Allianz Australia Insurance Limited v Pettersen

DETERMINATION OF REVIEW PANEL
CITATION:	Allianz Australia Insurance Limited v Pettersen [2025] NSWPICMP 22
CLAIMANT:	Jason Pettersen
INSURER:	Allianz Australia Insurance Limited
REVIEW PANEL
MEMBER:	Nolan
MEDICAL ASSESSOR:	Gorman
MEDICAL ASSESSOR:	Oates
DATE OF DECISION:	9 January 2025
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; classification of injuries and treatment disputes; claimant involved in a rear-end collision resulting in cervical spine soft tissue injury, lumbar spine L5/S1 disc pathology, and left leg radicular symptoms; cervical spine classified as a threshold injury; lumbar spine and left leg symptoms classified as non-threshold injuries due to partial rupture of fibrocartilage; dispute over the reasonableness and necessity of proposed treatments; lumbar spine surgery deemed not reasonable or necessary due to claimant’s psychological risks; pain education seminar and physiotherapy sessions found reasonable and necessary to address chronic pain and functional limitations; Held – cervical spine injury is a threshold injury; lumbar spine and left leg injuries are non-threshold; selected treatments approved as reasonable and necessary.
DETERMINATIONS MADE:	CERTIFICATE OF DETERMINATION 1. The Review Panel revokes the certificate of Medical Assessor Drew Dixon dated 11 October 2023 and issues a new certificate determining that: (a) the following injury caused by the motor accident: (i) cervical spine – musculo-ligamentous strains with discogenic/neurogenic pathologies *is a threshold injury* for the purposes of the Motor Accidents Injury Act 2017, and (b) the following injuries caused by the motor accident: (i) lumbar spine – musculo-ligamentous strains, tenderness, lumbar disc prolapse L5/S1, annular disc tear at L5/S1 (mri of lumbosacral spine dated 1 June 2022), previous minor back pain was resolved prior to the accident, and (ii) left leg/foot – sciatic pain radiating through the left leg and into the foot are not threshold injuries for the purposes of the Motor Accidents Injury Act 2017.**

FURTHER ASSESSMENT OF TREATMENT AND CARE - REASONABLE AND NECESSARY

Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017 (the Act)

The following treatment and care:
(a)    the specialist review by Dr Fadil Khaled, metabolic surgeon by Dr Pope on 16 August 2022 for the purposes of s 3.24 (Entitlement to statutory benefits for treatment and care);
(b)    the pain education seminar requested by Dr Tillman Bosell, pain specialist, on 27 September 2022 in relation to the cervical spine, lumbar spine and left leg for the purposes of s 3.24 (Entitlement to statutory benefits for treatment and care);
(c)    the 12-week rehabilitation plan requested by Rehab Dynamics from 8 November 2022 to 9 February 2023 in relation to the cervical spine, lumbar spine and left leg for the purposes of s 3.24 (Entitlement to statutory benefits for treatment and care), and
(d)    the eight sessions of physiotherapy requested in Allied Health Recovery Request No. 4 by OMNI Physiotherapy from 4 August 2022 to 14 October 2022 in relation to the cervical spine, lumbar spine and left leg for the purposes of s 3.24 (Entitlement to statutory benefits for treatment and care)
is reasonable and necessary in the circumstances.
The following treatment and care:
(a) the partial L5 and S1 laminectomy, microdiscectomy with rhizolysis above and below the pedicle by Dr Simon McKechnie, neurosurgeon on 1 November 2022 in relation to the lumbar spine and sacrum/coccyx for the purposes of s 3.24 (Entitlement to statutory benefits for treatment and care)
is not reasonable and necessary in the circumstances.

STATEMENT OF REASONS

INTRODUCTION

On 26 February 2022, the claimant, Jason Pettersen, was involved in a motor vehicle accident at approximately 5.30pm while travelling southbound along Parker Street in Kingswood, NSW (the motor accident). The claimant’s vehicle, a utility, was stationary in traffic when it was rear-ended by a Mazda sedan. The impact caused significant damage to the claimant’s vehicle and reportedly threw him forward in his seat. At the time of the accident, he was wearing a seatbelt, and the airbags in his vehicle did not deploy.
Within 24 hours of the motor accident, the claimant began experiencing mid-thoracic back pain, which progressively worsened over the following weeks. During an emergency consultation on 28 February 2022, he reported no neurological deficits and was diagnosed with whiplash. Initial management included analgesics and physiotherapy. Despite these interventions, the claimant’s symptoms persisted and escalated.
The claimant claims he sustained a range of injuries due to the motor accident. These include musculo-ligamentous strains in the cervical spine with suspected discogenic and neurogenic pathologies. In the lumbar spine, imaging revealed musculo-ligamentous strains accompanied by an L5/S1 disc bulge, annular tear, and partial impingement of the S1 nerve roots. He also reported radiating pain through his left leg and into his foot, consistent with S1 nerve root compression. Additionally, the claimant developed psychological symptoms diagnosed as post-traumatic stress disorder (PTSD), presenting with flashbacks, anxiety, sleep disturbances, and avoidance behaviours.
He claims that these injuries resulted in significant functional limitations, notably the inability to sit, stand, or drive for more than 30 to 60 minutes at a time. The claimant says he experienced difficulty performing heavy lifting, repetitive tasks, or household chores without assistance. Sleep disturbances and a reduced ability to engage in social and recreational activities further compounded his condition.
Despite conservative treatment, including physiotherapy, medication, and a cortisone injection, the claimant’s symptoms persisted. An MRI scan dated 1 June 2022 confirmed posterior disc bulging at L5/S1 with an associated annular tear and partial impingement of the S1 nerve roots.

MEDICAL ASSESSMENT MATTERS

The dispute referred to the Personal Injury Commission (the Commission) concerned the classification of the injuries sustained by the claimant in a motor accident, as well as the reasonableness and necessity of the proposed treatments. Central to the dispute was whether the claimant’s injuries, particularly to the cervical spine, lumbar spine, and left leg, met the threshold for classification as threshold or non-threshold injuries under the Motor Accident Injuries Act 2017 (NSW) (the Act).
Whether an individual’s injuries are classified as threshold or non-threshold under the Act significantly affects entitlement to statutory benefits and damages. Statutory benefits for loss of earnings and treatment expenses cease after 26 weeks if “the person’s only injuries resulting from the motor accident were minor injuries.” Furthermore, a claimant cannot recover damages under the Act if their “only injuries resulting from the motor accident were minor injuries.” The classification of the claimant’s right shoulder injury is therefore critical to determining his ongoing entitlements.
The Motor Accident Injuries Amendment Act 2022 (MAI Amendment Act) was assented to on 28 November 2022, with various amendments coming into force on 1 April 2023. Following these amendments, the terminology “minor injury” was replaced with “threshold injury,” and “minor injuries” became “threshold injuries.” Crucially, the substantive definition of what constitutes a minor injury remains unchanged and continues to apply to threshold injuries.
Any reference within these reasons to “minor injury” is to be understood as “threshold injury.” Similarly, references to the term “minor” when describing an injury allegedly caused by the motor accident should be interpreted as “threshold.”
A threshold injury is defined under s 1.6 of the Act as including a “soft tissue injury” or “a psychological or psychiatric injury that is not a recognised psychiatric illness.” Sub-section 1.6(2) of the Act provides that a “soft tissue injury” means:
“[A]n injury to tissue that connects, supports or surrounds other structures or organs of the body (such as muscles, tendons, ligaments, menisci, cartilage, fascia, fibrous tissues, fat, blood vessels and synovial membranes), but not an injury to nerves or a complete or partial rupture of tendons, ligaments, menisci or cartilage.”
The Act also allows for regulations to specify which injuries are included or excluded as threshold injuries. Clause 4 of Part 1 of the Motor Accident Injuries Regulation 2017 (MAI Regulation) explicitly includes within the definition of threshold injury “an injury to the spinal nerve root that manifests in neurological signs (other than radiculopathy).”
Part 5 of the Motor Accidents Guidelines (the Guidelines), promulgated under s 10.2 of the Act, provides the procedural framework for determining whether an injury caused by a motor accident qualifies as a threshold injury. Version 9.1 of the Guidelines, effective from 1 April 2023, applies to motor accidents occurring on or after 1 December 2017.
The Guidelines prescribe the following process for determining threshold injuries:
(a)    the assessment must determine whether the injury is a soft tissue injury, or a threshold psychological or psychiatric injury caused by the motor accident.
(b)    Insurers must not require diagnostic imaging solely to determine if an injury qualifies as a threshold injury, as imaging is not considered necessary for this purpose.
(c)    A diagnosis for a threshold injury decision must be based on a clinical assessment by a medical practitioner or suitably qualified person independent of the insurer.
(d)    The assessment must include evidence derived from:
(i)a comprehensive and accurate medical history, including pre-accident conditions;
(i)a review of all relevant records available at the time of the assessment;
(i)a detailed account of the injured person’s symptoms;
(i)a thorough physical and/or psychological examination, and
(i)diagnostic tests provided these correspond with symptoms and findings on examination.
For injuries to the neck and spine, the Guidelines at clauses 5.7-5.9, further address the necessity of assessing radiculopathy:
(a)    determining whether an injury to the neck or spine qualifies as a soft tissue injury requires an assessment of radiculopathy.
(b)    Radiculopathy is defined as dysfunction of a spinal nerve root where two or more clinical signs are present, including:
(i)loss or asymmetry of reflexes;
(i)positive sciatic nerve root tension signs;
(i)muscle atrophy or decreased limb circumference;
(i)anatomically localised muscle weakness, and
(i)reproducible sensory loss aligned with a spinal nerve root distribution.
(c)    If neurological symptoms do not meet these criteria, the injury will be assessed as a threshold injury.
In Briggs v IAG Limited Trading as NRMA Insurance [2022] NSWSC 372; 100 MVR 232 at [35], Wright J addressed the issue of causation in determining whether an injury qualifies as a threshold injury. His Honour observed that while causation is not explicitly addressed in Part 5 of the Guidelines, it is dealt with in Part 6, which pertains to assessments of permanent impairment. Wright J concluded that the principles applicable to causation in Part 6 should also apply to determinations of threshold injuries.
Part 6 of the Guidelines defines causation as requiring both a medical determination and a non-medical informed judgment. Specifically, causation requires verifying:
(a) whether the alleged factor could have caused or contributed to the impairment (a medical determination), and
(b) whether the alleged factor did cause or contribute to the impairment (a non-medical determination).
Wright J further explained that causation does not require the motor accident to be the sole cause, provided it was a contributing cause that was more than negligible. This aligns with the broader approach articulated in the Guides and the principles applied in common law.
In AAI Ltd T/as GIO v McGiffen [2016] NSWCA 229; 77 MVR 348, the Court of Appeal stressed that causation requires considering whether the motor accident materially contributed to the injury, even if there were other contributing factors.
Further, the appropriateness of proposed treatments to address the claimant’s ongoing symptoms and functional impairments required determination, including:
(a)    a partial left L5 and S1 laminectomy, microdiscectomy, and rhizolysis to address lumbar spine pathology and associated nerve root impingement;
(b)    additional physiotherapy sessions to manage ongoing functional limitations;
(c)    a one-day pain education seminar to provide psychological support and improve chronic pain management, and
(d)    a 12-week rehabilitation plan aimed at return-to-work management and functional improvement
The Commission has jurisdiction to determine disputes as to these medical assessment matters under Schedule 2, cl 2(b) and (e) of the Act, which empowers it to resolve whether an injury caused by the motor accident is a threshold injury for the purposes of the Act and whether any treatment and care provided or to be provided to the injured person is reasonable and necessary in the circumstances or relates to the injury caused by the motor accident for the purposes of s 3.24 of the Act.
Section 3.24 of the Act provides that statutory benefits are payable for treatment or care deemed reasonable and necessary, provided it is causally related to the injuries sustained in the accident.
The Guidelines, in cl 4.76, outline principles for reviewing treatment plans, requiring that treatments demonstrate effectiveness, adopt a biopsychosocial approach, empower recovery, focus on functional improvement, and rely on evidence-based research.
The medical assessment matters were referred initially to a single Medical Assessor for determination.

MEDICAL ASSESSMENT THE SUBJECT OF THE REVIEW

By certificate and reasons dated 11 October 2023 (the MAC), Medical Assessor Drew Dixon (the Medical Assessor) assessed the injuries sustained by the claimant, in the motor accident to determine the classification of the claimant’s injuries under Act and to evaluate the necessity and reasonableness of proposed treatments.
The Medical Assessor found that the claimant had sustained musculo-ligamentous strain injuries to the cervical spine. These injuries were classified as threshold injuries as they involved soft tissue damage without evidence of neurological compromise, fractures, or structural abnormalities. The absence of nerve root involvement or radiculopathy supported the classification of the cervical spine injury as a threshold injury.
In relation to the lumbar spine, the claimant exhibited disc desiccation, a posterior annular tear, and a mild posterior disc bulge at the L5/S1 level, which partially impinged the S1 nerve roots. The claimant reported persistent lower back pain radiating into the left leg and foot, consistent with radicular complaints. However, the Medical Assessor noted that there was insufficient clinical evidence of radiculopathy or neurological deficits to meet the criteria for a threshold injury. Consequently, the lumbar spine injury was classified as a non-threshold injury.
The left leg symptoms, including radiating pain, were attributed to the lumbar spine pathology, specifically the nerve root impingement at L5/S1. The Medical Assessor did not identify any independent or direct injury to the left leg.
The Medical Assessor considered the necessity of proposed treatments, including surgical intervention, physiotherapy, and pain management. A partial left L5 and S1 laminectomy, microdiscectomy, and rhizolysis were recommended to address the nerve root impingement and the claimant’s persistent symptoms. The Medical Assessor deemed the surgery reasonable and necessary, given the failure of conservative treatments such as physiotherapy and cortisone injections to provide sufficient relief. Physiotherapy sessions were also supported to improve the claimant’s functional limitations and reduce pain. Additionally, the Medical Assessor endorsed a one-day pain management seminar to address the claimant’s chronic pain and associated psychological distress, finding it an appropriate part of the recovery process.
In conclusion, the Medical Assessor classified the claimant’s cervical spine injury as a threshold injury and the lumbar spine and left leg injuries as non-threshold injuries. The Medical Assessor determined that the proposed surgical intervention, physiotherapy, and pain management seminar, determining that these treatments were reasonable and necessary to address the claimant’s ongoing pain, functional restrictions, and psychological well-being.

APPLICATION FOR REVIEW

The insurer, Allianz Australia Insurance Limited, applied for a review of the MAC under s 7.26 of the Act.
The insurer’s primary contention was that the Medical Assessor failed to adequately address the issue of causation, which was central to the dispute. The insurer’s submissions explicitly raised the question of whether the claimant’s alleged injuries were causally related to the motor accident. The insurer relied on the expert biomechanical report prepared by Road Safety Solutions, which concluded that the nature and mechanics of the accident were insufficient to cause the lumbar spine injuries claimed. Despite these submissions, the Medical Assessor did not engage substantively with the insurer’s causation arguments or the biomechanical evidence. The MAC merely noted that the insurer did not approve the requested treatment without providing any analysis of the causation issue. The insurer argued that a failure to address clearly articulated arguments constitutes a denial of procedural fairness, which required a medical assessor to address competing expert opinions and submissions.
The insurer further asserted that the Medical Assessor failed to consider material evidence, particularly the claimant’s pre-existing medical history. Records dating back to 2014 revealed a pattern of recurring back pain and injuries unrelated to the motor accident. The insurer submitted that this history was crucial for assessing whether the claimant’s lumbar spine pathology was a pre-existing condition rather than a result of the motor accident. Additionally, the insurer highlighted inconsistencies in the claimant's reported symptoms, such as varying accounts of whether sciatica affected the right or left side, which the Medical Assessor did not address in his reasoning. The failure to consider these inconsistencies, coupled with the omission of relevant evidence, was said to deny the insurer procedural fairness.
In evaluating the Medical Assessor’s determination of non-threshold injuries, the insurer contended that the reasoning was inadequate and unsupported by evidence. The assessment classified the lumbar spine injury as non-threshold based on subjective complaints of pain and the presence of an annular tear at L5/S1 but lacked sufficient objective findings, such as radiculopathy or neurological deficits, as required under cl 5.8 of the Guidelines. The insurer argued that this determination did not meet the requirement that decision-makers must articulate their reasoning process and demonstrate a clear pathway to their conclusions.
The insurer also raised concerns about the recommendations for treatment included in the MAC. For example:
(a)    metabolic surgeon consultation: the insurer argued that the recommendation for a consultation with a metabolic surgeon was unfounded, as the claimant's bloating and gastrointestinal symptoms predated the accident and were unrelated to his alleged injuries.
(b)    Lumbar spine surgery: the recommendation for lumbar surgery (partial left L5 and S1 laminectomy and microdiscectomy with rhizolysis) was similarly challenged, as it was based on the disputed premise that the lumbar pathology was causally linked to the motor accident.
(c)    Physiotherapy: the insurer noted that the claimant had already undergone 32 physiotherapy sessions without significant improvement and argued that further sessions were neither reasonable nor necessary. The Medical Assessor provided no explanation for why additional treatment would yield better results.
(d) Pain education seminar: the insurer contended that the recommendation for a one-day pain seminar lacked evidence of efficacy and failed to satisfy cl 4.76 of the Guidelines, which requires measurable and research-supported treatment outcomes.

The insurer submitted that these errors were not trivial but materially impacted the validity of the MAC.
The insurer concluded that the cumulative effect of the Medical Assessor’s errors, including the failure to consider causation, disregard of material evidence, inadequate reasoning, and unsupported treatment recommendations, warranted a review of the MAC.
The claimant opposed the insurer’s application for a review of the MAC, arguing that the assessment was not incorrect in a material respect.
In response, the claimant argued that the Medical Assessor had conducted a thorough and appropriate evaluation. He highlighted that the Medical Assessor took detailed history from the claimant, reviewed the history of the motor accident and subsequent symptoms, conducted a clinical examination, and considered all relevant documentation. Furthermore, the Medical Assessor provided a clear reasoning pathway for his conclusions, which included finding that the claimant’s injuries, such as the L5/S1 annular tear and radicular complaints, were caused by the motor accident. The claimant argued that the Medical Assessor’s findings met the procedural and evidentiary requirements outlined in the Guides and Guidelines.
Regarding causation, the claimant emphasised that the motor accident need only be a contributing cause, not the sole cause, of the injuries for the assessment to be valid. The claimant pointed to the Medical Assessor’s determination that the injuries were causally linked to the rear-end collision and noted that the Medical Assessor’s reasoning was sufficiently justified in the MAC. They further argued that the Medical Assessor’s statement confirming the review of all submitted documents satisfied the procedural requirements, as the Medical Assessor is not obligated to list or directly address every document or submission in detail.
The claimant criticised the insurer’s reliance on lengthy submissions and case law, arguing that they failed to demonstrate that the assessment was materially incorrect. The claimant cautioned that accepting the insurer’s arguments would set a precedent that could lead to a flood of unnecessary review applications based solely on dissatisfaction with medical assessments, undermining the purpose of the statutory scheme.
The claimant concluded that the Medical Assessor’s findings regarding the non-threshold classification and the reasonableness and necessity of the proposed treatments were accurate and supported by a clear reasoning process.
The President’s Delegate determined that there was reasonable cause to suspect the medical assessment conducted by Medical Assessor was materially incorrect.
The President’s Delegate found that causation was a central and disputed issue between the parties, constituting a “medical controversy.” The Delegate noted that a Medical Assessor must provide a clear reasoning pathway, particularly when addressing such controversies. The failure to engage substantively with the insurer’s arguments and evidence, including the biomechanical report, and the lack of a detailed reasoning process on causation, amounted to a material error.
Consequently, the Delegate accepted the insurer’s application for review and referred the matter to a Review Panel under s 7.26 of the Act. The Review Panel was initially constituted by Member Nolan, Medical Assessor Gorman, and Medical Assessor Stubbs. Following the death of Medical Assessor Stubbs, the Review Panel was reconstituted to include Medical Assessor Oates (the Panel).

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 MAI 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 18 December 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

The records from Our Medical Home Penrith provided an account of the claimant’s medical management following the motor accident.
On 28 February 2022, the claimant presented with mid-thoracic back pain following the accident. A diagnosis of whiplash was made, and neurological findings were normal. The claimant was advised to begin physiotherapy and use analgesics as needed. Subsequent consultation on 29 March 2022 noted persistent lower back pain lasting two days. Examination revealed no significant abnormalities, including normal gait, full range of motion, and no tenderness or paravertebral muscle spasm.
On 4 April 2022, the claimant was diagnosed with neuropathic pain, which was attributed to the accident. Lyrica (pregabalin) was prescribed at 25mg in the morning and 75mg in the evening to manage these symptoms. On 9 April 2022, an Allied Health Recovery Request was initiated to provide physiotherapy for cervical and lumbar spine injuries. The claimant reported functional limitations, including difficulty standing or sitting for more than 60 minutes and restrictions in activities like bending and lifting. Physiotherapy goals included reducing pain and stiffness while improving mobility.
A follow-up on 27 May 2022 documented limited progress. The claimant continued to experience stiffness and pain in the lumbar spine and reported difficulties performing daily activities. On 31 May 2022, the claimant was referred to Riverland Therapy Services for psychological treatment to address anxiety, depression, and post-accident trauma, which had significantly impacted the claimant’s mental health.
On 17 June 2022, a referral for an MRI of the lumbar spine was issued to investigate ongoing lower back pain and assess potential structural abnormalities. The diagnostic imaging was deemed necessary to guide further treatment plans. A review on 2 August 2022 noted slow progress in physiotherapy, with persistent lumbar stiffness and reduced functional capacity. The claimant continued to report significant pain and restricted movements.
On 3 August 2022, the physiotherapy plan was updated to focus on transitioning the claimant to self-management. The updated plan included education on home exercises designed to facilitate recovery and improve outcomes, as the claimant showed minimal improvement despite extensive therapy.
The clinical notes from Stanhope Medical Centre record relevantly as follows. Before the motor accident, the claimant had no significant musculoskeletal or neurological complaints. His medical history included episodic abdominal pain and gastroenteritis, which were well managed with dietary modifications and medications such as Movicol and Nexium. There were no reports of back pain, reduced mobility, or psychological distress prior to the motor accident.
Two days after the accident, on 28 February 2022, the claimant presented with mid-thoracic back pain and was diagnosed with whiplash. Neurological findings were normal, and the claimant was prescribed analgesics and referred for physiotherapy. A follow-up consultation on 1 March 2022 noted persistent back pain but no signs of structural damage or neurological deficits. Functional limitations began to emerge, including difficulties with mobility and daily activities.
By 29 March 2022, the claimant reported worsening lower back pain. While examinations continued to show no significant structural abnormalities, functional limitations, including restricted movement and pain, were evident. These symptoms prompted the initiation of a structured physiotherapy program to address lumbar stiffness and musculo-ligamentous strains.
From April to May 2022, the claimant engaged in physiotherapy under an Allied Health Recovery Request. On 9 April 2022, initial assessments highlighted significant limitations in sitting, standing, and bending. The therapy focused on reducing pain, stiffness, and improving mobility. However, by 27 May 2022, the claimant’s progress remained slow, with ongoing lumbar stiffness and persistent pain reducing his functional capacity.
In June 2022, an MRI confirmed posterior disc bulging at L5/S1 with partial impingement of the S1 nerve root, correlating with the claimant’s reported symptoms. This finding provided evidence of structural injury directly linked to the motor accident. On 17 June 2022, the claimant was referred for further diagnostic evaluations and continued physiotherapy.
By July 2022, the psychological impacts of the accident became apparent, with the claimant reporting anxiety and depression. These symptoms were attributed to the ongoing pain, functional limitations, and trauma from the motor vehicle accident. The claimant was referred to psychological therapy to address these concerns and support his recovery.
The bone scan conducted by Dr Jonathan Tow on 14 April 2022 aimed to assess ongoing thoracolumbar pain reported by the claimant following the motor accident. The study employed a three-phase regional bone scan with SPECT (Single Photon Emission Computed Tomography) and low-dose CT imaging of the lower thoracic and lumbosacral spine. A 745 MBq dose of Tc-99m HDP tracer was administered as part of the procedure.
The imaging revealed no abnormalities during the early-phase soft tissue evaluation. In the delayed-phase images, tracer distribution appeared uniform across the lower thoracic and lumbar spine, with no abnormal isotope uptake observed. SPECT/CT imaging further confirmed the absence of increased isotope activity in the thoracic and lumbar facet joints, thoracolumbar anterior intervertebral joints, sacroiliac joints, or costo-vertebral and costo-transverse joints.
Dr Tow concluded that the imaging showed no evidence of active arthropathy or other structural abnormalities that could account for the claimant’s reported thoracolumbar pain. The findings suggested that the claimant’s symptoms were not attributable to any detectable skeletal pathology.
The MRI scan of the claimant conducted on 1 June 2022, revealed findings consistent with his reported symptoms of persistent lumbar pain and right-sided radiation to the buttock. The imaging utilised sagittal T1, T2, STIR, and axial T2 and T2 FS sequences to evaluate the lumbosacral spine comprehensively.
The scan demonstrated normal lumbar lordosis without evidence of spondylolisthesis or vertebral body fractures. There was no defect observed in the pars interarticularis, and the conus medullaris was found to terminate at the L1/2 level, within normal anatomical limits. The L3/4 and L4/5 levels appeared unremarkable, showing no abnormalities.
However, at the L5/S1 level, the imaging identified mild posterior disc bulging accompanied by disc desiccation, indicative of degenerative changes. A posterocentral disc bulge was observed, partially impinging on the S1 nerve roots in the lateral recesses. Additionally, a small posterocentral annulus tear was noted at this level. The L5 nerve roots were unaffected, ruling out significant involvement at that level.
The conclusion of the report confirmed posterior disc bulging at the L5/S1 level with a posterocentral annulus tear and partial impingement of the S1 nerve roots in the lateral recesses. The findings were deemed consistent with the claimant’s clinical presentation, and clinical correlation was advised.
On 8 August 2022, Dr Simon McKechnie referred the claimant for an MRI of the lumbosacral spine due to persistent lower back pain and radicular symptoms, including left-sided sciatica. The referral aimed to assess the nature and extent of the injury, as conservative treatments such as physiotherapy and pain management had failed to provide adequate relief.
The MRI findings confirmed the presence of an L5/S1 annular tear with partial impingement of the S1 nerve root. These results were consistent with the claimant’s clinical presentation and provided the basis for Dr McKechnie’s recommendations. Following the review of the imaging, Dr McKechnie concluded that surgical intervention was necessary to address the nerve root compression and alleviate the claimant’s radicular symptoms. He proposed a partial left L5 and S1 laminectomy, microdiscectomy, and rhizolysis as the most appropriate course of action to relieve pain and improve functionality.
Dr McKechnie assessed that the lumbar spine pathology was directly linked to the motor accident, citing the mechanism of the rear-end collision as consistent with the development of the L5/S1 injury. He emphasised that the injury and its progression were causally related to the accident and that the proposed surgical intervention was both reasonable and necessary.
At the initial consultation on 17 June 2022, the claimant reported to Dr Matthew Tait, Head of Neurosurgery at Macquarie Neurosurgery and Spine significant back pain that began 24 hours after the accident and progressively worsened over the following three weeks. He described severe limitations in daily activities, including walking, standing, driving, and caring for his young child.
Dr Tait reviewed the claimant following an MRI scan of the lumbar spine, which identified a posterior annular tear at the L5/S1 level, accompanied by a disc protrusion causing left-sided S1 nerve root compression. The compression was noted as not severe. Dr Tait concluded that the claimant’s symptoms were likely attributable to this injury and considered the lumbar disc pathology causally related to the motor vehicle accident.
During the physical examination, the claimant exhibited a severely limited range of motion in the lumbar spine and an antalgic gait. While tenderness was noted in the lumbar spine, there was no reported pain in the sacroiliac joints or greater trochanters. A straight leg raise test was positive on the left side. Neurological assessments, including tone, reflexes, power, sensation, and coordination, were all within normal limits.
Dr Tait recommended a left-sided L5/S1 epidural injection as both a diagnostic and therapeutic measure. The injection aimed to confirm the source of the claimant’s symptoms and provide pain relief. Additionally, he supported ongoing physiotherapy and referred the claimant to a pain specialist, Dr Tillman Boesel, to address the persistent symptoms comprehensively.
Should conservative management, including the epidural injection and physiotherapy, fail to alleviate the claimant’s symptoms, Dr Tait indicated that surgical intervention might be necessary. He suggested that an anterior lumbar interbody fusion at the L5/S1 level could be the appropriate surgical option if required.
The report from Dr Y Han regarding the CT-guided left L5/S1 epidural injection for the claimant, dated 6 July 2022, provided details about the procedure and its immediate effects. The claimant underwent a CT-guided left L5/S1 epidural injection to address persistent lower back pain radiating to the left lower limb, associated with disc pathology at L5/S1. Informed consent was obtained following a discussion of the risks and benefits of the procedure. Preoperative checks and localisation of the injection site were conducted using CT imaging.
Under aseptic technique, a 22-gauge spinal needle was advanced into the left L5/S1 epidural space. A mixture of 1ml Dexamethasone and 2ml Bupivacaine was injected after confirming the needle's placement with a contrast dye. The claimant reported immediate pain relief following the procedure, and no immediate post-procedural complications were noted.
By 5 August 2022, the claimant had undergone the recommended epidural injection, which provided partial relief, reducing his pain severity to 3/10. Dr Tait, however, emphasised the need for a full course of conservative treatment, incorporating physiotherapy, pain management, and weight loss, before considering surgical intervention. Despite these measures, the claimant’s symptoms persisted, leading to a further review on 2 February 2023. Dr Tait noted that the claimant’s pain had occasionally worsened, with ongoing numbness in the left lower limb. He recommended updated imaging, as the previous scans were nearly a year old, to reassess the condition and determine the next steps.
Associate Professor Tilman Boesel’s report, dated 12 September 2022, provided an assessment of the claimant’s ongoing symptoms and outlined recommendations for managing their recovery following the motor accident. The report noted that the claimant continued to suffer from significant lower back pain radiating into the left leg, which had been compounded by psychological factors, including anxiety and symptoms consistent with PTSD. These psychological factors were identified as contributing to the chronic nature of the claimant’s pain and increasing the risk of long-term disability.
Associate Professor Boesel emphasised the importance of addressing both the physical and psychological components of the claimant’s condition. He recommended deferring surgical interventions until the claimant’s mental state improved. Instead, he proposed a multidisciplinary approach to recovery, including attendance at the “KickStart” programme – a one-day psychoeducational seminar aimed at equipping patients with self-management techniques to address chronic pain and psychological distress.
Dr McKechnie’s report, dated 13 September 2022, provided a clinical evaluation of the claimant’s condition and discussed potential treatment options following the motor accident. The claimant reported persistent lower back pain radiating into the left leg and foot, which had gradually worsened despite conservative management, including physiotherapy, anti-inflammatory medication, and a CT-guided epidural cortisone injection. The pain had significantly impacted the claimant’s ability to return to his pre-injury role as a storeperson, which required physically demanding tasks.
On examination, the claimant exhibited a reduced range of lumbar spine movement but maintained the ability to walk with reasonable coordination. No weakness was noted in the lower extremities. The MRI scan findings indicated disc desiccation and a small broad-based L5/S1 disc protrusion causing bilateral S1 nerve root impingement in the lateral recesses, which correlated with the reported symptoms.
Dr McKechnie discussed both conservative and surgical treatment options. He recommended a partial left L5/S1 laminectomy and microdiscectomy with rhizolysis above and below the pedicle to alleviate the nerve root compression. He estimated a 90% likelihood of improvement in the claimant’s radicular symptoms but noted that some lower back pain might persist post-surgery. The risks associated with the procedure, including complications such as infection, haemorrhage, or nerve damage, were explained to the claimant.
The claimant was advised to consider the surgical option, with a follow-up review scheduled in one month to evaluate progress and decide on the next steps.
Associate Professor Boesel’s report, dated 29 October 2022, evaluated the claimant’s ongoing symptoms and addressed concerns over the management of his recovery. The claimant continued to suffer from a persistent pain disorder stemming from his back injury, compounded by psychiatric diagnoses of anxiety and PTSD, as confirmed in a prior psychiatric review. Although the claimant had been prescribed Duloxetine (30–60mg daily) for both pain relief and anxiety, its effects were described as modest, with further benefits anticipated as the dosage increased. Additional pain management included the prescription of Feldene (20mg).

Associate Professor Boesel criticised the insurer’s decision to deny approval for the claimant’s attendance at the "KickStart" programme, a one-day psychoeducational seminar designed to equip patients with evidence-based self-management techniques for chronic pain. He characterised this intervention as cost-effective and essential to reducing the risk of chronic disability, particularly given the claimant’s “significant psychological yellow flags.”
The report highlighted concerns regarding the insurer’s refusal to fund necessary treatments, emphasising that this behaviour contradicted their obligations under a rehabilitation-focused claims process. Associate Professor Boesel strongly advised the insurer to reconsider its refusal and fund the requested intervention, framing it as a reasonable and necessary component of the claimant’s recovery.
Dr McKechnie’s report, dated 1 November 2022, provided a review of the claimant’s condition following the motor accident and recommended surgical intervention. The claimant continued to experience severe lower back pain radiating through the left leg and into the foot. These symptoms were consistent with MRI findings indicating left-sided S1 nerve root compression at the L5/S1 level. Despite nine months of conservative treatment, including physiotherapy, exercises, medication, and a cortisone injection, the claimant reported no improvement in symptoms.
Dr McKechnie discussed the diagnosis and the natural progression of the condition, as well as potential treatment options. He recommended a partial left L5 and S1 laminectomy, microdiscectomy, and rhizolysis above and below the pedicle to alleviate the radicular symptoms. The procedure was estimated to have a 90% likelihood of improving the radicular pain in the left leg. However, he explained that some lower back pain and numbness might persist.
The risks of the procedure were also outlined, including a 1 in 1,000 chance of paralysing complications or loss of bowel, bladder, and sexual function, and a 5% risk of other complications such as infection, haemorrhage, worsened pain, numbness, weakness, cerebrospinal fluid leakage, or recurrence requiring further surgery.
The claimant expressed a desire to proceed with the recommended surgery after all questions were addressed. Dr McKechnie stated his intention to seek approval from the insurer and planned to review the claimant’s progress in the coming weeks.
Dr McKechnie’s report, dated 7 December 2022, summarised the claimant’s condition and provided an update on the status of his proposed treatment. The claimant continued to report persistent lower back pain radiating to the left leg, consistent with MRI findings of left S1 nerve root compression at the L5/S1 level. Despite ongoing conservative treatment, including physiotherapy, core strengthening exercises, and medications such as Duloxetine, Lyrica, and anti-inflammatories, the claimant experienced no significant improvement.
Dr McKechnie noted that the insurance company had declined liability for the recommended surgical procedure, a partial left L5 and S1 laminectomy, microdiscectomy, and rhizolysis. The claimant had engaged legal representation to appeal this decision, and Dr McKechnie expressed his support for the appeal.
In the meantime, Dr McKechnie advised the claimant to continue with core-strengthening exercises, avoid repetitive bending or lifting over five kilograms, and maintain his current medication regimen. The report reiterated the necessity of the surgical intervention to address the claimant’s unresolved symptoms and improve his quality of life.
On 2 March 2023, Dr Tait reviewed updated imaging, which confirmed the continued presence of a posterior annular tear at L5/S1 with bilateral S1 nerve root compression. The claimant continued to experience significant difficulties with daily activities, including bending, dressing, shopping, and driving, alongside disturbed sleep and challenges caring for his young child. Dr Tait concluded that conservative measures had been exhausted, and that surgical intervention was necessary. He recommended an anterior lumbar interbody fusion (ALIF) at L5/S1, combined with pedicle screw insertion, estimating a 60-70% likelihood of significant pain improvement. He thoroughly explained the risks of the procedure, including the possibility of failure to improve, future adjacent segment disease, infection, and rare complications such as paralysis or bowel and bladder dysfunction. The claimant consented to the procedure, and Dr Tait submitted a request to the insurer for approval.
Despite this, on 11 May 2023, the insurer declined the request for a vascular surgeon consultation required for the ALIF procedure, asserting that the L5/S1 injury was not causally related to the motor vehicle accident. Dr Tait’s subsequent correspondence reaffirmed the necessity of surgery, supported by consistent imaging findings, the claimant’s ongoing symptoms, and the lack of improvement from conservative management. Dr Tait maintained that the claimant’s injuries were directly linked to the motor accident and that surgical intervention offered the best prospect of recovery.
The Allied Health Recovery Request, dated 9 April 2022, provided an account of the claimant’s post-accident condition and rehabilitation needs following the motor accident. The report identified significant musculoskeletal injuries to the cervical and lumbar spine, specifically musculo-ligamentous strains with associated discogenic and neurogenic pathologies. These injuries had manifested as persistent pain in the cervical region, including bilateral upper quadrant discomfort, and centralised and bilateral lumbar spine pain. The pain levels were reported as 4/10 on the Visual Analogue Scale (VAS), indicating moderate yet impactful discomfort. Observational findings included physical abnormalities such as flattened cervical lordosis, forward head posture, bilateral protracted shoulders, increased lumbar lordosis, and pelvic hitching, reflecting the severity of the claimant’s postural and structural impairments.
Functionally, the claimant’s capacity to engage in daily activities had been significantly diminished. At the time of the request, the claimant could sit or drive for no more than 60 minutes and could stand for the same duration. Bending, lifting, and moving items weighing more than two kilograms were not feasible, and the claimant required external assistance for basic household tasks such as cleaning, mopping, and dusting. This level of impairment not only impacted the claimant’s physical independence but also underscored the necessity for targeted rehabilitative intervention to restore functional capabilities.
The request outlined an action plan aimed at reducing pain, improving range of motion, and rebuilding physical strength. The physiotherapist proposed a combination of education, and a structured home-based exercise programme tailored to the claimant’s needs. Two specific rehabilitation goals were set for achievement by late April 2022: first, the claimant would be able to sit, walk, or stand for a continuous period of 90 minutes; second, the claimant would regain the capacity to lift and move items weighing four to five kilograms. These goals were designed to incrementally restore the claimant’s functionality and quality of life, aligning with the overarching principles of effective rehabilitation.
To support the claimant’s recovery, the request sought approval for eight standard physiotherapy sessions. These sessions were deemed necessary to address the claimant’s ongoing symptoms and functional restrictions. The proposed physiotherapy treatments aimed to reduce pain, enhance range of motion, and strengthen the injured areas, while complementing the home-based exercises and educational strategies already implemented. The sessions were framed as essential in facilitating the claimant’s transition towards greater physical self-sufficiency and reducing reliance on external support.
The Allied Health Recovery Request dated 27 May 2022 identified the claimant’s physical injuries, specifically musculo-ligamentous strains in both the cervical and lumbar spine regions, accompanied by discogenic and neurogenic pathologies. The claimant reported bilateral cervical pain extending into the upper quadrant and centralised lumbar pain radiating bilaterally. Pain levels were recorded as 3/10 on the VAS. Observations highlighted persistent abnormalities in posture, including flattened cervical lordosis, forward head posture, bilateral protracted shoulders, increased lumbar lordosis, and hitching of the pelvis.
Functionally, the claimant demonstrated significant limitations in daily activities. At the time of the assessment, the claimant could only sit or drive for up to 60 minutes and was similarly limited in standing. Tasks such as bending, squatting, or lifting items exceeding three kilograms were not feasible. Additionally, the claimant required assistance with household chores, including cooking, cleaning, and mopping, further evidencing the substantial impact of the injuries on their ability to perform basic activities of daily living.
To address these impairments, a tailored action plan was proposed by the physiotherapist. The plan combined education with a structured home-based exercise programme designed to enhance strength and mobility while alleviating pain. The primary rehabilitation goals were to enable the claimant to sit, walk, or stand for 90 minutes continuously by late June 2022 and to regain the capacity to lift and move items weighing up to four to five kilograms within the same timeframe.
The request sought approval for a continuation of physiotherapy sessions deemed essential for the claimant’s recovery. These sessions aimed to further reduce pain, restore range of motion, and improve strength in the affected regions. The treatment plan was framed as necessary for achieving incremental progress and mitigating the claimant’s reliance on external assistance for routine activities.
The Rehab Dynamics Case Conference Report, dated 31 May 2022, detailed the ongoing rehabilitation needs and progress of the claimant. The case conference aimed to evaluate the claimant’s rehabilitation progress and address ongoing limitations impacting his recovery and capacity to return to work. The report identified persistent challenges, including significant lower back pain, which continued to restrict the claimant's ability to perform daily activities and engage in employment-related tasks. Despite prior rehabilitation efforts, including physiotherapy and exercise programs, the claimant remained unable to return to his pre-injury role as a storeman due to ongoing pain and limited physical capacity.
The claimant’s pre-injury role required physically demanding activities, such as lifting heavy objects, loading trucks, and operating machinery. Post-accident, the claimant reported an inability to perform these tasks, with symptoms aggravated by bending, lifting, and prolonged standing. Additional barriers included difficulties with household chores and recreational activities, highlighting the broader impact of his injuries on daily living.
The conference outlined a plan to address these limitations through continued rehabilitation services. Recommendations included further physiotherapy to manage pain and improve functional capacity, as well as a focus on activities of daily living retraining. The report also emphasised the importance of ongoing medical consultations, including reviews with a neurosurgeon, pain specialist, and psychiatrist, to assess the necessity of surgical intervention and develop a comprehensive treatment strategy.
Rehabilitation goals were established to incrementally restore the claimant’s physical capacity and facilitate a gradual return to work. These included improving endurance for standing and sitting, increasing weight-lifting capabilities, and achieving functional milestones over a defined period. Regular case conferences were proposed to monitor progress and adjust the rehabilitation plan as necessary. The report concluded that the claimant would benefit from continued rehabilitation services to manage his injuries and support his recovery journey.
The Allied Health Recovery Request dated 16 June 2022 provided an updated assessment of the claimant’s rehabilitation needs following the motor vehicle accident on 26 February 2022. The report outlined the claimant’s ongoing symptoms, including cervical and lumbar spine musculo-ligamentous strains with associated discogenic and neurogenic pathologies. Pain levels were reported as 3/10 on the VAS, with areas of pain including the cervical spine, bilateral upper quadrant, and central and bilateral lumbar spine. Observations of the claimant’s physical state included flattened cervical lordosis, forward head posture, bilateral protracted shoulders, increased lumbar lordosis, and hitching of the pelvis.
Functionally, the claimant experienced considerable difficulties with daily activities. At the time of the report, the claimant could sit or drive for a maximum of 60 minutes and stand for the same duration. Tasks such as bending, squatting, or lifting items exceeding three kilograms were not feasible. The claimant relied on friends for basic household chores, such as cleaning and vacuuming, due to these restrictions.
The rehabilitation plan included continued physiotherapy sessions focused on reducing pain, increasing range of motion, and improving strength in the affected areas. The claimant’s physiotherapist also proposed a tailored home-based exercise programme to complement the in-person sessions. Specific goals were set for late June 2022, including the ability to sit, walk, or stand for up to 90 minutes and to lift and move items weighing four to five kilograms. The request supported the continuation of physiotherapy treatments, emphasising their importance in alleviating symptoms, restoring functionality, and enabling the claimant to achieve greater independence.
The Allied Health Recovery Request, dated 2 August 2022, provided a detailed update on the claimant’s rehabilitation progress and the necessity for continued physiotherapy sessions following the motor vehicle accident. The report outlined persistent physical impairments affecting the claimant’s cervical and lumbar spine. Diagnoses included musculo-ligamentous strains with discogenic and neurogenic pathologies. Pain was reported as 4/10 on the VAS, with specific areas of discomfort including bilateral cervical and upper quadrant pain as well as central and bilateral lumbar pain. Observational findings highlighted flattened cervical lordosis, forward head posture, bilateral protracted shoulders, increased lumbar lordosis, and pelvic hitching. These structural abnormalities underpinned the claimant’s reported limitations in physical function.
The claimant experienced significant restrictions in daily activities. He could only sit, stand, or drive for 30 minutes before symptoms became unmanageable. Tasks requiring bending, squatting, or lifting items heavier than three kilograms were not feasible. The claimant relied on assistance for household chores, including cleaning and vacuuming, further demonstrating the impact of his injuries on daily living.
The physiotherapist proposed an updated rehabilitation plan aimed at alleviating pain, increasing range of motion, and strengthening the injured areas. Goals were set for late August 2022, including the ability to sit, stand, or walk for up to 60 minutes and the capacity to lift and move items weighing four to five kilograms. The plan included education, a tailored home-based exercise programme, and in-person physiotherapy sessions.
The request sought approval for eight additional physiotherapy sessions, deemed necessary to address ongoing symptoms and achieve the established goals. These treatments aimed to complement the existing home-based programme while providing critical support for functional recovery. The claimant had already undergone 30 sessions of physiotherapy, but the physiotherapist highlighted the continued need for professional intervention to facilitate measurable improvements.
The Allied Health Recovery Request dated 3 August 2022 provided an update on the claimant’s rehabilitation progress and the rationale for additional physiotherapy sessions. The claimant continued to experience significant physical limitations following the motor vehicle accident. Diagnoses included musculo-ligamentous strains affecting both the cervical and lumbar spine, with associated discogenic and neurogenic pathologies. The claimant reported pain levels at 4/10 on the VAS, with symptoms localised to the cervical spine, upper quadrants, and central and bilateral lumbar regions. Observational findings highlighted structural impairments such as flattened cervical lordosis, forward head posture, bilateral protracted shoulders, increased lumbar lordosis, and hitching of the pelvis, all contributing to restricted mobility.
Functionally, the claimant was significantly limited in his daily activities. He was unable to sit, drive, or stand for more than 30 minutes without exacerbating symptoms. Tasks requiring bending, squatting, or lifting items heavier than three kilograms remained unfeasible. The claimant also relied on assistance for household chores such as cleaning and vacuuming, further illustrating the impact of his injuries on daily living.
To address these limitations, the physiotherapist proposed a continued rehabilitation plan, which included an additional eight physiotherapy sessions. These sessions aimed to reduce pain, improve range of motion, and strengthen the injured areas. The physiotherapist also implemented a home-based exercise programme and set specific goals for late August 2022. These included the ability to sit, walk, or stand for up to 60 minutes and to lift and move items weighing four to five kilograms.
The request justified the need for additional physiotherapy sessions by emphasising their importance in achieving incremental progress toward functional recovery. The physiotherapy was deemed essential to address ongoing symptoms, improve independence, and reduce the claimant’s reliance on external assistance.
The Rehab Dynamics closure report, dated 29 August 2022, provided an assessment of the claimant’s progress and the effectiveness of the rehabilitation services undertaken following the motor vehicle accident. The report detailed the claimant’s persistent symptoms and outlined areas where further intervention was necessary to support recovery.
The claimant continued to experience significant limitations in physical function, including ongoing lower back pain radiating to the left leg. These symptoms impacted daily activities and work-related tasks, such as prolonged sitting, standing, or driving. Additionally, bending, lifting, and engaging in repetitive physical activities remained challenging, further emphasising the claimant’s reduced functional capacity.
Despite participation in a structured rehabilitation programme, only minor improvements were observed in mobility and pain management. The report concluded that these gains were insufficient to restore the claimant’s ability to return to pre-injury work or achieve independence in daily living. The limitations highlighted a need for ongoing intervention to address unresolved symptoms.
The report recommended continued multidisciplinary support, including physiotherapy, consultations with a pain specialist, and follow-up with a neurosurgeon to explore potential surgical options. A focus on incremental recovery milestones and regular progress reviews was proposed to adjust the rehabilitation plan as required and optimise outcomes.
The Allied Health Recovery Request, dated 8 September 2022, summarised the claimant’s ongoing physical limitations and proposed additional physiotherapy treatments to address persistent symptoms resulting from the motor vehicle accident. The claimant’s physical impairments were attributed to musculo-ligamentous strains in the cervical and lumbar spine, with discogenic and neurogenic pathologies contributing to persistent pain. Pain levels were recorded at 4/10 on the VAS, indicating moderate but consistent discomfort. Observational findings included postural abnormalities such as forward head posture, flattened cervical lordosis, and increased lumbar lordosis, coupled with bilateral protracted shoulders and hitching of the pelvis.

Functionally, the claimant reported significant restrictions in daily activities. He was unable to sit, drive, or stand for longer than 30 minutes without experiencing exacerbated symptoms. Tasks involving bending, lifting, or repetitive movements were particularly challenging, necessitating external assistance for household chores such as cleaning and vacuuming. These limitations demonstrated the ongoing impact of the injuries on the claimant’s ability to maintain independence and perform essential activities.
To address these challenges, the treating physiotherapist recommended an additional eight physiotherapy sessions. The proposed treatments aimed to reduce pain, restore range of motion, and strengthen the injured areas, thereby improving the claimant’s functional capacity. Rehabilitation goals included enabling the claimant to sit, stand, or walk for up to 60 minutes by late September 2022 and regaining the ability to lift and move items weighing four to five kilograms. The request also included a continuation of the claimant’s tailored home-based exercise programme to support incremental recovery.
The Rehab Dynamics rehabilitation plan, dated 9 November 2022, outlined a comprehensive 12-week programme aimed at supporting the claimant’s recovery and facilitating a phased return to work. The primary goal was to enable the claimant to return to full-time employment as a storeperson with their pre-injury employer. The programme proposed incremental steps, with work hours increasing to 10 hours per week by week 4, 15 hours by week 8, and 20 hours by the end of the 12-week period.
The plan included several key components to ensure the claimant’s progress. First, a structured return-to-work management plan was proposed, focusing on gradually upgrading the claimant’s work capacity. Case management services were included to provide regular updates to medical practitioners and the insurer, ensuring close monitoring of the claimant’s functional gains and treatment progress. Additionally, monthly case conferences were recommended to coordinate with healthcare providers, review progress, and establish further goals.
To support the implementation of the plan, provider travel was arranged for case conferences and activities of daily living reviews. The plan also included the preparation of detailed rehabilitation reports, email updates, progress assessments, and a final summary report to document outcomes and inform decision-making.
The rehabilitation plan emphasised the importance of a multidisciplinary approach to recovery. The claimant was encouraged to remain active, attend physiotherapy sessions, and adhere to prescribed exercises. Regular consultations with medical specialist Dr Hossein Javaheri were included to guide treatment and address ongoing symptoms. Collaboration between physiotherapists and other providers formed the backbone of the programme, ensuring continuity of care and coordinated efforts.
The plan justified its recommendations by highlighting the claimant’s ongoing limitations caused by the accident and the need for a structured approach to manage physical capacity and reduce reliance on external support. The total cost of the programme was estimated at $3,425, covering all proposed services. The report concluded that the 12-week programme was essential to facilitate sustainable recovery and enable the claimant to resume his pre-injury role.

Biomechanical report

The Road Safety Solutions report, dated 11 July 2022, provided a biomechanical analysis of the motor accident. It recorded that the collision occurred when the claimant’s vehicle, a 2015 Nissan Navara utility, was struck from the rear by a 2010 Mazda sedan while stationary. The report described the collision as a 50% offset rear impact and estimated the velocity change of the claimant’s vehicle to be between 7 and 10.5kmph.
The claimant’s vehicle had undergone significant structural modifications, including the installation of rigid bumpers and a heavy-duty towbar. These modifications were noted to have eliminated the vehicle’s rear-end energy absorption capabilities. As a result, most of the collision energy was transferred to the front of the Mazda sedan. Photographic evidence supported this conclusion, showing minimal damage to the claimant’s vehicle compared to substantial deformation of the front-end structures of the Mazda. The report emphasised that these modifications reduced the overall impact on the claimant’s vehicle, further minimising the potential for injury.
The report examined the crash dynamics and concluded that the forces involved were insufficient to cause the injuries alleged by the claimant. Specifically, the lumbar spine injuries, including posterior disc bulging and annular tear at L5/S1, were deemed biomechanically implausible. The robust structure of the lumbar spine and the protective design of modern vehicle seating systems were cited as factors that would have prevented significant spinal damage. The velocity change experienced by the claimant’s vehicle was considered well below the threshold typically associated with lumbosacral injuries.
The biomechanical analysis also highlighted that the modifications to the claimant’s vehicle played a crucial role in mitigating the impact. The rigid rear structure absorbed minimal energy, while the bulk of the collision forces were absorbed by the insured vehicle. The report noted that this redistribution of energy further reduced the likelihood of injury to the claimant.
In addition to analysing the crash dynamics, the report evaluated the photographic evidence of the vehicles involved. The minimal damage to the claimant’s vehicle, as opposed to the significant deformation of the insured vehicle, corroborated the findings that the forces at play were minor. This reinforced the conclusion that the accident did not generate sufficient force to result in the injuries claimed by the claimant.
The report concluded that there was “no possibility” that the collision could have caused the lumbar spine injuries alleged by the claimant. It determined that the injuries were not causally related to the motor accident based on the biomechanical thresholds and the observed evidence.

RECONSIDERATION BY THE PANEL

The Panel determined that a re-examination of the claimant was required.

RE-EXAMINATION

Details of who attended the assessment

The claimant attended and was assessed unaccompanied by Medical Assessor Gorman. Medical Assessor Oates was present via MS Teams video link.

HISTORY

Pre-accident medical history and relevant personal details

The claimant gave a history of abdominal pain and bloating and constipation. He attended Nepean Hospital on 24 October 2021. Abdominal X-rays did not show a bowel obstruction. Ultrasound scans showed a fatty liver. He was discharged on Movicol for constipation and for consideration of further investigations.
The claimant did not recall any prior episodes of back pain; however, the Medical Assessors referred him to an entry in the medical evidence dated 26 August 2014 referring to onset of lower back pain after lifting a 30kg box when moving house. He said there was no associated leg pain and that this episode of pain settled within a few days. He took some medications but does not recall having any physiotherapy.
There was also a general practitioner (GP) record dating from 24 November 2015 referred to lower back pain after heaving lifting on 21 November 2015 consisting of 15-20kg concrete slabs at home. The claimant recalled this and said there was no leg pain and that the back pain settled within a couple of days.
It seems that both these previous episodes of low back pain were self-limiting.
The claimant said he had a previous history of reactive depression in 2021 when he was harassed by a new female supervisor at work. He reported the harassment to Human Resources (HR) and the supervisor was moved to a different section and his symptoms, which had consisted of a facial tic and lock jaw, resolved completely. He saw a GP at the time but did not see a psychiatrist and did not have any medications.
He lives in a house with his wife and two children. His wife works full-time as a store person. His children are aged seven and five years.
He worked as a hardware shop assistant for five years and then ten years as a storeman and forklift driver at DHL. He tried to return to work shortly after the motor accident but had to stop about four weeks afterwards because of severe low back pain. He has not returned to work since.
He is a non-smoker but does have a few drinks on a Saturday night. He has been advised to stop drinking by his treating psychiatrist, so has cut down.

History of the motor accident

The claimant confirmed he was the driver of a Nissan Navarro twin cab utility. He was rear-ended by a Mazda 3 on Northern Road in Kingswood, heading southbound towards the M4, in front of a Hungry Jacks store. He was in the left lane and his car was stationary when he was rear-ended.
He had a sore neck and upper lumbar spine pain at the time. There was no impact injury. He was able to self-extricate from the vehicle.

History of symptoms and treatment following the motor accident

He saw a GP, Dr Javaheri, for the first time two days after the accident on 28 February 2022 complaining of mid-thoracic pain and was diagnosed with a whiplash injury, prescribed analgesics and referred for physiotherapy. There was no neurological deficit.
He returned to the general practice on 1 March 2022 and again on 28 March 2022 complaining of back pain with normal physical examination recorded. He was advised to do physiotherapy. His symptoms were fluctuating.
He returned to the practice on 29 March 2022 asking for a certificate for work, as he had not been able to continue because of increasing severity of back pain. He was advised to see a different doctor for a WorkCover Certificate.
He saw another GP at the practice on 29 March 2022 complaining of lower back pain with no radiation. Range of movement was within normal limits and straight leg raise was normal bilaterally. He was advised simply analgesics and symptomatic treatment.
He started physiotherapy with Mr J Kang on 30 March 2022 and had complaints of neck and low back pain with tingling down both arms and that he had been back and forwards to work, hoping the symptoms would resolve by themselves, but over the preceding few weeks, symptoms had been getting worse.
He noted that he was the driver with his wife as front seat passenger and two children in the back seat. His car was still driveable after the accident.
When the Medical Assessors asked him about the exact site of pain and the interval between the onset of low back pain and the accident, he said that he was not happy with the doctors he had seen at the original clinic and had asked the insurer for permission to change GPs and thereafter started going to Dr Pope, who got scans done and made a referral to a specialist.
He commenced physiotherapy after he had ceased work approximately one month after the accident. He developed left leg pain at this time and after use of a nerve stimulator by the physiotherapist, developed significant burning pain down the left leg which prompted a visit to the Emergency Department at Hawkesbury Hospital in Windsor on 28 April 2022.
By that stage, he was on ibuprofen and Pregabalin 25mg twice daily. He was noted to have normal power in all limbs and normal light touch sensation in the lower limbs. The Pregabalin dose was increased, and he was put on regular paracetamol and to continue ibuprofen and follow up with the GP.
At review with Dr Pope on 24 May 2022, he was referred to Dr Matthew Tait, neurosurgeon, Kingswood for an opinion regarding the lumbar pain he had developed after the accident, which had not responded to physiotherapy and that he had developed burning paraesthesia in the left leg after neurostimulation treatment. At that stage, he was on Nuromol tablets
one to two twice daily.
At this time, Dr Pope ordered an MRI scan lumbar spine which was reported on 1 June 2022 to show mild posterior L5/S1 disc bulge with disc desiccation and posterocentral disc bulge abutting and partially impinging the S1 nerve roots in the lateral recesses, with a small posterocentral annular tear (high intensity zone). The L5 nerve roots were not impinged upon.
He was seen by Dr Tait on 17 June 2022. He noted severe limitation of lumbar range of movement with antalgic gait and tenderness over the lumbar spine, with a positive straight leg raise on the left but otherwise normal neurology in the lower limbs.
He noted the MRI scan showing an annular tear at L5/S1 with associated disc protrusion resulting in left-sided S1 nerve root compression, which was not severe. He diagnosed symptoms arising from the L5/S1 disc with an episode of left lower limb radiculopathy, which he thought was related to S1 nerve root compression, but this appeared to be spontaneously settling.
He ordered a left L5/S1 epidural injection as a diagnostic as well as therapeutic manoeuvre and that he should continue with physiotherapy and noted that he was due to see Dr Boesel, pain specialist, which Dr Tait thought would be an excellent approach.
Dr Tait opined that should the symptoms not settle with conservative management; it may be that he will require surgery most likely in the form of L5/S1 anterior lumbar interbody fusion.
The claimant underwent CT-guided left L5/S1 epidural injection on 6 July 2022. This reduced the left leg symptoms somewhat, but he had continuing pain and tenderness in the lower lumbar spine.
In the meantime, Dr Pope referred the claimant to metabolic surgeon, Dr Khaleal, on 14 August 2022 with symptoms of bloating and diarrhoea but no weight loss, for consideration of possible endoscopy.
The claimant said that because of the abdominal bloating and constipation, he did eventually see Dr Khaleal and he believes this was paid for by the insurer. He told Dr Khaleal that he would try and change his diet in order to tackle his weight problem, rather than resorting to surgery. The claimant informed the Medical Assessors he had put on about 20kg since the motor vehicle accident and from his best recall, he was 81kg prior to the accident.
The claimant saw Dr Boesel, pain specialist at Western Sydney Pain Centre, on 12 September 2022. He noted ongoing back pain but some relief of the left leg symptoms following epidural injection, limiting standing to 20 minutes and walking to 20 minutes, with partial relief of pain from lying flat and sleep disturbance with nightmares every two to three nights, waking up significantly distressed, and experiencing flashbacks to the accident, with reports of significant anxiety and having had a number of panic attacks, both at work and occasionally at night, with moderate depression.
He had been to see a psychologist in Wentworthville and had been referred to a psychiatrist, which Dr Boesel thought was strongly in his interest. The psychometric testing by Dr Boesel showed high levels of yellow flags in the form of severe pain-related catastrophising, loss of efficacy and anxiety and depression. He was noted to be obviously uncomfortable when sitting still and was anxious and jumpy on examination, with markedly reduced spinal extension and a positive Schober’s test indicating limited lumbar flexion. He showed allodynia (increased tenderness to light stroking of skin) across the lower back.
He diagnosed a mix of nociceptive and mechanical low back pain associated with an annular disc tear at L5/S1, with significant post-traumatic stress disorder and severe anxiety with yellow flags. He advised input from a psychiatrist and Duloxetine 30mg as an anti-depressant and for its beneficial effects on neuropathic pain.
He also advised deferring any consideration of surgical management until his mental state improves and he recommended a pain management program. He requested a further 12 sessions of physical therapy and attendance at a group pain education seminar.
Dr Pope then referred him to a neurosurgeon, Dr McKechnie, for second opinion and he saw this specialist on 13 September 2022. On examination, he was noted to walk reasonably well with reduced range of movement in the lumbar spine and no weakness. He noted the MRI findings as mentioned above and that the treatment options included conservative and surgical management, and he offered him left partial L5 and S1 laminectomy, microdiscectomy with S1 rhizolysis above and below the pedicle, which would give a 90% chance of improvement in left leg symptoms with less than 5% risk of complication, however, the low back pain was likely to persist to some degree.
At review by Dr Boesel on 29 October 2022, he noted that in the meantime, The claimant had been assessed by a psychiatrist and diagnosed with anxiety and post-traumatic stress disorder. Duloxetine was showing some modest benefit at 30-60mg per day. He was prescribed Feldene 20mg to assist with back pain. He noted the continuation of significant psychological yellow flags and that the claimant was at high risk of chronic disability and chronic pain.
The claimant was reviewed by Dr Tait on 2 February 2023 noting that pain has worsened since last review with occasional left lower limb pain and numbness, and he opined that the claimant would now benefit from an L5/S1 anterior lumbar interbody fusion with percutaneous screws, but that he wanted up to date imaging performed.
An MRI scan lumbar spine on 9 February 2023 showed stable appearances compared with the last scan.
An update bone scan on 13 February 2023 showed no significant increased uptake in the SI joints or in the lumbar spine facet joints to suggest active synovitis or foci of pain away from the disc.
Dr Tait then requested permission from the insurer to perform surgery, but this was declined.

Details of any injuries or conditions sustained since the motor accident

Nil relevant.

Current symptoms

The claimant said his neck, which was a minor focus of symptomatology compared with the lumbar spine, settled down shortly after the motor vehicle accident.
He continues to have upper lumbar back pain which radiates to the lower lumbar and into the left leg. This has remained a problem, and he chuckles and laughs in an effort to reduce pain during the day. His sleep is still disturbed. He cannot do heavy lifting. He orders the groceries online and they bring it into a table in the garage for his wife to bring inside.
He cannot mow the lawns now and his wife has to do it. He cannot help with the dishes and cannot continue with his hobby of cooking. He has not returned to work.
He gets intermittent radicular symptoms to the left leg.

Current and proposed treatment

He takes Lyrica 75mg twice daily, Duloxetine 60mg per day, Piroxicam one daily, Clonidine two at night, Palexia SR zero to three times per week, Iberogast for bloating, and Movicol for constipation.
Early on he tried a Norspan patch in place of Palexia but got headaches and drowsiness and had an episode of faecal incontinence, so did not persist with this treatment.
He does not want to have spine surgery, as he is able to walk around at the moment and does not want to risk ending up in a wheelchair.

CLINICAL EXAMINATION

General presentation

He was right hand dominant. He was of heavy build with height 178cm and weight 106.3kg.
He sat with visible discomfort, moving his weight from side to side in his seat frequently, and he would chuckle and giggle when answering questions and when moving, which he said relieved the backpain.
He leaned heavily on either arm, but particularly the left arm, because he said the pain shoots down the right side of his back and leg, and by doing this he can take weight off the right side of his body.
He said he can sit for about 20 minutes comfortably. His gait was antalgic on the left leg. He had difficulty standing still and was tending to shift weight from one leg to the other in a rocking manoeuvre. He could only stand on tip toes momentarily, but was able to heel walk satisfactorily. He could squat only one-third, which he said was limited by pain shooting up his back.

Cervical spine (cervicothoracic)

There was a full range of movement in flexion, extension, lateral flexion and rotation. Power, reflexes and sensation were normal. The reflexes were noted to be brisk, likely a manifestation of anxiety.
Upper arm girth; right 33cm, left 32cm at 10cm above the olecranon. Forearm girth; right equals left equals 29cm at 10cm below the olecranon.

Lumbar spine (lumbosacral)

There was marked restriction of active movement with flexion and extension one-quarter of normal range. Lateral flexion was one-third normal range to the right and one-half to the left. Rotation was restricted to one-half.
Feather light palpation over the upper lumbar spine was said to feel very uncomfortable and cause a sensation like a “jolt” up and down the back and caused worsening pain in the lower lumbar spine.
The reflexes were brisk and symmetrical. Power in the lower limbs was normal. Sensation was said to be globally decreased to light touch and pin prick in the entire left lower extremity in a non-dermatomal distribution.
Thigh girth; right 48.5cm, left 49cm at 5cm above the patella. Calf girth; right 41cm, left 41.5cm at 10cm below the patella.
Supine straight leg raising was 40° on the right and 50° on the left with complaint of low back pain, but there were no radiating symptoms to the legs, hence a negative nerve stretch test.

Left leg/foot

There was no abnormality on palpation and inspection or range of movement in this part, and no evidence of direct injury to this part, but rather it was affected by referred symptoms from the lumbar spine.

Abdomen

Soft and non-tender. Normal percussion note. The liver was non-palpable and non-tender liver edge. Abdominal circumference was 116cm.

Comments on consistency

The claimant was consistent in his presentation. Prominent pain behaviour was apparent.
The presentation was somewhat unusual with frequent giggling and chuckling, which the claimant explained was in an effort to reduce back pain.

Imaging

No imaging was brought to this assessment.

PANEL’S DETERMINATIONS

Causation

The Panel determined that the motor accident materially caused the claimant's injuries to the cervical and lumbar spine. Contemporaneous medical records documented consistent symptoms shortly after the motor accident, including mid-thoracic and lower back pain, which progressively worsened. Diagnostic imaging, particularly the MRI dated 1 June 2022, revealed a posterior disc bulge at L5/S1 with an annular tear and partial impingement of the S1 nerve root. The MRI findings of a posterior disc bulge and annular tear, alongside consistent reports of radicular symptoms, substantiate the conclusion that the lumbar spine pathology is causally related to the motor accident These findings objectively correlated with the claimant's reported symptoms, including lower back pain and radicular complaints affecting the left leg.
The insurer relied heavily on a biomechanical report, which argued that the collision forces, estimated at 7 to 10.5kmph, were insufficient to cause the alleged lumbar spine injuries. The report also highlighted the minimal damage to the claimant's vehicle, which had reinforced bumpers and a towbar, and asserted that these factors would have mitigated injury risks. However, the Panel found this evidence less persuasive when compared with the clinical and imaging findings. It noted that biomechanical analyses, while informative, do not account for individual variability in injury susceptibility. In this case, the claimant's immediate symptoms, subsequent diagnostic imaging, and clinical presentation outweighed the biomechanical analysis.
Pre-accident medical records referenced isolated incidents of back pain in 2014 and 2015, both caused by lifting heavy objects. These episodes were acute, self-limiting, and resolved within days without requiring long-term intervention. The Panel concluded that these prior incidents were unrelated to the claimant's current lumbar spine pathology. The lack of evidence for any ongoing or chronic back issues before the motor accident further supported the causal link between the motor accident and the claimant’s injuries.

Threshold injury assessment

The Panel assessed the claimant’s injuries against the statutory definitions in the Act, classifying them as either threshold or non-threshold injuries.
Cervical spine: the cervical spine injury was classified as a threshold injury due to its soft tissue nature and the absence of neurological compromise or structural abnormalities This classification was supported by contemporaneous medical records documenting the injury and its resolution without evidence of neurological compromise or structural abnormalities. The insurer did not contest this classification, and the Panel found no reason to deviate from the evidence.
Lumbar spine: the lumbar spine injury, involving an L5/S1 disc protrusion and annular tear, was classified as a non-threshold injury. The insurer argued that the imaging findings did not meet the criteria for a non-threshold injury and noted the absence of objective evidence of radiculopathy. However, the Panel determined that the disc pathology constituted a partial rupture of fibrocartilage, which is distinct from a soft tissue injury under the Act. The clinical timeline of symptoms, the diagnostic findings, and the claimant's persistent radicular complaints supported this classification as a non-threshold injury.
Left leg: the left leg symptoms were determined to be radicular in nature, stemming from lumbar spine nerve root impingement. The claimant’s left leg symptoms were attributed to radicular pain originating from the lumbar spine injury. The insurer argued there was no direct injury to the left leg and questioned its causal link to the accident. The Panel agreed that there was no direct injury but affirmed that the left leg symptoms were causally related to the lumbar spine pathology. This conclusion was supported by diagnostic imaging and the claimant's clinical presentation.

TREATMENT DISPUTES

Reasonableness and necessity of treatment

The Panel carefully evaluated the proposed treatments under s 3.24 of the Act, weighing the evidence for and against their necessity and reasonableness.
Metabolic surgeon review: the claimant experienced a 20kg weight gain after the motor accident. The claimant's weight gain, a result of reduced activity due to accident-related injuries, necessitated medical intervention to mitigate secondary health complications. The Panel finds this review reasonable and necessary to address the weight gain, which represented a significant health issue directly linked to the motor accident. While the insurer contested the causal relationship, the Panel emphasises the disruption to the claimant’s previously active lifestyle as a direct consequence of the motor accident.
Lumbar spine surgery: the proposed partial L5/S1 laminectomy, microdiscectomy, and rhizolysis are not deemed reasonable or necessary at this stage. The claimant argued that conservative treatments had failed, making surgical intervention the next logical step. However, the Panel determined that the claimant’s psychological state, including post-traumatic stress disorder and anxiety, poses significant risks to successful surgical outcomes. It emphasises the need for comprehensive psychological and pain management before considering surgery.
Pain education seminar: the seminar was deemed appropriate for addressing abnormal pain behaviour and psychological distress, consistent with evidence-based chronic pain management practices The claimant exhibited abnormal pain behaviour and significant psychological distress, both of which were linked to the motor accident. The seminar was viewed as an evidence-based intervention that could address these issues and contribute to functional improvement. The Panel found this approach consistent with best practices for managing chronic pain.
12-Week rehabilitation plan: the proposed multidisciplinary rehabilitation plan, targeting chronic pain and psychological recovery, was also supported by the Panel. The structured and multidisciplinary nature of the rehabilitation plan targets both physical and psychological recovery, offering a comprehensive approach to address the claimant’s complex condition. The insurer argued that previous rehabilitation efforts had yielded limited results. However, the Panel notes that the structured, multidisciplinary nature of the proposed plan offers a more comprehensive approach to the claimant’s complex condition. It is deemed reasonable and necessary for achieving meaningful recovery.
Physiotherapy sessions: the request for eight additional physiotherapy sessions is found reasonable and necessary. While prior physiotherapy sessions yielded limited improvement, the additional sessions focus on addressing specific functional limitations and core strength, critical for the claimant’s incremental recovery.

SUMMARY OF THE PANEL’S FINDINGS

In summary, the Panel determined that the claimant’s cervical spine injury is a threshold injury, while the lumbar spine and left leg symptoms are classified as non-threshold injuries.
The proposed treatments, except for the lumbar spine surgery are considered reasonable and necessary. However, the Panel has concluded that the lumbar spine surgery should be deferred pending psychological improvement.

[2025] NSWPICMP 22

9 January 2025