Allianz Australia Insurance Limited v Premdas-Rogers (No 2)

DETERMINATION OF REVIEW PANEL
CITATION:	Allianz Australia Insurance Limited v Premdas-Rogers (No 2) [2023] NSWPICMP 255
CLAIMANT:	Christine Elizabeth Premdas-Rogers
INSURER:	Allianz Australia Insurance Limited
REVIEW Panel
MEMBER:	Susan McTegg
MEDICAL ASSESSOR:	Shane Moloney
MEDICAL ASSESSOR:	Thomas Rosenthal
DATE OF DECISION:	8 June 2023
CATCHWORDS:	MOTOR ACCIDENTS – The claimant sustained injury in an accident on 14 July 2016 (the 2016 accident) which resulted in cervical disc protrusion and C5/6 disc replacement surgery; an earlier accident on 18 December 2014 (the 2014 accident) resulted in amputation of left index and middle fingers; treatment disputes relating to both accidents; causation of ulnar nerve injury; treatment relating to ulnar nerve injury; past and future pain management; Held – following 2016 accident loss of power in left hand and increasingly dropping things; ulnar nerve injury related to the 2016 accident; initial radicular pain/radiculopathy masked the ulnar nerve injury in the left arm; symptoms of C7 radiculopathy and ulnar nerve injury difficult to differentiate clinically; treatment related to ulnar nerve injury relates to 2016 accident and is reasonable and necessary in the circumstances; held pain management related to 2014 accident was reasonable and necessary to date of 2016 accident; thereafter pain management related to 2016 accident and reasonable and necessary to date; future pain management related to injury caused by 2016 accident but not reasonable and necessary in circumstances.
DETERMINATIONS MADE:	*MOTOR ACCIDENTS COMPENSATION ACT 1999* Review Panel Certificate issued under Part 3.4 of the Motor Accident Compensation Act 1999 following a review under s 63 as to THE ASSESSMENT MADE BY THE REVIEW PANEL UNDER S 63(4) IS AS FOLLOWS: The Panel revokes the replacement certificate of Medical Assessor Drew Dixon dated 27 July 2022. In relation to the 2016 accident the Panel finds the following treatment was reasonable and necessary in the circumstances: · left arm ulnar nerve decompression surgery; · past pain management specialist consultations from 14 July 2016 to date; · past consultation with Dr Colin Andrews and nerve conduction studies associated with the ulna nerve symptoms, including consultations and nerve conductions studies by Dr Colin Andrews on 1 May 2018; · past Dr Sergides consultations re ulna nerve including consultations with Dr Sergides on 14 September 2018, 20 November 2018, 16 May 2019, and surgery on 7 August 2019; · past Dr Nogajski consultations and nerve conduction studies from 2018 to date; · past Dr Noakes ultrasound to the elbow from 2018 to date; · past Dr Garfinkel, anaesthetist from 2018 to date, and · all past treatment from 2018 onwards, associated with the ulna nerve symptoms, including Dr Chai MRI imaging 13 September 2018. In relation to the 2016 accident the Panel finds the following treatment relates to the injury caused by the accident: · left arm ulnar nerve decompression surgery; · past pain management specialist consultations from 14 July 2016 to date; · past consultation with Dr Colin Andrews and nerve conduction studies associated with the ulna nerve symptoms, including consultations and nerve conductions studies by Dr Colin Andrews on 1 May 2018; · past Dr Sergides consultations re ulna nerve including consultations with Dr Sergides on 14 September 2018, 20 November 2018, 16 May 2019, and surgery on 7 August 2019; · past Dr Nogajski consultations and nerve conduction studies from 2018 to date; · past Dr Noakes ultrasound to the elbow from 2018 to date; · past Dr Garfinkel, anaesthetist from 2018 to date, and · all past treatment from 2018 onwards, associated with the ulna nerve symptoms, including Dr Chai MRI imaging 13 September 2018. In relation to the 2016 accident the Panel finds the following treatment was not reasonable and necessary in the circumstances: · future pain management specialist consultations from the date of assessment and continuing. In relation to the 2016 accident the Panel finds the following treatment relates to the injury caused by the accident: · future pain management specialist consultations from the date of assessment and continuing.

STATEMENT OF REASONS

INTRODUCTION

Ms Christine Premdas-Rogers (the claimant) suffered injury in a motor vehicle accident on 18 December 2014 (the 2014 accident) and in a subsequent accident on 14 July 2016 (the 2016 accident).
Allianz Australia Insurance Limited (the insurer) is the relevant insurer with liability to pay any damages to Ms Premdas-Rogers under the Motor Accident Compensation Act 1999 (MAC Act) in respect of both accidents.
The claimant is now 62 years of age and prior to the accident worked as an endodontist.
Ms Premdas-Rogers alleges she sustained the following injuries in the 2014 accident:
(a)    fracture of manubrium;
(b)    L4 fracture;
(c)    occipital laceration;
(d)    amputation of the left index and middle fingers including substantial surgical scarring, and
(e)    psychiatric injuries.
Ms Premdas-Rogers alleges she sustained the following injuries in the 2016 accident:
(a)    injury to the neck;
(b)    cervical disc protrusion:
(c)    increased numbness in her hands and fingers, and
(d)    aggravation of anxiety and post-traumatic stress disorder.
Following the 2014 accident Ms Premdas-Rogers was taken by ambulance to Royal North Shore Hospital where she was an inpatient until 24 December 2014. She was diagnosed with amputation of left fingers 2 and 3 requiring surgery by way of debridement and insertion of

K-wires; subtle undisplaced fracture of the manubrium; L4 anterior wedge fracture requiring brace; and an 8mm scalp laceration over right occipital-parietal region requiring stapling.
Following the 2016 accident Ms Premdas-Rogers consulted her general practitioner (GP) Dr Soper the following day. She reported pain on the right side of her lower back and her lower neck bilaterally. She had a loss of balance and aggravated her post-traumatic stress disorder.
On 25 September 2017 Dr Sergides performed a C5/6-disc replacement surgery. On 6 December 2017 Dr Sergides noted Ms Premdas-Rogers still had some neuropathic pain in her fingers which had improved.
On 14 September 2018 Dr Sergides noted gradual decrease in function in the left hand and numbness on the ulnar side of the hand. On 7 August 2019 Dr Sergides carried out ulnar nerve decompression surgery.
The dispute referred to Medical Assessor Dixon was whether treatment both past and future related to injury caused by the accident and whether it is reasonable and necessary in the circumstances.
A dispute in similar terms was also referred to Medical Assessor Dixon in respect of the 2014 accident.

MEDICAL ASSESSMENT UNDER REVIEW

Replacement Certificate of Medical Assessor Dixon

The following treatment disputes were referred to Medical Assessor Dixon for assessment:
·        whether the physical injuries give rise to a need for past left arm ulnar nerve decompression surgery which is causally related to the injury sustained in the subject accident;
·        whether the physical injuries give rise to a need for past left arm ulnar nerve decompression surgery which is reasonable and necessary in relation to the injury sustained in the subject accident;
·        whether the physical injuries give rise to a need for pain management specialist consultations which is causally related to the injury sustained in the subject accident;
·        whether the physical injuries give rise to a need for pain management specialist consultations which is reasonable and necessary in relation to the injury sustained in the subject accident;
·        whether the physical injuries give rise to a need for any future pain management specialist consultations from the date of assessment and continuing which is causally related to the injury sustained in the subject accident;
·        whether the physical injuries give rise to a need for any future pain management specialist consultations from the date of assessment and continuing which is reasonable and necessary in relation to the injury sustained in the subject accident;
·        whether the physical injuries give rise to a need for past consultation with Dr Colin Andrews and nerve conduction studies associated with the ulna nerve symptoms, including consultations and nerve conductions studies by Dr Colin Andrews on 1 May 2018 which is causally related to the injury sustained in the subject accident;
·        whether the physical injuries give rise to a need for past consultation with Dr Andrews and nerve conduction studies associated with the ulna nerve symptoms, including consultations and nerve conductions studies by Dr Colin Andrews on 1 May 2018 which is reasonable and necessary in relation to the injury sustained in the subject accident;
·        whether the physical injuries give rise to a need for past Dr Sergides consultations re ulna nerve including consultations with Dr Sergides on 14 September 2018, 20 November 2018, 16 May 2019, and surgery on 7 August 2019 which is causally related to the injury sustained in the subject accident;
·        whether the physical injuries give rise to a need for past Dr Sergides consultations re ulna nerve including consultations with Dr Sergides on 14 September 2018, 20 November 2018, 16 May 2019, and surgery on 7 August 2019 which are reasonable and necessary in relation to the injury received in the subject accident;
·        whether the physical injuries give rise to a need for past Dr Nogajski consultations and nerve conduction studies from 2018 to date of assessment which is causally related to the injury sustained in the subject accident;
·        whether the physical injuries give rise to a need for past Dr Nogajski consultations and nerve conduction studies from 2018 to date of assessment which is reasonable and necessary in relation to the injury sustained in the subject accident;
·        whether the physical injuries give rise to a need for past Dr Noakes ultrasound elbow from 2018 to date of assessment which is causally related to the injury sustained in the subject accident;
·        whether the physical injuries give rise to a need for past Dr Noakes ultrasound elbow from 2018 to date of assessment which is reasonable and necessary in relation to the injury sustained in the subject accident;
·        whether the physical injuries give rise to a need for past Dr Garfinkel, anaesthetist from 2018 to date of assessment which is causally related to the injury sustained in the subject accident;
·        whether the physical injuries give rise to a need for past Dr Garfinkel, anaesthetist from 2018 to date of assessment which is reasonable and necessary in relation to the injury sustained in the subject accident;
·        whether the physical injuries give rise to a need for all past treatment from 2018 onwards, associated with the ulna nerve symptoms, including Dr Chai MRI imaging 13 September 2018 which is causally related to the injury sustained in the subject accident, and
·        whether the physical injuries give rise to a need for all past treatment from 2018 onwards, associated with the ulna nerve symptoms, including Dr Chai MRI imaging 13 September 2018 which is reasonable and necessary in relation to the injury sustained in the subject accident.
Medical Assessor Dixon assessed the claimant on 24 March 2022 and issued a certificate. As a result of an obvious error application Medical Assessor Dixon issued a Replacement Certificate dated 27 July 2022. He certified the following treatment related to the injury caused by the 2016 accident and that the treatment was reasonable and necessary in the circumstances:
·        past left arm ulnar nerve decompression surgery;
·        past pain management specialist consultation;
·        future pain management specialist consultations from the date of assessment and continuing;
·        past consultation with Dr Andrews and nerve conduction studies associated with the ulna nerve symptoms, including consultations and nerve conduction studies by Dr Colin Andrews on 1 May 2018;
·        past Dr Sergides consultations re ulna nerve including consultations with Dr Sergides on 14 September 2018, 20 November 2018, 16 May 2019 and surgery on 7 August 2019;
·        past Dr Nogajski consultations and nerve conductions studies from 2018 to date of assessment;
·        past Dr Noakes ultrasound elbow from 2018 to date of assessment;
·        past Dr Garfinkel, anaesthetist from 2018 to date of assessment, and
·        all past treatment from 2018 onwards, associated with the ulna nerve symptoms, including Dr Chai MRI imaging 13 September 2018.
In relation to the 2014 accident Medical Assessor Dixon certified the following treatment was related to the accident and reasonable and necessary in the circumstances:
· past pain management specialist consultation, and
· future pain management specialist consultations from the date of assessment and continuing.

REVIEW PROCEDURE

The present application is a review of a medical assessment pursuant to s 63 of the

MAC Act. The relevant medical assessment was undertaken by Medical Assessor Drew Dixon on 24 March 2022. Following an obvious error application Medical Assessor Dixon issued a replacement certificate dated 27 July 2022.
An application for review of the medical assessment of Medical Assessor Dixon was lodged on 25 August 2022 within 28 days of the date on which the replacement certificate of Assessor Dixon was made available to the parties.[1]
[1] Section 63(7) of the MAC Act.
On 17 October 2022 the delegate of the President being satisfied there was reasonable cause to suspect that the medical assessment was incorrect in a material respect having regard to the particulars set out in the application referred the medical assessment to the Review Panel (the Panel).[2]
[2] Section 63(2B) of the MAC Act.
The Personal Injury Commission (the Commission) commenced operation on
1 March 2021 and the Claims Assessment and Resolution Service was abolished by
cl 3 of Part 2, Division 2, Schedule 1 to the Personal Injury Commission Act 2020 (the PIC Act).
Under cl 14A(1)(vii) of Schedule 1 of the PIC Act pre-establishment proceedings include proceedings that before the establishment of the Commission were required or permitted to be dealt with by a review panel for a medical assessment constituted under the MAC Act.
Clause 14F of Schedule 1 of the PIC Act states 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 after 1 March 2021 the new review provisions apply.
The new review provisions provide that a review panel consists of two Medical Assessors and a Member assigned to the Motor Accidents Division of the Commission.[3] The President’s delegate referred this application for review to the panel.
[3] Section 63(3) of the MAC Act.
Part 5 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.[4]
[4] Section 41(2) of the PIC Act.
Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the PIC Act. A Review Panel determines how it conducts and determines the proceedings and may determine the proceedings solely based on the written application.[5]
[5] Rule 128 of the PIC Rules.
The review is by way of a new assessment of all matters with which the medical assessment is concerned.[6]
[6] Section 63(3A) of the MAC Act.
On 13 March 2023 the Panel agreed an examination was required.

EVIDENCE BEFORE THE REVIEW PANEL

The Panel issued a Direction to the parties on 23 February 2023. In response to that Direction the insurer confirmed the documents sought to be relied upon were the indexed documents uploaded to the portal paginated from pages 1 to 764 and marked A2. The solicitor for the claimant uploaded a bundle of documents paginated from pages 1 to 1,647 and marked AD2.

Treating medical evidence

The treating medical records disclose the history set out herein.
Following the accident on 18 December 2014 the claimant was taken by ambulance to Royal North Shore Hospital.[7] The ambulance report noted the car in which the claimant was a passenger impacted at high speed with a telegraph pole shearing the pole completely from its base.
[7] A2 p 4.
Ms Premdas-Rogers was discharged from Royal North Shore Hospital on 24 December 2014 having undergone debridement to the severe left hand wound with amputation to the mid metacarpal level of the left index and left middle finger. She also suffered an undisplaced fracture of the manubrium, an L4 anterior wedge fracture requiring a brace and an 8mm scalp laceration over the right occipital-parietal region requiring stapling.[8]
[8] A2 p 9.
Ms Premdas-Rogers consulted her GP Dr Soper on 5 January 2015 when she reported the accident and noted she had sustained a fracture of L4, an undisplaced fracture of the mediastinum, the amputation of two fingers from the left hand and an eight centimetre laceration over the occiput of the scalp.[9] She reported neuropathic pain in her left and pain in her lower back.
[9] A2 p 27.
On 3 March 2015 Ms Premdas-Rogers consulted Dr Lewis Holford, pain specialist for treatment of the neuropathic pain.[10] He reported she had predominantly neuropathic left upper limb pain, including phantom digit pain complicated by possible post-traumatic stress disorder. He noted there were three main components to her pain:
·        phantom limb pain in the second and third digits;
·        intermittent lancinating pain radiating from the elbow as far as the fingers of the left hand, and
·        a constant deep “gnawing” pain, radiating diffusely throughout the left forearm and fingers.
[10] A2 pp 434 and 455.
On 17 March 2015 Dr Singer, psychiatrist and pain management specialist of the Northern Pain Centre diagnosed an adjustment disorder.[11]
[11] A2 p 432.
On 23 May 2015 Dr Soper reported Ms Premdas-Rogers had returned to work in Chatswood part time, working three hours a day for two days and on 9 June 2015 Dr Soper reported she was working four hours a day three days a week.[12]
[12] A2 pp 36 and 37.
On 7 April 2015 Ms Premdas-Rogers consulted Dr Buckley, rehabilitation physician.[13] He reported she had benign positional vertigo (BPPV) probably as a result of the head injury, although it was resolving. He thought there was a high likelihood of some brain injury noting she had memory impairment, and a range of abnormal neurological signs with diplopia, left sided facial sensory and motor impairment and left sided hyperreflexia.
[13] A2 p 136.
On 13 May 2015 the claimant returned to work and continue to upgrade her days and hours. On 23 July 2015 physiotherapist Skye Pailthorpe reported the claimant had experienced an increase in back pain and considerable fatigue as a result of rapidly increasing her work hours.[14]
[14] A2 p 144.
On 1 October 2015 Dr Soper stated: “Christine reported that the function of the left hand had significantly improved over the last 6 months, though still reporting phantom limb pain, functional stiffness and intermittent cramping”.
By 10 December 2015, one year post accident, the claimant was working eight hours per day three days per week at Chatswood.
Sally Ting, physiotherapist provided physical therapies including a home exercise programme for spinal mobility, upper extremity strengthening, lower extremity strengthening, trunk strengthening and abdominal strengthening. On 17 December 2015 she stated the claimant had reported a reduction in her back pain symptoms and that she felt “stronger in her left arm”.[15]
[15] A2 p 140.

Independent physiotherapist David Young provided a report dated 3 December 2015. Notwithstanding significant improvement he noted the claimant had significant neuropathic pain in her left arm, spine pain, inability to sit for long periods of time, subjective dizziness and vertigo.[16]
[16] A2 p 163.
On 9 March 2016 Dr Soper reported back pain limited the claimant’s ability to sit for prolonged periods to work, the amputated fingers meant she needed to re-train herself to use her hands differently for surgery, she was seeing a psychologist for post-traumatic stress disorder. The prognosis was for slow improvement over the next year. Dr Soper suggested Ms Premdas-Rogers pushed herself further than she should in increasing her work hours resulting in increased pain levels.[17]
[17] A2 p 117.
As of 26 April 2016, the claimant reported to Dr Soper she was working full time, three days at Chatswood, one day per month at Wodonga, one day per fortnight at Canberra and three days per fortnight at Westmead. She had been off gabapentin for seven days and was coping with the pain.
On 14 July 2016 the claimant was involved in the 2016 accident. She consulted Dr Soper on 15 July 2916.[18] He reported a semi-trailer going at 100 kmph pulled into her lane and hit the driver’s side. She reported she had seized up badly with pain in her lower back on the right side and her lower neck bilaterally. He also reported she lost balance and aggravated her post-traumatic stress disorder.
[18] A2 p 46.
On 26 July 2016 Dr Singer reported: “Swiped by truck on M5. Car self-corrected and wrenched left arm: painful neck, left arm and biceps with some flare of left neuropathic pain”.[19]
[19] AD2 p 484.
On 8 August 2016 Dr Soper found altered sensation in her left arm, loss of grip and pins and needles since the whiplash injury. Ms Premdas-Rogers was undergoing physiotherapy and remedial massage once a week. Psychologist Cathy Ebert stated the post-traumatic stress disorder had got worse since the court case for her husband (arising out of the 2014 accident) and the recent 2016 accident.[20]
[20] A2 p 46.
On 22 August 2016 Dr Soper reported the claimant was losing sensation in her left thumb and her ring finger, she had pins and needles down her whole arm, her phantom pain was more frequent and she was losing some sensation in the 5^th finger. She had dropped some instruments due to lack of power.
On 13 September 2016 Dr Soper reported the hand was getting worse, the claimant was starting to drop things due to muscular weakness.[21]
[21] A2 p 48.
On 13 October 2016 Dr Mobbs, neurosurgeon, reported symptoms were primarily in her left hand.[22] He thought the left C6 and left C7 nerves were the generator of the neck symptoms. He reported:
“She has weakness of triceps on the left as well as reduced triceps reflex. Her grip strength on the left is reduced, more so that I would expect with the amputation of her second and third digits”.
[22] A2 p 249.
On 24 October 2016 Keystone Professionals who had been involved in case management services in relation to the 2014 accident recorded the claimant reported a “marked increase” in her pain and symptoms since the 2016 accident, noting her left-hand function had deteriorated which was affecting her capacity to perform her pre-injury duties.[23]
[23] A2 p 171.
On 21 November 2016 Dr Holford reported the claimant’s involvement in the 2016 accident resulting in a significant whiplash injury, neck pain, back pain, left upper limb pain and numbness.[24] He reported there had been a flare up of the left upper limb phantom pain since the accident and the C6/7 nerve root injection by Dr James You on 5 November.
[24] A2 p 446.
On 8 December 2016 physiotherapist, Dr Trudy Rebbeck, noted intermittent neck pain, intermittent headache, intermittent dizziness, left sided intermittent sharp and shooting pain in left arm, which had improved with recent injections and left sided hand anaesthesia and paraesthesia.[25] She reported an exacerbation in symptoms since the 2016 accident including increased arm pain and sensory loss in the left hand, as well as increased neck pain and the onset of headaches and dizziness.
[25] A2 p 166.
On 2 May 2017 Dr Singer reported upper limb symptoms following the original accident and then an exacerbation following the 2016 accident. He said she described neuropathic phantom limb type pain, but also a loss of strength and sensory abnormalities, including proprioceptive problems and numbness.[26]
[26] A2 p 489.
On 25 May 2017 Dr Sergides, neurosurgeon reported numbness in the left arm, forearm and hand were interfering with the claimant’s ability to work. She also reported paraesthesia and thought her left arm was weak. The numbness predominantly occurred in the ring and little finger of the left hand and more recently in the left thumb.[27] He stated it was following the 2016 accident that the numbness in the left hand became more troublesome. He recommended an MRI and a bone scan.[28]
[27] AD2 p 774.
[28] A2 p 268.
The same day Dr Mobbs reported the MRI scan of the cervical spine of 16 August 2016 revealed changes at the C5/6 and C6/7 levels with bilateral foraminal stenosis, with a disc herniation at C6/7 causing significant impingement of the exiting C7 nerve root.[29]
[29] A2 p 425.
On 22 August 2017 Dr Holford reported no improvement in left upper limb symptoms following cervical transforaminal epidural steroid injection on 5 April 2023. He suggested awaiting the review with Dr Sergides.[30]
[30] A2 p 413.
On 29 August 2017 Dr Sergides noted the progression of numbness and loss of grip in the claimant’s left hand and recommended surgical intervention by means of an anterior cervical discectomy and disc replacement. He reported a bone scan demonstrated marked uptake particularly on the left, in the intervertebral and uncovertebral joints at C5/6. A recent MRI scan showed bilateral foraminal stenosis at C5/6, more on the left than the right.[31]
[31] A2 p 266.
On 17 September 2017 Dr Mobbs stated assuming Ms Premdas-Rogers had exhausted her conservative management options then he considered surgery to be reasonable, although he questioned the level of involvement of the C6/7 level noting Dr Sergides thought the symptoms were C5/6 related.[32]
[32] A2 p 246.
On 18 September 2017 Dr Sergides reported he estimated the likelihood of an 80-90% chance of significant improvement in neck and arm pain with surgery.[33]
[33] A2 p 265.
Dr Sergides performed the C5/6-disc replacement surgery on 25 September 2017 at North Shore Private Hospital.[34]
[34] A2 pp 250, 262.
On 6 December 2017 Dr Sergides, neurosurgeon noted the claimant was happy with the C5/6 surgery results.[35] While she still had some neuropathic pain in her fingers, this had improved and overall symptoms improved significantly. She was back at work and had had no problems. She reported her quality of life had increased.
[35] A2 p 261.
On 1 May 2018 Dr Colin Andrews carried out ulna nerve conduction studies which he reported revealed mild left ulnar nerve entrapment at the elbow.[36] He noted clinical examination didn’t pick up any obvious weakness of the left hand although there was sensory impairment. He referred the question of surgical decompression to the neurosurgeon.
[36] A2 p 242.
On 14 September 2018 Dr Yanni Sergides reported the C5/6 surgery had alleviated pain in her left shoulder, neck, scapular and left thumb and the neuropathic phantom pain had not changed.[37] He reported a gradual loss of function of the left arm and numbness over the ulnar side of the left hand was a relatively new thing over the last few months. He noted some wasting of the thenar eminence which was not present before. Whilst pin prick sensation was much reduced in the ulnar distribution it could also mimic C8 nerve root distribution. He noted the recent MRI did not show any compression of the C7/8 and T1 nerve root. Nerve conduction studies suggested mild ulnar nerve compression on the left. He recommended review by a neurologist.
[37] A2 p 259.
On 12 November 2018 Dr Nogajski, neurologist saw the claimant on referral from Dr Sergides for neurological assessment.[38] He reported the claimant felt since the 2016 accident her left hand had become weaker with a reduction in sensitivity in all remaining digits. He concluded the 2016 accident triggered some worsening of hand function, presumably through peripheral nerve injury although he stated he did not see anything on the MRI scan to show further surgery was warranted. He suggested repeat nerve conduction studies and electromyography (EMG) studies.
[38] A2 p 284.
On 9 October 2018 Dr Nogajski reported nerve conduction studies did not provide any electrophysiological evidence for any left ulnar neuropathy.[39]
[39] AD2 p 445.
On 12 November 2018 Dr Nogaski reported repeat nerve conduction studies showed some evidence for a left ulnar nerve lesion although he noted the pattern was not typical for a lesion at the elbow. He recommended an ultrasound of both elbows which he reported showed changes suggestive of radiological evidence for ulnar neuropathy. He referred the claimant back to Dr Sergides to consider surgery.[40]
[40] AD2 p 453.
On 20 November 2018 Dr Sergides noted there was no electrophysiological evidence for left arm neuropathy.[41] He also clarified the history stating Ms Premdas-Rogers had noticed a deterioration in function of her left arm and hand over the last 18 months and not only the last few months as suggested by his report of 14 September 2018.
[41] A2 p 258.
On 30 January 2019 Ms Catherine Ebert, clinical psychologist reported the claimant had undergone cognitive behavioural therapy and dialectical behaviour therapy for treatment of psychophysiological dizziness and post-traumatic stress disorder.[42]
[42] A2 p 527.
On 15 March 2019 Dr Singer reported ongoing neuropathic pain, and whilst functioning at a high level felt the claimant was vulnerable to depression.[43]
[43] A2 p 474.
On 16 May 2019 Dr Sergides reported fatigue and weakness of grip in the left hand.[44] He reported repeat nerve conduction studies done by Joe Nogajski suggested an ulnar neuropathy and an ultrasound of the elbows suggested irritation/inflammation at the elbow.[45] He recommended ulnar nerve decompression surgery, which was carried out on 7 August 2019.
[44] A2 p 257.
[45] AD2 p 458.
On 2 August 2019 the claimant attended a case conference with Dr Singer, Dr Holford and Ms Hando, clinical psychologist.[46] Physically she was considered to have progressed well. The neuropathic pain in her left hand was relatively well controlled with medication.
[46] A2 p 468.
On 7 August 2019 Ms Premdas-Rogers underwent left ulnar nerve decompression surgery at North Shore Private Hospital under the care of Dr Sergides.[47] The anaesthetist was Dr Craig Garfinkel.
[47] AD2 p 470.
On 8 August 2019 the claimant returned to see Dr Holford the day after the ulna nerve decompression surgery.
On 30 August 2019 Dr Singer reported the claimant had undergone a left ulnar nerve decompression with Dr Sergides which was successful.[48]
[48] A2 p 466.
On 4 April 2020 Catherine Ebert, psychologist reported the claimant continued to present with symptoms of post-traumatic stress disorder and depression in the context of her injury, ongoing health issues, current divorce proceedings and workplace related issues.[49]
[49] A2 p 648.
On 7 April 2020 Dr Singer reported continued pain and weakness in both arms related to previous injuries. On 19 May 2020 Dr Singer reported the claimant was struggling with a number of stressors relating to family matters and her work.[50] He also reported she had had a recurrence of neuropathic pain in her left hand as well as sensory disturbance and motor difficulties causing problems with her grip.
[50] A2 p 462.
On 18 September 2020 Dr Stephanie Barnes, neurologist reported increased phantom pains where here left 2^nd and 3^rd digits should be. She found the ulnar nerve decompression helpful but felt she had deteriorated since then. She had continued to see Dr Singer through the Northern Pain Centre and prescribed Gabapentin to assist with phantom pain and sleep.
On 10 November 2020 Dr Singer reported Ms Premdas-Rogers continued to experience pain and motor dysfunction in her left hand as well as discomfort in the right hand.[51] He recommended hand physiotherapy, and a trial of Valdoxan to help her sleep.
[51] A2 p 659.
The claimant attended Macquarie Hand Therapy for hand therapy. In a report dated 22 March 2021 Sally Wajon recommended nerve gliding exercises and strengthening exercises.[52]
[52] A2 p 672.
On 19 September 2021 Dr Archer GP reported left hand function was becoming more difficult, getting swelling and pain and discussed with the claimant attendance at a hand therapy clinic.[53]
[53] A2 p 598.

Statement of Stephen Premdas-Rogers

The claimant’s former husband provided a statement dated 14 December 2017. At paragraph 51 of that statement Mr Premdas-Rogers addressed the claimant’s presentation following her discharge from Royal North Shore Hospital after the 2016 accident, stating:
“After she came home from hospital I noticed that she had lost of a lot of sensation and feeling and grip in her left arm and hand which limited her capacity to attend to her personal needs and doing anything around the house. She was clearly in a lot of pain down that arm and in her hand”.[54]

Investigations
MRI Cervical spine, 29 June 2017[55]
[54] AD2 p 45.
[55] A2 p 274.

The report concludes:
“Persisting moderate degenerative disc disease C5/6 with a broad based disc protrusion with canal stenosis and moderate bilateral foraminal narrowing.
When comparted to a previous study from 16/8/2016 – PRP Gordon, the changes at C5/6 are similar. There has however been regression of the left posterolateral disc protrusions at C6/7 and T1/2.”

Limited bone scan, 29 June 2017[56]
[56] A2 p 394.

The report commented:
“1.     The scan demonstrates markedly increased osteoblastic activity surrounding the left lateral aspect of the C5/6 intervertebral junction and moderately, the left C5/6 facet joint in keep active intervertebral degenerative changes and facet joint arthritis.
2.     There is mildly increased osteoblastic activity surrounding the C6/7 intervertebral junction.
3.     There is moderately increased osteoblastic activity accompanying arthritis of the left T1/2 facet joint.”

MRI Cervical spine, 13 September 2018[57]
[57] A2 p 271.

The report concludes:
“There has been interval C5/6 disc replacement surgery since the previous study from 19/08/2018 with reduction in degree of bilateral foraminal stenosis as a result.
The C6/7 left-sided disc protrusion seen previously is no longer evidence.
The remainder of the appearances are stable and unchanged from the previous study.”

Nerve conduction study/EMG, 19 February 2019[58]
[58] A2 p 288.

The report concludes:
“There is some electrophysiological evidence for a left ulnar neuropathy, although with most of the changes affecting first dorsal interosseus. This may relate to trauma in the hand rather than at the elbow.”

Ultrasound both elbows, 10 April 2019[59]

[59] A2 p 289.

The report concludes:
“Mild hypoechoic swelling of the ulnar nerves in the upper cubital tunnel, more so on the left side where there were mild symptoms with transducer pressure over the nerve, compatible with mild ulnar neuritis. No nerve subluxation”.

Medico-legal reports

Dr Lorraine Jones, rehabilitation specialist

Dr Jones assessed the claimant on 16 June 2016, some four weeks prior to the 2016 accident. She reported ongoing back pain daily, pain with sitting, and phantom pain in her left hand. She found Ms Premdas-Rogers needed to be seen at the Pain Clinic every six weeks.[60]

Report of Patricia Jungfer, psychiatrist
[60] AD2 p 308.

Dr Jungfer assessed the claimant and provided a report dated 12 August 2016, some three weeks after the 2016 accident.[61] She reported not only neck pain but a change in the quality of the pain in her left hand following the 2016 accident.
[61] A2 p 536.
She diagnosed post-traumatic stress disorder – chronic as a result of the 2014 accident with a resurgence of her symptoms following the 2016 accident.

Report of Pauline Langeluddecke, clinical psychologist

In a report dated 5 September 2016 Ms Langeluddecke reported testing indicated Ms Premdas-Rogers’ cognitive abilities were well preserved and in keeping with her premorbid estimate.[62] She found no weakness attributable to a traumatic brain injury. She reported:
“Dr Premdas-Rogers reported a ‘minor’ MVA on 14 July 2016 resulting in a whiplash injury. This adversely affected ‘sensory perception’ in her left hand …”.

Report of Dr Angelo Virgona psychiatrist
[62] A2 p 548.

Dr Virgona provided a report dated 16 May 2017.[63] He diagnosed a chronic adjustment disorder with mixed anxiety and depressed mood.

Report of Clinical Associate Professor Michael Fearnside, neurosurgeon
[63] A2 p 568.

In a report dated 23 January 2018 Associate Professor Fearnside reported the injury sustained in the 2014 accident and noted ongoing low back pain and neuropathic pain in her hand and the lower portion of her left forearm.[64] She required regular medication for the neuropathic pain affecting the left hand.
[64] A2 p 276.
Associate Professor Fearnside reported as a result of the 2016 accident Ms Premdas-Rogers sustained injuries to her neck and thoracic regions. He reported she experienced generalised spinal pain and left brachial radicular pain which “was different from the neuropathic pain in her left forearm and hand”. He stated:
“Prior to the subject accident on 14/7/16 the neuropathic pain had predominately involved the left hand, the amputation stumps and extended across the wrist to about the junction of the mid and lower thirds of the forearm. Following the accident on 14/7/16 she developed a more typical left brachial radicular pain with referred pain from the neck across the shoulder girdle and down the left arm”.
Associate Professor Fearnside reported following the 2016 accident there was a deterioration in the function of the claimant’s left hand. He noted the total disc replacement at C5/6 performed by Dr Sergides on 23 September 2017.
At the time of his assessment Associate Professor Fearnside reported:
“In the left arm, the brachial radicular pain had resolved. She had impaired sensation on the thumb and thenar eminence and the fourth and fifth fingers of her left hand. There was impaired sensation on the palm of the left hand and also on the residual dorsum. The sensation on the dorsum of her hand resolved following the surgery. She also said that she had not experienced any neuropathic pain or phantom sensations of the amputated second and third fingers recently.”
He concluded from a neurosurgical perspective no further treatment was required. He recommended she remain under the care of Dr Holford for treatment of her neuropathic pain.

Report of Dr Seamus Dalton, rehabilitation physician

Dr Dalton assessed the claimant and 30 May 2017 and provided a report dated 25 September 2017.[65]
[65] A2 p 227.
He reported after Mr Premdas-Rogers was discharged from the hand therapist’s care in early 2016 she ceased all exercises and had no further treatment for her hand other than painkillers for ongoing neuropathic pain. He reported in the 2016 accident Ms Premdas-Rogers wrenched her left arm when she straightened the steering wheel as the car corrected. Dr Dalton reported following the 2016 accident the claimant started to experience shooting pain in her left hand and arm which got progressively worse and her arm became weaker.
Dr Dalton concluded Ms Premdas-Rogers had largely recovered from the injuries sustained in the 2014 accident other than the injury to the left hand and the amputation of the index and middle fingers. He concluded the most significant injury from the 2016 accident was a wrenching injury to her left upper limb which appeared to have provoked symptoms of a left C7 radiculopathy associated with a C6/7-disc protrusion, with some exacerbation of the pre-existing neuropathic left upper limb symptoms.

RELEVANT LEGAL AUTHORITY

In accordance with s 58(1)(a) and (b) of the MAC Act a medical assessment matter includes a dispute as to “whether the treatment provided or to be provided to the injured person was or is reasonable and necessary in the circumstances” and “whether any such treatment relates to the injury caused by the motor accident”.
In AAI Limited v Phillips[66] Davies J was asked to consider the question of causation in determining whether proposed surgical treatment was related to injury caused by one or more of three motor accidents. That case considered the words “whether any such treatment relates to the injury caused by the motor accident” where they appear in s 58(1) of the MAC Act.
[66] AAI Limited t/as AAMI v Phillips [2018] NSWSC 1710.
Davies J found the motor accident need only be a material contribution to the need for treatment and he further stated the Panel should have considered whether the proposed surgery would not have arisen but for the occurrence of one or more of the accidents being considered.
In Wingfoot Australia Partners Pty Ltd v Kocak Harrison AsJ at [57] confirmed that a Review Panel has “an obligation to set out its actual path of reasoning so as to enable a reader to determine whether it fell into error”. [67]

SUBMISSIONS

[67] Wingfoot Australia Partners Pty Ltd v Kocak [2013] HCA 43; (2013) 252 CLR 480.

The insurer’s submissions

The insurer provided submissions dated 24 August 2022. The insurer noted Medical Assessor Dixon issued two certificates for the claimant in relation to both accidents and that both certificates contain material error.
In the 2014 accident the claimant sustained left upper limb injuries and required left upper limb treatment including physical therapies with Ms Ting which included upper extremity strengthening. By March 2015, Ms Pailthorpe reported “Previously, she was experiencing a sharp piercing pain down her left arm to her fingers.” In November 2015, David Young diagnosed neuropathic pain in the left arm.
The insurer submits the claimant was experiencing left upper limb symptoms in her arm, hand and forearm by way of pain, pins and needles and numbness following the 2014 accident and prior to the 2016 accident.
The insurer argues Medical Assessor Dixon erred in finding the ulna nerve symptoms were causally related to the 2016 accident. The insurer relies upon the report of Dr Sergides to submit that the onset of the left ulna nerve symptoms was in mid-2018 and was not causally related to either the 2014 or the 2016 accident. In September 2018 Dr Sergides reported “The gradual loss of function of left arm and numbness over the ulnar side of her left hand was a relatively new thing over the last few months. She had some wasting of the thenar eminence which was not present before”.
The insurer notes no history of injury to the left elbow or ulna nerve and submits it is difficult to see how the ulna nerve symptoms in 2018 were causally related to the 2016 accident.
The insurer also notes there were similar ulna nerve findings in the contralateral uninjured right upper limb referred to by Medical Assessor Dixon.
In relation to pain management the insurer submits Medical Assessor erred in attributing ongoing pain management to both accidents but notes that he stated, “with regard to pain management the claimant has required ongoing pain management from Dr Louis Halford which she had seen prior to the subsequent accident on 14 July 2016”. The insurer submits the pain management must be related to the 2014 accident.

Claimant’s submissions

The claimant provided submissions dated 21 September 2022 addressing the question to be determined by the delegate.
The claimant submits the insurer incorrectly relied upon the report of Dr Sergides from September 2018 where he stated, “the gradual loss of function of left arm and numbness over the ulnar side of her left hand was a relatively new thing over the last few months”.
The claimant refers to the report of Dr Mobbs dated 13 October 2016:
“She has weakness of triceps on the left as well as reduced triceps reflex. Her grip strength on the left is reduced, more so that I would expect with the amputation of her second and third digits”.
On 14 July 2016 Dr Pauline Langeluddecke, clinical psychologist reported the claimant had been involved in a further accident on 14 July 2016 which had “adversely affected ‘sensory perception’ in her left hand…”.
On 25 May 2017 Dr Sergides reported:
“Christine complains of numbness in her left arm, forearm and hand which she finds intrusive and interferes with her ability to work. She also experiences parasthesiae and thinks that her left arm is weak. The numbness predominantly occurs in the ring and little finger of the left hand and more recently in the left thumb…
Christine was involved in two motor vehicle accidents. The first was in December 2014 during which she sustained a fracture to the L4 vertebrae and lost the index and middle finger of her left hand. She was involved in a further motor vehicle accident in July 2016 during which she sustained a whiplash injury. It’s following this that the numbness in her left hand became more troublesome…”
The claimant submits the above are symptoms of ulnar neuritis which was subsequently diagnosed and treated by ulnar nerve decompression.
The claimant also relies upon the opinion of Associate Professor Fearnside who reported the onset of pain in the left shoulder and arm after the 2016 accident was different to her previous symptoms in that region arising from the 2014 accident.
The claimant submits she has required past pain management consultations in relation to both the 2014 and 2016 accident and continues to require the same.

MEDICAL EXAMINATION

Mrs Premdas-Rogers attended the medical suites of the Commission on 17 May 2023. She was unaccompanied. Medical Assessor Rosenthal and Medical Assessor Moloney undertook the interview and an examination of her injuries.

Pre-accident history

Ms Premdas-Rogers stated that she was in good health prior to the accident and at that time was living with her husband and two children. She had migrated from the UK in 2013. She stated that she was fit at that stage and was regularly running preparing for a triathlete event. She was working full-time as an endodontist.

History of the motor vehicle accidents and subsequent treatment

On 18 December 2014, Mrs Premdas Rogers was a passenger in a car which her husband was driving. He lost control of the car and collided with a telegraph pole which snapped at the base. This caused their car to flip over and land on its passenger side. She was unable to get out of the car and had to be cut out by the emergency crew. The ambulance officer treated her and transported her to Royal North Shore Hospital. At that stage, there was bleeding from the scalp laceration and trauma to the left hand.
At Royal North Shore Hospital, a traumatic amputation compound wound of the left index and middle fingers was undertaken with subsequent further surgery by the hand surgeon. There was a scalp laceration which was sutured and a wedge fracture of L4 lumbar spine which was treated conservatively with a back brace. There was also a stable fracture of her manubrium. Mrs Premdas Rogers states that at that stage she had back pain, headaches, pain in the left hand associated with neck pain and a shooting pain down the left arm with the development of phantom pain in the amputated finger area.
In 2015 Mrs Premdas Rogers had returned to part-time work, had undergone rehabilitation and was under Westmead Hospital for treatment. Due to a change in a work situation, she also started endodontic work in Canberra as well as part-time in Sydney. She states that the left arm felt very weak when driving this distance. The Canberra employment initially was once a month and had increased to twice a month at the time of the second accident.
On 14 July 2016, there was a second motor vehicle accident. At that time Mrs Premdas-Rogers was driving to Canberra on the M5 when a truck collided with the driver side of her car. She was able to drive her car off the road and the police attended the scene. Due to this impact, she turned around and drove back to Sydney. Mrs Premdas-Rogers consulted her GP, Dr Soper with back spasm. She recalls that shortly after this accident, while attending the graduation of her son, she developed a very sharp pain down the left arm whilst sitting in the auditorium. Her GP then referred her to a neurosurgeon, Dr Mobbs and a cervical cortisone injection was arranged. This initially gave good relief for nearly three months. There was a follow-up with another neurosurgeon, Dr Sergides who arranged two more cortisone injections which were of no benefit. Due to this poor response, Dr Sergides undertook the disc replacement of the C5/6 level in 2017. Mrs Premdas Rogers states that this operation improved the burning pain shooting down the left arm.
In 2018 there was a development of increased pain around the left elbow, forearm and increase weakness in the left hand. This resulted in her dropping instruments at work when held in the left hand. She states that there was no other accident or injury related to this development. Various nerve conduction studies were undertaken and on 7 August 2019, an ulna nerve decompression surgery was undertaken by Dr Sergides. This procedure initially relieved the pain around the left elbow but gradually returned. She was followed up by Dr Barnes a neurologist and attended the Northern Pain Centre.
Due to persistent pain and numbness in the left remaining fingers and weakness, Ms Premdas-Rogers had to retire from working as an endodontist.

Current symptoms

The main problem is with the left hand. She stated weakness in the left hand resulted in her dropping things such as cups and plates and can no longer hold a shopping bag with the left hand. She is limited in her cooking due to this and feels weak in the 4th and 5th fingers associated with some numbness and pain over the dorsum of the hand. She can no longer play musical instruments such as the piano due to this.
Due to a recent fall which resulted in fractured ribs, she has chest pain and persistent low back pain. The right hand becomes uncomfortable due to overuse.
Ms Premdas-Rogers has returned to living in Sydney and lives alone. She is now divorced from her husband. Her employment was terminated in March 2022 due to persistent dropping of instruments from the left hand. She is presently unemployed.
Ms Premdas-Rogers stopped driving and a friend drove her in for the interview today.

Present treatment

Ms Premdas-Rogers attends a pain clinic under the supervision of Drs Singer and Holford. She consults an ophthalmologist for follow-up with cataracts and also Dr Barnes, neurologist.
Present medication is Gabapentin 300mg at night, Efexor One-A-Day, Nurofen three-day or Panadol osteo for a day when the pain flares. She also takes an aspirin One-A-Day, antihistamines and progesterone.
Ms Premdas-Rogers consults her GP on a regular basis.

Clinical examination

Ms Premdas-Rogers walked into the rooms with a normal gait and sat comfortably during the interview. She stated she is right-handed. There was evidence of a haematoma around her right orbit which was due to a fall six days before the interview caused by an onset of vertigo. Her treating neurologist considers that this is probably due to benign positional vertigo which has resulted in several falls since the first accident.

Cervical spine

On testing range of movement, flexion/extension, side bending and rotation were all 80% of expected range. There was a pale 9cm surgical scar horizontally at the base of the neck due to the cervical disc replacement.
There was a normal range of the shoulders and elbows and on neurological examination of the upper limbs reflexes were equal bilaterally with normal power except for the left hand. No upper arm muscle wasting was noted with the circumferences of the upper arms 32.5cm in the right and 33cm on the left (10cm above the olecranon process) and in the upper forearms 28cm in the right and 27cm on the left (10cm below the olecranon process).

Upper limbs

The right arm was asymptomatic except for slight decrease in sensation to light touch over the 4th and 5th fingers.
On examination of the left arm, left wrist had a full range of movement as did the left thumb. On assessing the 4th and 5th fingers, there was significant weakness in adduction but normal flexion. There was decreased sensation on the palmar aspect of the 4th and 5th fingers and decree sensation over the ulnar side of the left forearm. On testing the ulnar nerve, there was a positive Tinel’s test at the left cubital fossa.

PANEL DELIBERATIONS
Causation of the ulnar nerve injury

The Panel refers to the insurer’s submissions. The Panel does not agree the onset of the left ulnar nerve symptoms was in mid-2018 and not causally related to either the 2014 or the 2016 accident.
Applying the test of material contribution referred to by Davies J in Phillips the Panel is satisfied that the ulnar nerve injury is causally related to the 2016 accident. The Panel finds the initial radicular pain/radiculopathy would have masked the ulnar nerve injury in the left arm and when that was treated it became more apparent that there was a separate ulnar nerve problem. Symptoms of C7 radiculopathy and ulnar nerve injury are similar, and difficult to differentiate clinically.
The ulnar nerve affects the little and ring fingers. Following the 2016 accident Ms Premdas-Rogers complained of a loss of power in the left hand and increasingly found herself dropping things.
In his statement Mr Stephen Premdas-Rogers referred to the loss of sensation, feeling and grip in the left hand and arm following the 2016 accident.
On 8 August 2016 Dr Soper found altered sensation in her left arm, loss of grip and pins and needles.
In her report dated 12 August 2016 Dr Jungfer also reported a change in the quality of the pain experienced by the claimant in her left hand following the 2016 accident.
On 22 August 2016 Dr Soper reported loss of sensation in the left thumb and ring finger, pins and needles down the whole arm and loss of sensation in the 5th finger. He reported she had dropped some instruments due to lack of power.
On 13 September 2016 Dr Soper reported the hand was getting worse and Ms Premdas-Rogers was starting to drop things.
On 13 October 2016 Dr Mobbs reported symptoms primarily in the left hand. Whilst he thought the left C6 and C7 nerves were the generator of the neck symptoms he reported the grip strength on the left was reduced more than he would have expected due to the amputation of her second and third digits.
On 24 October 2016 Keystone Professionals reported a deterioration in left hand function since the 2016 accident.
On 8 December 2016 Dr Trudy Rebbeck, physiotherapist reported an exacerbation in symptoms since the 2016 accident including increased arm pain and sensory loss in the left hand.
On 25 May 2017 Dr Sergides reported numbness in the ring and little finger of the left hand had become more troublesome since the 2016 accident.
On 29 August 2017 Dr Sergides noted the progression of numbness and loss of grip in the claimant’s left hand. He, not surprisingly, at that time considered those symptoms were related to the cervical radiculopathy and recommended disc replacement surgery.
In a report dated 25 September 2017 Dr Dalton reported Ms Premdas-Rogers wrenched her left arm when she straightened the steering wheel in the 2016 accident and thereafter, she experienced shooting pain in her left hand and arm which got progressively worse and her arm weaker.
On 14 September 2018 Dr Sergides reported the disc replacement surgery performed on 25 September 2017 alleviated the pain in the left shoulder, neck, scapular and left thumb. However, Ms Premdas-Rogers continued to report a loss of function of the left arm and numbness over the ulnar side of the left hand. Dr Sergides noted nerve conduction studies suggested a mild ulnar nerve compression on the left. He recommended review by a neurologist.
Whilst nerve conduction studies undertaken by Dr Nogajski on 9 October 2018 did not provide any electrophysiological evidence for a left ulnar neuropathy, subsequent studies suggested an ulnar neuropathy. The Panel notes that nerve conduction studies are not always reliable and can be operator dependent, so does not consider the varying results to be significant.
In any event, the ulnar nerve decompression undergone by Ms Premdas-Rogers on 7 August 2019 was reportedly successful. The Panel notes the anaesthetist was Dr Craig Garfinkel and assumes the treatment dispute relating to Dr Garfinkel relates to that attendance.
Therefore, the Panel finds that the ulnar nerve decompression surgery, all investigations relating to the ulnar nerve and all specialist attendances pertaining to the ulnar nerve was causally related to the injury sustained in the 2016 accident.
The Panel also finds that the ulnar nerve decompression surgery, all investigations relating to the ulnar nerve and all specialist attendances pertaining to the ulnar nerve were reasonable and necessary in the circumstances.

Pain management

There is a dispute as to pain management, whether it is causally related to either the 2014 or the 2016 accident and/or whether it continues to be necessary in respect of both accidents. The dispute is in relation to both past and future pain management.
The Panel notes the serious injuries sustained by the claimant in both the 2014 and the 2016 accident.
The claimant first consulted Dr Holford pain specialist for treatment of the neuropathic pain in March 2015 following the 2014 accident. She also commenced treatment with Dr Singer, psychiatrist of the Northern Pain Centre who diagnosed an adjustment disorder.
Notwithstanding the opinion of Dr Jones, the treating records suggest gradual improvement in the claimant’s coping following the 2014 accident. As of 26 April 2016, Ms Premdas-Rogers had returned to work full time, had been off Gabapentin for seven days and was coping with the pain.
Unfortunately, the 2016 accident intervened resulting in an exacerbation of symptoms and the need for ongoing pain management.
The Panel is of the view pain management was related to the 2014 accident and was reasonable and necessary in the circumstances up until the date of the 2016 accident.
Thereafter, the Panel considers the exacerbation of her injuries in the 2016 accident resulted in a need for pain management causally related to that accident.
However, it is nearly seven years since the 2016 accident and whilst the claimant continues to consult Dr Holford and Dr Singer at the Northern Pain Clinic she also consults her GP on a regular basis. The Panel notes her current medication includes Gabapentin, Efexor and Nurofen.
The Panel is of the view the claimant’s GP can manage her pain and that ongoing pain management relating to the 2016 accident is not reasonable and necessary in the circumstances.

PANEL’S FINDINGS

In relation to the 2016 accident the Panel finds the following treatment was reasonable and necessary in the circumstances:
·        left arm ulnar nerve decompression surgery;
·        past pain management specialist consultations from 14 July 2016 to date;
·        past consultation with Dr Colin Andrews and nerve conduction studies associated with the ulna nerve symptoms, including consultations and nerve conductions studies by Dr Colin Andrews on 1 May 2018;
·        past Dr Sergides consultations re ulna nerve including consultations with Dr Sergides on 14 September 2018, 20 November 2018, 16 May 2019, and surgery on 7 August 2019;
·        past Dr Nogajski consultations and nerve conduction studies from 2018 to date;
·        past Dr Noakes ultrasound to the elbow from 2018 to date;
·        past Dr Garfinkel, anaesthetist from 2018 to date, and
·        all past treatment from 2018 onwards, associated with the ulna nerve symptoms, including Dr Chai MRI imaging 13 September 2018.

In relation to the 2016 accident the Panel finds the following treatment relates to the injury caused by the accident:
·        left arm ulnar nerve decompression surgery;
·        past pain management specialist consultations from 14 July 2016 to date;
·        past consultation with Dr Colin Andrews and nerve conduction studies associated with the ulna nerve symptoms, including consultations and nerve conductions studies by Dr Colin Andrews on 1 May 2018;
·        past Dr Sergides consultations re ulna nerve including consultations with Dr Sergides on 14 September 2018, 20 November 2018, 16 May 2019, and surgery on 7 August 2019;
·        past Dr Nogajski consultations and nerve conduction studies from 2018 to date;
·        past Dr Noakes ultrasound to the elbow from 2018 to date;
·        past Dr Garfinkel, anaesthetist from 2018 to date, and
·        all past treatment from 2018 onwards, associated with the ulna nerve symptoms, including Dr Chai MRI imaging 13 September 2018.
In relation to the 2016 accident the Panel finds the following treatment was not reasonable and necessary in the circumstances:
· future pain management specialist consultation from the date of assessment and continuing.
In relation to the 2016 accident the Panel finds the following treatment relates to the injury caused by the accident:
· future pain management specialist consultation from the date of assessment and continuing.

[2023] NSWPICMP 255

8 June 2023