17 February 2025, and is supported by a clinical record and cervical X-ray by the medical officer, Role 2 facility, Afghanistan, dated 21 June 2010.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Sprain and Strain (Reasonable Hypothesis) (No. 27 of 2020)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament
- forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon
- inability to obtain appropriate clinical management for sprain or strain
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with severe posterior neck pain with muscle spasm, tenderness over the C5/6 spinous processes and right paraspinal and trapezius muscles, and loss of rotation and side bending on 21 June 2010.
The diagnosis was made clinically by the medical officer on 21 June 2010, two days after the fall: midline tenderness at C5/6, right paraspinal and trapezius spasm, reduced and painful rotation and side bending, pain on resisted movement, and a normal neurological examination, with radiographs excluding fracture. Pain and tenderness began within an hour of the injury, meeting the Statement of Principles definitions of both sprain and strain.
After the condition arose, it was worsened during your service. On warlike service in Iraq on 14 February 2016, while training partner-force soldiers in close-quarter combat as part of your operational duties, you were thrown onto a concrete floor and landed on the back of your head and shoulders. In the same incident on warlike service in Iraq your posterior neck muscles were forcefully stretched as your neck was driven into flexion and rotation. During warlike service in Iraq from February to May 2016 you could not obtain physiotherapy or imaging for your aggravated neck injury because neither was available at your base and your MRI referrals were cancelled twice for operational reasons.
This has then led to further investigations and the diagnosis of your condition of Pain, Disc Narrowing at C5/6 and Perineural Cyst (Worsening). I have accepted your condition of Pain, Disc Narrowing at C5/6 and Perineural Cyst (Worsening).
Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that the worsening of this condition is related to your wartime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 14 February 2016.
