AAI Limited t/as AAMI v Nasr

DETERMINATION OF REVIEW PANEL
CITATION:	AAI Limited t/as AAMI v Nasr [2025] NSWPICMP 23
CLAIMANT:	Tony Nasr
INSURER:	AAMI
REVIEW PANEL
MEMBER:	Nolan
MEDICAL ASSESSOR:	Gibson
MEDICAL ASSESSOR:	Couch
DATE OF DECISION:	9 January 2025
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; assessment of treatment and care; claimant involved in a side-impact motor vehicle collision resulting in lumbar spine injury and delayed reporting of cervical spine symptoms; dispute over whether CT scans of the cervical and lumbar spine were reasonable and necessary and related to injuries caused by the accident; cervical spine symptoms first reported 14 months post-accident; CT scan findings of degenerative changes deemed unrelated to trauma; lumbar spine injury, including L4/5 annular tear and disc bulging with nerve root impingement, causally linked to the motor accident; delayed reporting of symptoms attributed to financial necessity and progressive symptom onset; lumbar spine CT scan found reasonable and necessary to guide ongoing treatment; Held – cervical spine CT scan not reasonable, necessary, or related to the motor accident; lumbar spine CT scan reasonable, necessary, and causally related to the motor accident.
DETERMINATIONS MADE:	CERTIFICATE OF DETERMINATION Replacement Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017 1. The Review Panel revokes the Certificate of Medical Assessor Hyde Page dated 20 March 2023. 2. The Review Panel issues a new certificate determining as follows: (a) The following treatment and care: (i) CT scan report of the lumbosacral spine and sacroiliac joints dated 13 October 2021, RELATES TO THE INJURY caused by the motor accident and is REASONABLE AND NECESSARY IN THE CIRCUMSTANCES. (b) The following treatment and care: (i) CT cervical spine report dated 15 October 2021, DOES NOT RELATE TO THE INJURY caused by the motor accident and is NOT REASONABLE AND NECESSARY IN THE CIRCUMSTANCES.

STATEMENT OF REASONS

INTRODUCTION

Tony Nasr, the claimant, was involved in a motor vehicle accident while driving a Toyota HiLux, which was later written off on 27 June 2020 (the motor accident). He claims he suffered immediate pain in his neck and lower back, though he delayed seeking treatment until October 2020. His general health was noted as good prior to the motor accident, and he had no history of cervical or lumbar spine injuries. He claims that post-accident symptoms included persistent neck and lower back pain radiating to his left leg.
On 7 October 2021, the claimant requested approval for referrals from Dr Dimuthu Samaranayake, relevantly, for a CT scan of the cervical spine and a CT scan of the lumbar spine, pursuant to s 3.24 of the Motor Accident Injuries Act 2017 (the Act).
In its internal review decision dated 25 August 2021, the insurer denied the requests.
The CT scan of the cervical spine was denied on the basis that the claimant’s first reported complaint of a neck injury occurred 14 months post-accident. It was not supported by contemporaneous medical or physiotherapy notes, which did not document any complaints or symptoms related to the cervical spine during that period. The insurer concluded that the reported neck symptoms were not causally linked to the motor vehicle accident and that the requested scan would not contribute to the claimant’s recovery or provide clinically justified information.
The CT scan of the lumbar spine was similarly declined, with the insurer stating that it would duplicate prior imaging, including a CT scan and MRI, which had already revealed degenerative changes unrelated to the accident. The insurer emphasised that the claimant’s current symptoms were more likely attributable to the natural progression of pre-existing degenerative conditions rather than trauma from the accident. In support of this position, the insurer cited medical literature suggesting limited utility of CT scans in addressing back pain, particularly in cases of sciatica, and concluded that further imaging would not enhance the claimant’s recovery.
The CT scan report of the lumbosacral spine and sacroiliac joints was conducted on

12 October 2021 and reported on 13 October 2021 by Dr Jaspal Hunjan. The findings were examined in the context of the claimant's clinical history, which included a previously identified annular tear on MRI, disc bulging at L4/5, facet strain at L4/5 and L5/S1, and left-sided sacroiliac joint radiating pain. The imaging was performed using highly titrated, ultra-low dose, high-resolution 160-slice helical technology to ensure optimal clarity and detail.
The lumbosacral spine findings included chronic anterior bridging osteophytes at T12/L1, with vertebral body and disc heights well-preserved. At L5/S1, a mild, broad-based posterior paracentral disc bulge was identified, accompanied by reactive hypertrophy of the right L5 facet joint and minor mass effect on the right transiting S1 nerve. Early facet osteoarthritis and a pars defect (spondylolysis) were also observed at this level. At L4/5, there was a low-grade disc bulge slightly biased to the left of the midline, causing reactive hypertrophy of the left L4 facet joint and early bilateral facet osteoarthritis, with mild left foraminal stenosis. A similar low-grade disc bulge was identified at L3/4, oriented slightly to the left, along with perineural fibrosis of the left L3 but no evidence of stenosis. At L2/3, a slightly right-biased disc bulge was present without impingement or stenosis. At L1/2, no significant spondylotic changes were observed.
The report concluded that the claimant exhibited chronic multilevel spondylotic disease, particularly at L5/S1, L4/5, and L3/4. Reactive hypertrophy was noted at L5/S1 and L4/5, suggesting degenerative changes, and no central canal stenosis was identified. The pars defect at L5/S1 was described as well-circumscribed, indicating chronicity rather than acute trauma.
The sacroiliac joints were evaluated as smooth, with maintained joint spaces and no evidence of subchondral sclerosis or cystic changes. The bilateral appearances of the SI joints were unremarkable. However, Dr Hunjan noted that sacroiliac joint pain could still be present despite unremarkable radiographic findings, given the lag between radiographic evidence and clinical symptoms related to arthritis.
The CT cervical spine report, conducted and reported on 15 October 2021 by Dr Eugene Ng, evaluated the claimant’s cervical spine following the motor accident at 60 kmph. The accident had resulted in persistent lower neck and lumbar spine pain. The report provided detailed findings on the structural integrity of the cervical spine and identified potential sources of the claimant’s symptoms.
Dr Ng observed normal bony alignment throughout the cervical spine, with no evidence of facet joint arthrosis or malalignment. There were no fractures, avulsion injuries, or abnormalities at the C1/C2 junction or atlantoaxial joints. The spinous processes appeared intact, and no disc bulges of clinical significance or bony lesions were detected at these levels.
At the C2/3, C3/4, and C4/5 levels, moderate foraminal compromise was identified at the left C4/5 level, which Dr Ng noted could predispose the claimant to left C5 radiculopathy. However, there was no evidence of central canal or lateral recess stenosis at these levels or adjacent levels. The C5/6, C6/7, and C7/T1 levels showed no disc bulge, central canal stenosis, or other abnormalities, with these segments appearing unremarkable.
The report concluded that the moderate foraminal stenosis at C4/5 was caused by uncovertebral osteophytes and mild facet joint arthrosis, which likely resulted in impingement of the left C5 nerve root. This finding could account for the claimant’s reported symptoms of left C5 radiculopathy. Dr Ng recommended that, if the clinical symptoms aligned with the imaging findings, a C4/5 transforaminal injection could be considered as a trial for symptomatic relief. The imaging did not reveal any significant disc bulges, fractures, or acute structural changes, reinforcing the chronic degenerative nature of the findings at C4/5 rather than trauma-specific changes.
The claimant referred the dispute over the treatment and care medical assessment matter to the Personal Injury Commission (Commission) for assessment under the Act, specifically, whether referrals for lumbar and cervical spine CT scans:
(a)    are reasonable and necessary in the circumstances under Schedule 2, cl 2(b) of the Act;
(b)    related to an injury caused by the motor accident, also under Schedule 2, cl 2(b) of the Act, and
(c)    would improve recovery under Schedule 2, cl 2(c) of the Act (now repealed).
The medical assessment matter was referred initially to a Medical Assessor.

MEDICAL ASSESSMENT THE SUBJECT OF THE REVIEW

By certificate and reasons dated 20 March 2023 (the MAC), Medical Assessor Murray Hyde-Page (the Medical Assessor) evaluated the treatment and care medical assessment matter.
The Medical Assessor concluded that the lumbar and cervical spine injuries were caused by the motor vehicle accident. This finding was supported by notes from the claimant’s general practitioner (GP), Dr Hany Hanna, and treating professionals including an orthopaedic surgeon and a physiotherapist.
The CT scans were deemed reasonable and necessary to assess the injuries resulting from the accident.
The scans were also found to facilitate recovery by enabling accurate injury assessments and guiding treatment decisions. Even normal findings on CT scans were considered valuable for excluding critical conditions.
The Medical Assessor determined that the CT scans of the lumbar and cervical spine were directly related to the motor vehicle accident. The scans were reasonable, necessary, and beneficial for the claimant’s recovery.

APPLICATION FOR REVIEW

The determination of the President’s delegate, dated 13 June 2023, addressed the insurer’s application for review of the MAC challenging the Medical Assessor’s determination that the claimant’s cervical and lumbar spine conditions were causally related to the motor accident and were CT scans of both were reasonable and necessary.
The insurer contended that there was no evidence to establish a causal link between the accident and the claimant’s cervical spine injury. The insurer argued that the delay of approximately nine months between the accident and the first reported symptoms of a cervical spine injury significantly undermined the assertion of causation. The insurer contended that this delay indicated the cervical spine injury may have resulted from another, unrelated cause. It further argued that the Medical Assessor had failed to address this substantial argument in his reasoning, which rendered the medical assessment incomplete and potentially incorrect in a material respect.
In response, the claimant disputed the necessity for a review and maintained that the MAC was accurate and consistent with his history and symptoms.
After reviewing the application, reply, and all supporting documentation, the President’s delegate concluded that the insurer’s concerns warranted referral to a review panel. Specifically, the delegate found that the Medical Assessor had failed to address the nine-month delay in symptom reporting and its implications for causation. This omission was deemed significant because it ignored a central argument put forward by the insurer and raised reasonable grounds to question the accuracy of the medical assessment.
The delegate determined that there was reasonable cause to suspect the medical assessment was materially incorrect and referred the matter to the Review Panel (the Panel), presently constituted, for further consideration.

REVIEW PROCEDURE

Clause 14F of Schedule 1 of the Personal Injury Commission Act 2020 (the PIC Act) provides that the new review provisions apply in relation to a decision of a new decision-maker. A "new decision maker" is defined in cl 14A(1) of Schedule 1 of the PIC Act. As the medical assessment the subject of the review was made on or after 1 March 2021, the new review provisions apply.
Section 7.26(5A) of the Act provides that a review panel consists of two Medical Assessors and a Member assigned to the Motor Accidents Division of the Commission. Accordingly, the President's delegate referred the matter to this Panel to assess.
Section 41(2) of the PIC Act enables the Commission to make rules with respect to the practice and procedure before the Commission including proceedings before a panel reviewing a decision of a Medical Assessor.
Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the PIC Act. Rule 128 of the PIC Rules provides that a review panel determines how it conducts and determines the proceedings and may determine the proceedings solely based on the written application.
The review is by way of a new assessment of all matters with which the medical assessment is concerned.
By directions issued on 14 July 2023, the parties were directed to provide the Panel a joint bundle of material on which they relied upon the Review. That direction was complied with. The following is a summary of the relevant material provided.

MATERIAL ON THE REVIEW

Dr Hany Hanna referred the claimant for a CT scan of the lumbar spine on 2 October 2020 due to complaints of left-sided sciatica.
The findings indicated that the overall lumbar spine structure was normal, with proper segmentation and maintained disc height across all levels. At the L2/3 and L3/4 levels, no evidence of disc bulging, focal protrusion, or narrowing of the central canal or foramina was observed. At the L4/5 level, minimal diffuse disc bulging was noted, along with early signs of facet joint osteoarthritis. However, there was no significant narrowing of the foramina or central canal. At the L5/S1 level, a minor lobulated disc caused slight indentation of the anterior thecal sac, but no significant central canal or foraminal narrowing was identified.
The interpretation concluded that there were mild spondylotic changes but no definitive neural impingement. The CT scan did not reveal a clear cause for the patient's left-sided sciatica. Dr John O’Rourke, who conducted the analysis, recommended an MRI if symptoms persisted to further investigate the issue.
The claimant underwent an MRI of the lumbar spine on 5 January 2021 following a referral from Dr Indira Datt. The MRI was requested to investigate left-sided pain radiating into the buttock, which the claimant attributed to injuries sustained in the motor accident.
The findings revealed that vertebral body height and alignment were normal, and the conus signal, shape, and position were unremarkable. The cauda equina nerve roots were also noted to be normal. However, there was evidence of reduced disc height and hydration from the L3 level to the sacrum, with no paraspinal soft tissue abnormalities.
At the L1/2 and L2/3 levels, no abnormalities were observed. At the L3/4 level, there was a slight reduction in disc height and hydration without central canal or neuroforaminal stenosis. At the L4/5 level, the scan identified significant findings, including a reduction in disc height and hydration with shallow posterior disc displacement. Although no central canal stenosis was observed, a left lateral annular rent extended into the left neural exit foramen, with likely contact to the exiting left L4 nerve root and descending left L5 nerve root. The facet joints at this level were preserved. At the L5/S1 level, there was no evidence of central canal or neuroforaminal stenosis.
The radiologist concluded that the MRI findings demonstrated a left lateral recess annular rent with posterior soft disc bulging in contact with the exiting left L4 nerve root and the descending left L5 nerve root. These findings likely accounted for the claimant’s reported pain. The report recommended further investigation through CT-guided steroid injections and local anaesthetic intervention should the symptoms persist.
On 4 February 2021, the claimant reported worsening pain in the lower back with radiating symptoms into the left leg, which had persisted since the motor vehicle accident. Clinical findings included severe pain in the left lower back, exacerbated by movement. Deep tissue release to the lumbar spine (L5/S1) was prescribed alongside home exercises, such as straight leg raises (SLR) limited to 40 degrees. Despite these interventions, the claimant continued to experience significant pain and functional restrictions.
By 4 March 2021, there was a noted reduction in symptoms, with the claimant reporting 40% relief of lower back pain. However, he continued to experience shooting pain in the left leg and aching in the buttock. Clinical findings included palpated pain in the left facet joint at L4/5 and L5/S1, with SLR improving to 60 degrees. Deep tissue release was continued, and additional back strengthening exercises were recommended to address persistent radiating pain and improve functionality.
On 18 March 2021, the claimant demonstrated further progress, with a reported 30% reduction in radiating pain to the left leg. He had been performing elastic band exercises, squatting, and straight leg raise (SLR) exercises as part of his rehabilitation routine. Despite these advancements, he continued to report stiffness and tenderness in the lower back, highlighting the need for ongoing treatment.
By 22 April 2021, the claimant reported feeling 50% better in his lower back but continued to experience intermittent radiating pain. Clinical findings included tenderness in the left lumbar region, with further improvement in SLR and reduced pain intensity. Home exercises and deep tissue release to the L5/S1 region were maintained as part of his treatment plan.
On 6 May 2021, the claimant attempted to return to work on light duties, working three days a week. However, he experienced worsening symptoms after 30 minutes of walking or standing, with significant discomfort in the lower back and left leg. Functional limitations included difficulty with prolonged sitting, bending, and lifting. Clinical observations continued to note pain and stiffness, particularly in the left lower back, with the claimant requiring further adjustments to his rehabilitation program.
By 25 May 2021, the claimant reported reduced pain intensity in the legs after shorter work durations and periods of rest. However, recurring stiffness and soreness in the lower back persisted, particularly after activities such as bending, rotating, pushing, and pulling. Straight leg raise improved to 70 degrees with less discomfort, reflecting incremental progress in mobility.
On 6 July 2021, the claimant resumed light duties at work but continued to report persistent lower back pain and stiffness. Clinical notes documented soreness and tenderness in the lumbar spine, with limitations in bending beyond 90 degrees. Home exercises, including SLR and mobilisation, were reviewed and maintained, reflecting the need for ongoing management of his symptoms.
By 19 July 2021, the claimant reported further progress, returning to full-time work with restricted duties. However, he continued to experience intermittent stiffness and tenderness in the lower back, alongside residual radiating pain into the left leg. Straight leg raise remained at 60–70% of the normal range, with less pain. Deep tissue release and home exercises were continued, focusing on mobility and strength to address lingering symptoms. Functional activities, such as walking for 30 minutes or driving for 20–30 minutes, were possible but still provoked mild discomfort.
The physiotherapy assessment and treatment plan, dated 19 July 2021, was provided by

Mr Peter Dong, a physiotherapist, in response to the claimant’s presentation of severe pain following the motor accident. The claimant was referred for rehabilitation by Dr Hany Hanna after imaging, including the MRI of the lumbar spine performed on 5 January 2021, identified a left lateral annular rent at L4/5 with disc bulging contacting the L4 and descending L5 nerve roots. The physiotherapy report detailed the claimant’s significant physical limitations, and the interventions provided to address them.

Initially, the claimant experienced severe pain radiating from his lower back to his left buttock and leg, accompanied by numbness and tingling. His capacity to walk, stand, and drive was substantially restricted, with activities being limited to durations of 15 minutes each due to exacerbation of pain. Objective findings included palpable tenderness in the left facet joint at L4/5 and L5/S1, reduced lumbar range of motion in all planes, and shooting pain radiating into the left leg during straight leg raise tests. The left leg also exhibited greater sensitivity to pain than the right, with observed tightness and tenderness in the back muscles.
Physiotherapy treatment for the claimant focused on pain relief, restoring functionality, and assisting with his return-to-work goals. Over the course of 12 weeks, the claimant engaged in a rehabilitation program comprising passive joint mobilisation, active muscle strengthening, and functional training. These interventions resulted in marked progress, including 90% relief of radiating pain from the lower back to the left leg and 65% relief of general lower back pain. Additionally, the numbness and tingling sensations in the left leg were significantly reduced.
Despite these improvements, the claimant continued to experience intermittent low back pain with occasional radiating sensations to the left leg. Functional limitations persisted, including difficulty standing or walking for more than 40 minutes and lifting objects over 5kg with twisting motions. The physiotherapist noted, however, that the claimant’s walking and sitting tolerances had increased to 45–60 minutes without significant exacerbation of symptoms. He was able to drive for 60 minutes and had resumed full-time work with restricted duties, demonstrating progress toward his rehabilitation goals.
The ongoing treatment plan emphasised core strengthening exercises to improve stability and reduce back strain. Specific interventions included exercises targeting the lower abdominal and deep intersegmental muscles, such as the multifidus, as well as hamstring and iliopsoas stretching. Additionally, ergonomic adjustments and self-management strategies were introduced to prevent recurrent episodes of pain, particularly during work activities.
The physiotherapist concluded that the claimant had made meaningful progress toward achieving his rehabilitation and return-to-work objectives. However, ongoing physiotherapy was recommended to further improve his functional capacity, reduce intermittent back pain, and enable a more complete return to his pre-injury condition.
Dr Medhat Guirgis provided a report dated 23 March 2021 regarding the claimant following the motor accident. The claimant reported being involved in a collision caused by a double-parked vehicle that pulled out without warning, leading to an impact on the passenger side of his car and a subsequent collision with parked cars on the opposite side of the road. At the time of the accident, the claimant was performing the duties of a full-time civil work construction site machine operator. Despite experiencing pain, he attempted to continue his work duties but was forced to cease work on 15 December 2020 due to worsening symptoms. No significant past medical history was noted.
Dr Guirgis diagnosed the claimant with an L4-5 intervertebral disc injury, including a left centro-oblique posterior annular tear associated with a shallow posterior and left-sided disc protrusion. This pathology was noted to extend into the neural exit foramen, with contact to the exiting left L4 nerve root and descending L5 nerve root. The findings correlated with the claimant’s reported symptoms of pain and functional limitations.
Dr Guirgis provided several recommendations, including discussions on the role and risks of CT-guided L4-5 epidural injections. He advised the claimant to continue conservative treatment and arranged for electrophysiological testing before considering invasive measures. Additionally, Dr Guirgis advised avoiding heavy manual handling and machinery that could exacerbate his condition. The report emphasised the need for ongoing management and precautions to address the claimant’s condition effectively.
Dr James Bodel, an orthopaedic surgeon, examined the claimant on 8 June 2023. The consultation and subsequent report assessed the claimant’s injuries, their causation, and their impact on his functionality and ability to work. Dr Bodel reviewed the documentation provided, including the mechanism of injury, prior investigations, and the claimant’s treatment history.
Dr Bodel noted that the claimant, a plant operator, was involved in the motor accident on during which his car was struck and pushed across the road, colliding with parked vehicles. The claimant reported immediate mild pain following the accident but continued working until December 2020, when the pain became unbearable, particularly in the lower back. He subsequently ceased work until mid-2021 before returning in a limited capacity.
Dr Bodel identified the claimant’s injuries as including a musculoligamentous injury to the neck, probable minor rotator cuff pathology in the right shoulder, and a partial ligamentous and cartilaginous injury to the L4/5 disc in the lumbosacral spine. The claimant also reported ongoing symptoms of pain in the lower back, left buttock, and left thigh, with referred pain to the shoulders. Dr Bodel found no evidence of pre-existing conditions or subsequent injuries that could explain the pathology observed.
The physical examination revealed tenderness in the neck, right shoulder, and lower back, with restricted range of motion in these areas. Despite this, there was no clinical evidence of radiculopathy in the lower limbs, and the claimant retained full motor function in the extremities. Dr Bodel noted asymmetry in movement and guarding, consistent with the claimant’s reported symptoms and the findings on prior imaging, including MRI evidence of an annular tear at L4/5.
Dr Bodel concluded that the claimant’s injuries were causally related to the motor vehicle accident. He described the injury to the L4/5 disc as meeting the definition of a threshold injury under the Act due to the ligamentous and cartilaginous damage identified. The claimant was found to have ongoing impairments, including chronic pain and limited range of motion, which impacted his daily activities and ability to fully return to his pre-injury function.
Regarding treatment, Dr Bodel opined that the care provided to the claimant, including rest, physiotherapy, and analgesic medication, had been reasonable and necessary. He recommended that the claimant continue with conservative management, including core strengthening exercises and periodic reviews by his GP. Dr Bodel emphasised the importance of avoiding heavy manual work and suggested ongoing monitoring of the claimant’s functional capacity.
Dr Bodel assessed the claimant’s whole-person impairment using the American Medical Association Guidelines (4th Edition). He assigned a 12% impairment rating, incorporating a 5% impairment for the lumbar spine, 5% for the cervicothoracic spine, and 2% for the right upper extremity. This combined rating reflected the claimant’s ongoing symptoms and limitations resulting from the motor accident.

THRESHOLD INJURY DETERMINATION

The matter was referred to the Medical Assessor Mohammed Assem, to evaluate whether the claimant sustained injuries that exceeded the statutory threshold of a “threshold injury” under the Act, and whether his reported injuries, particularly an annular tear at L4/5 with associated disc protrusion, were causally related to the motor accident. Medical Assessor Assem issued his certificate on 12 July 2022, following an assessment conducted on

18 May 2022.
The claimant alleged that the motor accident caused a significant injury to his lumbar spine, evidenced by imaging findings, clinical symptoms, and his inability to perform certain physical activities without pain. He specifically pointed to an MRI dated 5 January 2021, which identified an annular tear at the L4/5 level with posterior disc bulging contacting the left L4 and L5 nerve roots. The insurer disputed the severity of the injury and its causation, arguing that it met the statutory definition of a threshold injury and questioning the link between the accident and the imaging findings.
Medical Assessor Assem recorded that the claimant reported that the motor accident occurred when another vehicle pulled into his path, causing a collision. He described being thrown side to side during the impact but did not report immediate pain or discomfort. He was able to drive his vehicle, which was later deemed a write-off, to his brother’s home. The airbags did not deploy, and the claimant stated that he experienced no significant limitations immediately after the accident. He continued to work in his physically demanding role as a plant operator for approximately three months post-accident, despite gradually worsening lower back pain radiating into his left thigh and buttock. He did not seek medical attention until October 2020, nearly three months after the accident, when he consulted his GP,

Dr Hany Hanna, due to his increasing discomfort.
Medical Assessor Assem noted that Dr Hanna referred the claimant for a CT scan on

2 October 2020, which revealed mild spondylotic changes and minor disc bulges but no definitive neural impingement. Medical Assessor Assem noted that the claimant continued working despite his symptoms.
The Medical Assessor noted that on 5 January 2021, an MRI was conducted, identifying an annular tear at L4/5 with posterior disc bulging contacting the left L4 and L5 nerve roots. Following these findings, the claimant began physiotherapy with Mr Dong in February 2021, which provided partial relief but failed to resolve his symptoms entirely. Mr Dong’s clinical notes recorded intermittent relief of radiating pain, with some improvement in lower back discomfort. However, the claimant continued to report limitations with prolonged standing, sitting, and heavy lifting.
During the assessment conducted by Medical Assessor Assem, the claimant described persistent lower back pain radiating into his left groin and thigh, as well as difficulty performing routine activities such as prolonged sitting, standing, and walking. The physical examination revealed tenderness over the L4/5 vertebra, limited range of motion, and muscle atrophy, with a 1.5cm reduction in the left thigh circumference and a 1cm reduction in the left calf compared to the right side. Despite these findings, the neurological assessment, including reflexes and sensory evaluations, was normal. Neural tension tests were negative, and the claimant did not meet the criteria for lumbar radiculopathy as outlined in the Motor Accident Guidelines (January 2019).
Medical Assessor Assem reviewed the imaging results alongside the claimant’s clinical presentation. The CT scan performed in October 2020 demonstrated mild degenerative changes without definitive neural impingement, while the MRI conducted in January 2021 identified findings consistent with an annular tear and posterior disc bulging. However, Medical Assessor Assem emphasised that these imaging findings were not, in themselves, definitive evidence of trauma. He noted that such findings could be attributable to degenerative changes or occupational stress, particularly given the claimant’s history of physically demanding work as a plant operator.
In analysing the issue of causation, Medical Assessor Assem placed significant weight on the claimant’s delayed reporting of symptoms and his ability to perform heavy manual work for three months post-accident. The claimant reported continuing to operate a 28-tonne bulldozer and lifting heavy loads such as cement bags, activities that would have been severely restricted had a traumatic annular tear occurred during the accident. The absence of immediate and significant symptoms following the accident undermined the claimant’s assertion that the motor vehicle collision caused the lumbar spine injury. Medical Assessor Assem also noted that the delayed onset of symptoms was inconsistent with the expected clinical presentation of a traumatic annular tear.
The determination concluded that the lumbar spine injury, including the annular tear and disc protrusion, was not caused by the motor vehicle accident. Medical Assessor Assem reasoned that if the accident had caused an acute disc lesion with an annular tear, the claimant would have experienced immediate and severe pain that would have interfered with his ability to perform heavy manual work. The claimant’s ability to sustain regular physical activity post-accident, combined with the delayed reporting of symptoms, was more consistent with degenerative changes or occupational stress.
Additionally, the injury was classified as a “threshold injury” under the Act. Medical Assessor Assem determined that the claimant did not exhibit signs of radiculopathy as required to exceed the statutory threshold for a non-threshold injury. Medical Assessor Assem emphasised that while the claimant may have ongoing symptoms, these did not elevate the injury beyond the definition of a threshold injury as outlined in the Act.

REVIEW OF THRESHOLD DISPUTE

The claimant sought a review of the medical assessment undertaken by Medical Assessor Assem. The claimant argued that his injuries were significant, directly caused by the accident, and were non-threshold injuries. The Review Panel to which the review was referred reviewed all the evidence, including clinical records, imaging findings, and submissions from both the claimant and the insurer.
Relevantly, the Review Panel undertook an assessment of whether the claimant’s lumbar spine injuries, including an annular disc tear at L4/5 with disc protrusion contacting the left L4 and L5 nerve roots, were causally related to the motor accident. The Review Panel considered the claimant’s medical history, imaging findings, and neurological symptoms in making their determination.
The Panel acknowledged the radiological evidence showing an annular tear and disc protrusion at L4/5. However, it noted that such findings could either result from trauma or reflect degenerative changes, particularly in individuals with physically demanding occupational histories. The claimant’s work as a plant operator, involving regular use of heavy machinery, was identified as a possible contributing factor to degenerative changes in the lumbar spine. Despite this, the Review Panel considered the clinical evidence and mechanism of injury to determine causation.
The claimant’s delayed onset of significant symptoms and functional impairment was evaluated. The Review Panel noted that the claimant initially reported mild pain following the accident and only sought medical attention months later. While this delay suggested the possibility of a gradual progression of symptoms, the Review Panel also found neurological evidence consistent with radiculopathy, including wasting of the left thigh and leg, a positive sciatic nerve root stretch test, and asymmetrical depression of the medial hamstring reflexes at L5. These findings satisfied the statutory criteria for radiculopathy under Part 5.9 of the Motor Accident Guidelines.
In applying the principles of causation, the Review Panel used the “but for” test to consider whether the injuries would have occurred but for the motor vehicle accident. Based on the clinical evidence, mechanism of injury, and the claimant’s progressive symptoms, the Review Panel concluded that the motor accident was the likely cause of the annular tear and its associated symptoms. It further accepted the claimant’s explanation that financial pressures compelled him to continue working post-accident, despite worsening symptoms.
The Review Panel ultimately concluded that the claimant sustained a lumbar spine injury involving an annular disc tear at L4/5 with disc protrusion contacting the left L4 nerve root and descending left L5 nerve root. This injury was classified as a non-threshold injury under the Act. Additionally, the claimant exhibited radiculopathy at the L5 level, evidenced by clinical findings such as muscle wasting, reflex asymmetry, and positive nerve root tension tests.
The Review Panel determined that the motor accident was causally related to the lumbar spine injury and associated radiculopathy. It revoked the certificate of Medical Assessor Assem and classified the lumbar spine injury as a non-threshold injury and related to the accident.

RE-EXAMINATION

This Panel determined to re-examine the claimant by way of MS Teams taking a detailed history for the purpose of making a determination as to causation of the cervical and lumbar injuries. In attendance were Member Nolan and Medical Assessor Gibson. The following is a contemporaneous summary of the oral history taken.
The claimant was a 31-year-old plant operator with six years of experience operating heavy machinery at the time of the motor accident.
At the time of the accident, he was driving a Toyota Hilux on a familiar street near his parents’ home. He described the incident as occurring at night when a vehicle that was double-parked suddenly pulled out into his path without signalling. The claimant stated that he had already committed to overtaking the stationary vehicle when it unexpectedly moved, leading to a side impact. The force of the collision pushed his vehicle into a parked car on the opposite side of the road. He explained that the motor accident happened so quickly that he had no time to brake. His vehicle sustained extensive front-end damage and was later deemed a total loss. Despite being equipped with airbags, they did not deploy during the motor accident.
The claimant recounted being in a state of shock immediately following the accident. He was able to drive his vehicle to his brother’s house, which was nearby, but did not call the police or ambulance at the scene. He later reported the incident to the police as part of the insurance process. The claimant admitted that his primary focus initially was on resolving liability disputes with the other driver, who denied fault and claimed the claimant was responsible for the collision. This, he stated, delayed his pursuit of medical care.

Post-accident symptoms and their onset

During the history-taking process, the claimant was questioned extensively about the onset of his symptoms. He stated that he began experiencing pain in his lower back two days after the motor accident. This pain progressively worsened over time and became more severe with physical activity. The claimant described the pain as radiating into his left thigh and buttock, a pattern consistent with sciatica. While the lower back pain became his primary concern, he also reported intermittent neck pain, which he described as less intense and more manageable. The Panel asked why he did not report neck pain earlier in his treatment history. The claimant explained that the neck symptoms were sporadic and overshadowed by the debilitating pain in his lower back and left side.
The Panel also explored the progression of the claimant’s symptoms. He stated that while he initially tried to manage the pain with home remedies, such as topical creams, the symptoms became unbearable over time, particularly when exacerbated by his work activities. He noted that prolonged sitting, exposure to vibrations, and the jolting associated with operating a 28-tonne bulldozer significantly worsened his condition. By December 2020, approximately six months after the accident, the claimant reported reaching a breaking point and took a seven-month leave of absence from work.

Employment history and occupational considerations

The claimant was questioned about his employment history and whether his work could have contributed to his symptoms. He stated that he had worked as a plant operator for six years before the accident, operating heavy machinery on construction sites for housing estates and factories. His role required long hours of sitting, frequent exposure to vibrations, and occasional jolting when working on uneven terrain. The Panel asked whether he had experienced any similar symptoms before the motor accident. The claimant denied any history of back or neck pain and asserted that he had been fully capable of performing his duties prior to the motor accident.

In response to questions about his post-accident work capacity, the claimant stated that he returned to work after his seven-month leave but was initially placed on light duties. These involved less physically demanding tasks, such as gatekeeping and recording truck registrations. After three months, he resumed his regular responsibilities, but the ongoing pain limited his productivity and increased his reliance on pain management strategies.

Medical consultations and imaging results

The claimant first sought medical attention from his GP, Dr Hany Hanna, on 2 October 2020, approximately three months after the accident. He presented with complaints of lower back pain and sciatica. A CT scan ordered by Dr Hanna revealed mild degenerative changes in the lumbar spine but no definitive neural impingement. When his symptoms persisted, an MRI was performed on 5 January 2021, which identified a left lateral annular tear at the L4/5 level with nerve root contact. This finding correlated with the claimant’s clinical presentation of radiating leg pain.
The Panel asked about the findings of orthopaedic surgeon Dr Guirgis, who reviewed the MRI results. The claimant reported that Dr Guirgis confirmed the annular tear and attributed it to the motor accident. Dr Guirgis recommended conservative management, including physiotherapy and, if necessary, CT-guided steroid injections.

Rehabilitation and treatment

Physiotherapist Peter Dong supervised the claimant’s rehabilitation and documented his significant functional limitations. Mr Dong noted restricted mobility, reduced walking tolerance, and difficulty with tasks such as prolonged standing and lifting. The claimant underwent a structured rehabilitation program involving passive joint mobilisation, core strengthening exercises, and ergonomic training. Although he experienced some improvement, he reported ongoing lower back pain that continued to impact his daily life and work performance.
In response to questions about pain management, the claimant stated that he trialled several medications, including Lyrica, Panadeine Forte, and Voltaren gel, but experienced adverse side effects. He eventually transitioned to medicinal cannabis (THC), which provided some relief for his chronic pain and post-traumatic stress disorder symptoms. The claimant described the post-traumatic stress disorder as manifesting in sleep disturbances and emotional distress following the accident.

Delayed reporting of symptoms

The Panel asked about the delay in reporting neck pain. The claimant acknowledged that his initial focus was on his lower back pain, which was more debilitating. He added that his psychological symptoms, including post-traumatic stress disorder, developed gradually and became more noticeable as his physical condition persisted. The Panel also questioned whether any occupational or pre-existing factors could have contributed to his condition. The claimant denied any pre-existing issues and consistently attributed his symptoms to the motor vehicle accident.

Causation

A central issue in the discussions was whether the annular tear identified on the MRI represented a traumatic injury caused by the accident or pre-existing degenerative changes. The claimant maintained that he had no prior history of back or neck pain and asserted that his symptoms were directly linked to the accident.

Current status

At the time of the re-examination interview, the claimant reported persistent lower back pain that affected his daily activities and sleep. He continued to experience flare-ups of neck pain and relied on medicinal THC for pain relief and post-traumatic stress disorder management. He awaited the insurer’s approval for further physiotherapy and imaging.

PANEL’S CONCLUSIONS

Section 3.24(2) of the Act provides that no statutory benefits are payable for the cost of treatment and care if the treatment and care concerned was not reasonable and necessary in the circumstances or did not relate to the injury resulting from the motor accident. This dual requirement necessitates an analysis of both the reasonableness and necessity of the CT scans of the cervical and lumbar spine, as well as their causal connection to injuries sustained in the motor accident.

Cervical spine CT scan

The claimant first reported cervical spine symptoms 14 months after the motor accident. This significant delay in symptom onset was unaccompanied by contemporaneous medical or physiotherapy notes documenting neck pain during the intervening period. Such a delay raises serious questions about the clinical necessity of the scan for addressing any injury arising from the accident, especially one which the claimant described was intermittent.
The CT scan conducted on 15 October 2021 identified degenerative findings at C4/5, including uncovertebral osteophytes and mild facet arthrosis. These findings were characteristic of long-standing, age-related processes rather than acute trauma. Additionally, the scan did not result in any changes to the claimant’s treatment plan, nor did it provide actionable diagnostic insights to address his condition. The sporadic and less severe nature of the claimant’s cervical symptoms, compared to his lumbar spine complaints, further supports the conclusion that the scan did not contribute meaningfully to his treatment and care. Thus, it was not reasonable or necessary in the circumstances as required under s 3.24(2) of the Act.
The cervical spine CT scan also fails to satisfy the requirement that it relate to an injury resulting from the motor accident. The absence of immediate neck pain or symptoms, combined with the degenerative nature of the findings, strongly suggests that the cervical spine condition was unrelated to the motor accident. The findings from the scan are more plausibly attributable to pre-existing degenerative changes or occupational stress rather than trauma resulting from the motor accident.
Accordingly, the cervical spine CT scan does not satisfy either limb of s 3.24(2) of the Act.

Lumbar spine

In the context of considering the causation of the lumbar spine injury, the Panel has considered the divergence of opinion and reasoning between Medical Assessor Assem and the Review Panel’s findings on the causation of the lumbar spine injury.
Medical Assessor Assem adopted a narrow approach, placing significant emphasis on the delayed reporting of symptoms, the claimant’s ability to continue working for several months following the accident, and the degenerative findings in the imaging. He concluded that the lumbar spine injury was not causally linked to the motor vehicle accident, attributing it instead to pre-existing conditions or occupational stress. This interpretation applied a rigid view of factual causation, which insufficiently accounted for the broader context of the claimant’s circumstances, the traumatic nature of the incident, and clinical findings during examination.
In contrast, the Review Panel employed a more thorough analysis that incorporated the findings from its own examination of the claimant. During re-examination, the claimant provided a consistent account of the mechanism of the motor accident, describing a significant side-impact collision that pushed his vehicle into parked cars. He reported lower back pain within two days of the motor accident, which progressively worsened over time, eventually radiating into his left thigh and buttock. The Panel observed during examination that the claimant exhibited tenderness over the L4/5 vertebra, reduced range of motion, and muscle asymmetry consistent with radiculopathy. These clinical findings aligned with imaging results, including evidence of an annular tear and disc bulging at L4/5, which directly impinged on the nerve roots.
Applying the “but-for” test, the Review Panel concluded that the lumbar spine injury would not have occurred but for the motor accident. The timing and progression of symptoms, coupled with imaging findings indicative of trauma rather than degenerative processes, strongly supported this conclusion. Furthermore, the Review Panel accounted for the claimant’s financial necessity to continue working despite his worsening condition, recognising this as a reasonable explanation for the delayed reporting of significant symptoms. This contextual understanding ensured that the delayed symptom onset did not sever the causal connection between the accident and the injury.
The Review Panel’s findings demonstrated that the motor accident was a necessary condition of the lumbar spine injury. Moreover, the Panel acknowledged the principle of material contribution, which applies in cases where multiple factors contribute to an injury. By recognising that the motor accident materially exacerbated a pre-existing vulnerability in the claimant’s lumbar spine, the Review Panel avoided the restrictive focus of Medical Assessor Assem, who attributed the injury solely to degenerative changes.
The evidence provided on review by this Panel supports the finding that the lumbar spine injury sustained, specifically the annular tear and disc bulging at L4/5, was caused by the motor accident. A detailed review of the records, including medical imaging, clinical observations, and the re-examination findings, establishes the requisite causal relationship between the trauma of the accident and the injury, and justifies the reasonableness and necessity of the second CT scan.
The claimant's description of the accident reveals significant forces involved in the collision. The side-impact, which pushed his vehicle into parked cars, created a mechanism of injury consistent with trauma to the lumbar spine. During the re-examination, the claimant reported experiencing lower back pain within two days of the motor accident, which progressively worsened and eventually radiated into his left thigh and buttock. This timeline is consistent with trauma-related radiculopathy. Despite continuing to work due to financial necessity, the claimant experienced significant functional limitations, including difficulty sitting, walking, and lifting. These symptoms were corroborated by the imaging findings, which revealed a left lateral annular tear at L4/5 with posterior disc bulging contacting the left L4 and L5 nerve roots. The MRI conducted on 5 January 2021 confirmed these findings, and further medical opinions, including those of Dr Guirgis and Dr Bodel, identified these abnormalities as likely traumatic and directly attributable to the motor accident.
The clinical findings during the Review Panel’s re-examination reinforced this causation finding. Objective evidence included tenderness over the L4/5 vertebra, reduced range of motion, muscle asymmetry, and nerve root tension consistent with radiculopathy. These findings aligned with the imaging results and the claimant's reported symptoms, underscoring the traumatic mechanism of the motor accident’s material contribution to the injury.
The Panel concludes that the second CT scan of the lumbar spine, conducted in 2021, was reasonable and necessary. Although earlier imaging, including a CT scan in October 2020 and an MRI in January 2021, had revealed findings consistent with trauma, the subsequent CT scan provided updated diagnostic insights into the progression of the injury. This was crucial for guiding ongoing treatment, as the scan confirmed nerve root impingement and validated the continued need for conservative management, such as physiotherapy and potential CT-guided steroid injections.
The physiotherapy records, including those from Peter Dong, documented steady but incomplete progress in pain relief and functional improvement. The continued presence of radiculopathy symptoms, including pain radiating into the left leg, required diagnostic re-evaluation, justifying the second CT scan. Moreover, the CT scan ensured that the treatment plan remained targeted and appropriate. The scan’s utility in confirming the persistence and severity of the injury directly contributed to the claimant’s treatment and care and was therefore both reasonable and necessary under s 3.24(2) of the Act.
In conclusion, the lumbar spine injury was caused by the motor accident, as demonstrated by the claimant’s consistent narrative, the mechanism of injury, and corroborating medical evidence, including imaging findings and clinical observations. The second CT scan was reasonable and necessary as it provided critical diagnostic information that ensured the appropriateness of the claimant’s ongoing treatment and directly supported his care.

[2025] NSWPICMP 23

9 January 2025