De Bruin v Arthur Tzaneros Discretionary Trust & Luke Webber Trust

CERTIFICATE OF DETERMINATION OF MEMBER
CITATION:	De Bruin v Arthur Tzaneros Discretionary Trust & Luke Webber Trust [2022] NSWPIC 444
APPLICANT:	Nicholas De Bruin
RESPONDENT:	Arthur Tzaneros Discretionary Trust & Luke Webber Trust
MEMBER:	Brett Batchelor
DATE OF DECISION:	8 August 2022
CATCHWORDS:	WORKERS COMPENSATION - Claim for the cost of lumbar spinal surgery as a result of a frank incident in the course of the applicant worker’s employment with the respondent; the respondent resists the claim principally on the appropriateness of the surgery having regard to the applicant’s young age, his psychological condition, comorbidities from which he suffers and chronic pain resulting in opioid addiction; the applicant’s reasonable necessity for surgery supported by his treating neurosurgeon and spine surgeon, a second neurosurgeon and spine surgeon and an orthopaedic and spine surgeon; the respondent relies on the opinion of an orthopaedic surgeon who asserts the effects of the frank injury; an aggravation of pre-existing degenerative condition would have ceased; Held — finding that such effects have not ceased; surgery proposed by the applicant’s treating neurosurgeon and spine surgeon reasonably necessary as a result of the frank injury; the respondent ordered to pay the applicant’s section 60 of the Workers Compensation Act 1987 expenses; including the costs of and incidental to the surgery.
DETERMINATIONS MADE:	The Commission determines: 1. The surgery proposed by Dr Rao, L3/4 total disc replacement and L4/5 anterior lumbar interbody fusion, is reasonably necessary as a result of the injury to the lumbar spine sustained by the applicant on 27 December 2019. 2. The respondent is to pay the applicant’s costs and expenses pursuant to s 60 of the Workers Compensation Act 1987 as a result of injury to the lumbar spine on 27 December 2019, including the costs of and incidental to such surgery.

STATEMENT OF REASONS

BACKGROUND

Nicholas De Bruin (the applicant/Mr De Bruin) claims medical expenses pursuant to s 60 of the Workers Compensation Act 1987 (the 1987 Act) as a result of injury to his lumbar spine on 27 December 2019 arising out of or on the course of his employment as a picker/packer by Arthur Tzaneros Discretionary Trust & Luke Webber Trust (the respondent). On that day, Mr De Bruin was working at the Coles Distribution Centre, Smeaton Grange, NSW. He had been so employed for about three years.
On the day of injury the applicant was engaged in picking up bottles of soft drink which had fallen from a pallet onto the floor of the Centre, and potentially into the path of forklifts operating in the building. As he bent over, he felt the immediate onset of sharp pain in his lower back which extended into his left leg. Me De Bruin was conveyed to Campbelltown Hospital where he was attended by a doctor and given prescriptions for pain relief medication. He was not admitted to the hospital.
On the day of the injury the applicant consulted a general practitioner, Dr Khan, who referred him for an MRI scan of his lumbar spine, which was carried out the same day[1]. From 8 January 2020 Mr De Bruin consulted doctors at the Spring Farm Medical Centre, where he had previously been a patient. On 24 January 202 Dr Yassa of that Centre referred the applicant to Dr Rao, neurosurgeon and spine surgeon, for opinion and management[2]. Dr Rao has continued to treat Mr De Bruin. Dr Rao first saw the applicant on 3 February 2020.
[1] Application to Resolve a Dispute (ARD) p 71, noting that the page numbers in these reasons are those in the electronic records of the Personal Injury Commission (the Commission).
[2] ARD p 70.
The applicant subsequently underwent conservative treatment of his injured back, including physiotherapy, hydrotherapy, facet joint injections on 19 February 2020 and 24 March 2020, epidural injection on 30 April 2020, ingestion of significant amounts of analgesic medication, and pain management administered by Dr Sushama Deshpande, pain management specialist and consultant anaesthetist.
Dr Rao reviewed the applicant on 10 September 2020 and reported to Dr Yassa. He organised further investigation in the form of an MRI scan and X-ray[3]. On 15 September 2020 the applicant underwent an MRI scan and X-ray of his lumbar spine, as requested by Dr Rao[4].
[3] ARD p 63.
[4] ARD p 107.
On 12 November 2020 at the request of the respondent’s insurer, icare Workers Insurance (icare), the applicant was independently medically examined by Dr Richard Powell, orthopaedic surgeon, who provided a report dated 23 November 2020[5]. Dr Powell expressed his belief that it was reasonable to conclude that the applicant’s employment, with reference to the injury of 27 December 2019 did represent a substantial contributing factor to the development of the applicant’s injury. He said that Mr De Bruin’s lower back remained a source of ongoing symptoms despite an extensive conservative management programme. Noting:
(a)    the chronic pain syndrome;
(b)    mental health issues;
(c)    narcotic dependence;
(d)    the applicant’s age, and
(e)    the absence of any definitive radicular signs,
Dr Powell did not consider Mr De Bruin a good candidate for surgery. He recommended continued conservative management focusing on [sic, an] active rehabilitation programme incorporating core strengthening work and regular pool based exercise. He said that this should be done in association with pain management, allowing issues relating to narcotic dependence and mental heal to be addressed, noting that further discussion of mental health fell outside his expertise.
[5] Reply p 7.
On 20 November 2020 Dr Rao made a request for surgery to icare[6]. The procedure proposed by Dr Rao was in two stages, namely L3/4, L4/5 anterior to psoas interbody fusion (stage 1), and L3-L5 posterior decompression and fusion (stage 2).
[6] ARD p 57.
On 11 December 2020 Dr Powell provided a supplementary report to icare responding to Dr Rao’s request for surgery of 20 November 2020[7]. He did not believe Mr De Bruin was the ideal surgical candidate for the reasons previously expressed by him in his report of 23 November 2020 and also having regard to the applicant’s age, 27 years, and that the proposed surgery involving fusing the L3/4 and L4/5 segments would place significant load on adjacent segments, and probably condemn Mr De Bruin to further surgery in the future.
[7] Reply p 14.
On 16 December 2020 icare issued to the applicant the first of a number of notices pursuant to s 78 of the Workplace Injury Management and Workers Compensation Act 1998 (the 1998 Act) in which it summarised the treatment which Mr De Bruin had undergone throughout 2020 and declined liability for the following treatment sought by him:
(a)    left lumbar radio frequency ablation;
(b)    medical admission for opiate reduction, and
(c)    the surgery requested by Dr Rao referred to in [7] above[8].
[8] ARD p 39.
Dr Powell issued supplementary reports in 2021 as follows:
(a)    on 20 January 2021, in which he addressed the mechanism of the injury suffered by the applicant on 27 December 2021 and ongoing symptoms claimed to have resulted from that injury[9];
(b)    on 14 July 2021, in which he discussed the applicant’s employment with the respondent, the mechanism of injury on 27 December 2019 and if the employment was the main contributing factor in the development of the multilevel disc pathology from which the applicant suffered[10], and
(c)    on 22 September 2021, in which he said that the surgery proposed was not reasonable and necessary for management of the injury sustained on 27 December 2019, and also:
(i)that he did not believe that the applicant’s employment and workplace incident that occurred on 27 December 2019 represented the main contributing factor in the permanent aggravation of the pre-existing disease process, and
(ii)that he was unable to reconcile the nature of employment with the extent of the reported symptoms and incapacity, and the need for surgery[11].
[9] Reply p 18.
[10] Reply p 20.
[11] Reply p 23.
On 10 March 2021 the applicant was seen by Dr Darwish, neurosurgeon and spinal surgeon, at the request of his solicitor. Dr Darwish produced a report of that date[12].
[12] ARD p 52
On 18 August 2021 the applicant was seen by Dr Singh, orthopaedic and spine surgeon, at the request of Dr George of the Spring Farm Medical Centre. Dr Singh produced a report of that date to Dr George[13].
[13] ARD p 48.
On 19 November 2021 Dr Rao reviewed the applicant and reported to Dr George[14]. He noted that Mr De Bruin had not improved over the previous year, and that symptoms were worse on the left side but that there was occasional right sided pain and radiculopathy. Surgical management was still recommended and to be performed as soon as possible with a view to returning Mr De Bruin back to usual activities of daily life and living.
[14] ARD p 59.
Dr Rao noted that they were still awaiting approval from the insurer for the requested surgery dated 20 November 2020 and updated surgical request dated 18 August 2021. He discussed that at the applicant’s age he would like to limit the number of fusion levels and proposed an amended surgery plan in the form of fusion at L4/5 and total disc replacement (TDR) at L3/4. That would limit chances of Adjacent Segment Degeneration. Surgery would be performed over two stages within the one admission with two presentations to theatre. Dr Rao expressed hope that the insurer would approve the surgery as a matter of urgency.
The seven s 78 and review notices issued by icare in evidence are dated from 16 December 2020, referred to at [9] above, to 28 April 2022[15]. In the last mentioned notice the insurer reviewed the history of the applicant’s treatment and his claim pursuant to s 60 of the 1987 Act for the cost of medical treatment. [I]care continued to deny liability for the cost of medical or related treatment expenses in accordance with its decision dated 10 January 2021. In that s 78 notice[16] the insurer denied liability for the surgery proposed by Dr Rao in his report dated 19 November 2021 (and amended on 23 December 2021), that is, the L3/4 TDR and the L4/5 anterior lumbar interbody fusion.
[15] ARD pp 9-39 (reverse date order).
[16] ARD p 14.

ISSUES FOR DETERMINATION

The parties agree that the only issue remaining dispute is whether the surgery proposed by Dr Rao namely, L3/4 TDR and L4/5 anterior lumbar interbody fusion, is reasonably necessary as a result of the injury to the lumbar spine sustained by the applicant on 27 December 2019.

PROCEDURE BEFORE THE COMMISSION

I am satisfied that the parties to the dispute understand the nature of the application and the legal implications of any assertion made in the information supplied. I have used my best endeavours in attempting to bring the parties to the dispute to a settlement acceptable to all of them. I am satisfied that the parties have had sufficient opportunity to explore settlement and that they have been unable to reach an agreed resolution of the dispute.
The parties attended a conciliation/arbitration hearing on 25 July 2022 conducted via MS Teams. Ms Goodman of counsel appeared for the applicant instructed by Mr Loveridge. The applicant attended. Mr Grant of counsel appeared for the respondent instructed by Ms Ralph.

EVIDENCE

Documentary evidence

The following documents were in evidence before the Commission and considered in making this determination:
(a)    ARD and attached documents;
(b)    Reply and attached documents;
(c)    Application to Admit Late Documents (AALD) dated 16 June 2022 with the following attachments:
(i)Certificate of Determination – Consent Orders issued by the Commission on 29 July 2021 in matter number W1931/21;
(ii)Supplementary report of Dr Darwish dated 3 July 2021, and
(iii)Report of Dr Singh dated 2 September 2021.

Oral evidence

There was no application to adduce oral evidence or to cross examine the applicant.

SUBMISSIONS

The submissions of the parties are recorded, a transcript of which can be obtained on request. I will not repeat them in full. In summary, they are as follows.

Applicant

The applicant notes the history of his treatment, and the change of recommendation for surgery by Dr Rao in his report dated 19 November 2021. He submits that the insurer is aware of the exact nature of the surgery, as evidenced by the s 78 notice dated 28 April 2022 referred to at [15] above. The applicant notes that this latest recommendation for surgery has never been put to Dr Powell, who is the only doctor saying that surgery is not appropriate. Dr Powell’s rationale for his opinion is that the mechanism of injury would not normally produce the pathology in evidence in the lumbar spine, the age of the applicant, and the comorbidities from which he suffers. Dr Powell does agree with Dr Rao that Mr De Bruin has not responded to conservative treatment.
The applicant submits that he has undergone physiotherapy, hydrotherapy, and comprehensive pain management under the care of Dr Deshpande. Dr Powell acknowledges that, notwithstanding the failure of conservative treatment to relieve the applicant’s symptoms, this treatment should be continued.
In respect of the comorbidities referred to by Dr Powell, the applicant submits that he has made significant efforts to prepare himself for surgery in the form of an attempt to give up, or reduce his smoking and lose weight. The applicant denies that the evidence supports a diagnosis of abnormal illness behaviour. The applicant submits that it is not apparent if Dr Powell has seen the reports of Dr Deshpande chronicling his pain management treatment.
The applicant submits that Dr Singh, who it appears was asked to comment on the original surgery proposal of Dr Rao, supports the appropriateness of the surgery, as does Dr Darwish, although Dr Darwish does not believe that the applicant needs the two-stage procedure. Dr Darwish has not commented on the revised procedure recommended by Dr Rao.
The applicant submits that his employment must be found to be a material contributing factor to the need for surgery, and in this case he has support from Dr Rao, Dr Darwish and Dr Singh.
The applicant also highlights the qualifications of Dr Rao, Dr Darwish and Dr Singh, noting their specialisation in spine surgery, compared with Dr Powell’s speciality as an orthopaedic surgeon only.
The applicant seeks an award in his favour pursuant to s 60 of the 1987 Act, to include specific reference to the surgery proposed by Dr Rao.

Respondent

The respondent notes that the applicant’s reliance on the nature and conditions of his employment, in addition to the conceded frank injury on 27 December 2019, is not conceded by the respondent. The respondent also notes that the different surgeries proposed by Dr Rao do not change its position in denying the reasonable necessity for surgery.
The respondent submits that there are two phases of the case to be considered, namely:
(a) the applicant’s physical problems, and the proposed surgery to address those, and
(b) the applicant’s psychological make up.
A good deal of what Dr Powell says in respect to his objection to the proposed surgery relates to matters other than the surgery per se.
The respondent submits that what is missing from the applicant’s case is any material from an expert psychologist or psychiatrist on his condition. It is apparent that the applicant was receiving treatment from a psychologist before the 2019 injury, and his psychological state is a factor to be considered when considering the matters referred to in Diab v NRMA Ltd[17] as to the reasonable necessity for surgery. The respondent notes however that those matters are guides only, and that each case must be determined on its own facts.
[17] [2014] NSWWCCPD 72 (Diab).
The respondent submits that there are a number of matters in this case that would lead the Commission to prefer the opinion of Dr Powell as opposed to the opinions of Dr Rao, Dr Darwish and Dr Singh. The applicant’s history of psychological problems appears from the clinical notes of the general practitioner at the Spring Farm Medical Centre[18], commencing with the attendances on 27 September 2019 and 15 October 2019[19]. The respondent also refers to the applicant’s statement dated 24 April 2020[20] in which he refers to the stress he experienced in January 2020 following his injury on 27 December 2019. The applicant acknowledges in that statement that because of the severity of his pain his mental health was “going downhill’, and that his general practitioner, while not agreeing to increase his dosage of anti-depressants, did refer him to a psychologist. The respondent then refers to the applicant’s treatment by his neurosurgeon from February onwards, the weekly visits to the psychologist, and the doubling of the dose of anti-depressants.
[18] ARD p 150.
[19] ARD p 158.
[20] ARD p 4.
The respondent also refers to the applicant’s reaction to the cortisone injection he received.
The respondent refers to the pain management treatment of Dr Deshpande, and specifically to the reports dated 7 May 2020 (x2)[21]. In the longer report of that date, Dr Deshpande lists the applicant’s current problems, and also the fact that he had pre-injury depression which worsened since the injury, requiring fortnightly psychological assistance and recent doubling of the dose of anti-depressant.
[21] ARD pp 146-147.
The respondent notes that Dr Singh commented on the original surgery proposal of Dr Rao, and does not embark upon any reasoning that it may not be appropriate because of the applicant’s psychological state.
The respondent notes that there are two aspects to the surgery proposal of Dr Rao, and submits that the doctor overlooks the complexity of the surgery when considering the first proposal. Dr Rao also agrees with Dr Powell that the applicant has comorbidities which are discussed in the report to the applicant’s solicitor dated 30 June 2021[22].
[22] ARD p 49.
The respondent refers to the report of Dr Powell dated 23 November 2020 (referred to above at [6]), and the comorbidities from which the applicant suffers. The respondent submits that these should have prompted discussion by a psychologist and evidence thereof. These comorbidities are emphasised by Dr Powell in subsequent reports.
The respondent notes that it is major surgery proposed by Dr Rao, and questions if the applicant fully understands the likely outcome thereof, including its effect on his psychological state. Dr Rao also does not, according to the respondent, explain why he changes his mind as to the type of surgery proposed.
In conclusion the respondent submits that, having regard to the foregoing matters, the surgery is not reasonably necessary as a result of the injury on 27 December 2019.

Applicant in response

The applicant submits that Dr Rao in his report dated 28 February 2022[23] deals with the applicant’s opioid dependence, and offers a critique on Dr Powell’s opinion. Dr Rao notes that the longer the applicant waits for surgery with such dependence, pain causing mental health issues, and inability to work or engage in social activities, the more detriment he will suffer.
[23] ARD p 45.
The applicant refers to the report of Dr Deshpande dated 7 May 2020[24] in which approval is sought from icare for further consultations, and further treatment including an initial appointment with a clinical psychologist. Dr Rao, in his report dated 10 September 2020[25] refers to proposed discussion with Dr Deshpande regarding ongoing pain management , radiofrequency ablation, and/or surgery.
[24] ARD p 138.
[25] ARD p 63.
The applicant submits that quite clearly, Dr Rao has addressed the psychological aspect of the proposed surgery, and its impact on the applicant. The applicant also notes that, notwithstanding psychological issues that pre-dated the back injury, he had no time off work but consulted his general practitioner for treatment of his anxiety. The applicant emphasises Dr Rao’s opinion that the sooner the surgery is carried out, the better off he will be. The applicant also submits that, postoperatively, the applicant will have access to the type of treatment that Dr Deshpande provides.

The applicant submits that having regard to the relevant matters according to the criteria if reasonableness set out by Roche DP at [88] in Diab, and also to what Burke CCJ stated in Rose v Health Commission (NSW)[26] the surgery proposed by Dr Rao is reasonably necessary as a result of injury on 27 December 2019.
[26] (1986) NSWCC 2; (1986) 2 NSWCCR 32 (Rose).

FINDINGS AND REASONS

At [88] in Diab, Deputy President Roche sets out the relevant matters, according to the criteria of reasonableness in the context of s 60 of the 1987 Act as follows:
(a)     the appropriateness of the particular treatment;
(b)     the availability of alternative treatment, and its potential effectiveness;
(c)     the cost of the treatment;
(d)     the actual or potential effectiveness of the treatment, and
(e)     the acceptance by medical experts of the treatment as being appropriate and likely to be effective.
At [89] Roche DP said:
“With respect to point (d), it should be noted that while the effectiveness of the treatment is relevant to whether the treatment was reasonably necessary, it is certainly not determinative. The evidence may show that the same outcome could be achieved by a different treatment, but at a much lower cost. Similarly, bearing in mind that all treatment, especially surgery, carries a risk of a less than ideal result, a poor outcome does not necessarily mean that the treatment was not reasonably necessary. As always, each case will depend on its facts.”
At [90] Roche DP noted that while the above matters are “useful heads for consideration”, the “essential question remains whether the treatment was reasonably necessary”, citing Margaroff v Cordon Bleu Cookware Pty Ltd[27].
[27] [1997] NSWCC 13; (1997) 15 NSWCCR 204 at 208C.
In Rose, Burke CCJ said at [48A-C]:
“3.     Any necessity for relevant treatment results from the injury where its purpose and potential effect is to alleviate the consequences of injury.
4.      It is reasonably necessary that such treatment be afforded a worker if this Court concludes, exercising prudence, sound judgment and good sense, that it is so. That involves the Court in deciding, on the facts as it finds them, that the particular treatment is essential to, should be afforded to, and should not be forborne by, the worker.
5.      In so deciding, the Court will have regard to medical opinion as to the relevance and appropriateness of the particular treatment, any available alternative treatment, the cost factor, the actual or potential effectiveness of the treatment and its place in the usual medical armoury of treatments for the particular condition.”
The respondent concedes that the applicant has undergone extensive conservative treatment for his injured back, a matter noted by Dr Powell, but focuses its submissions on whether surgery is reasonably necessary (not reasonable and necessary as Dr Powell says consistently in his reports) having regard to the age of the applicant, a chronic pain syndrome mentioned by the doctor, abnormal illness behaviour which is denied by the applicant, his psychological state, and his reaction to aspects of the conservative treatment to date. This last mentioned matter is in respect of Mr De Bruin’s reaction to at least one injection which Dr Matthew Lee unsuccessfully tried to administer into the lumbar spine on 17 November 2020[28].
[28] ARD p 106.
At the hearing the respondent in submissions did not assert that the applicant should not undergo the surgery based on the opinion of Dr Powell that any aggravation from the “minor workplace incident” sustained over 12 months prior to his report of 20 January 2021 would have settled by that date. Similarly, the respondent does not resist the surgery on the basis of Dr Powell’s belief that the applicant’s employment and the workplace incident that occurred on 27 December 2019 does not represent the main contributing factor in the permanent aggravation of the pre-existing disease process. That is not the test for the reasonable necessity for surgery in any event. The test, as submitted by the applicant, is whether the applicant’s employment is a material contributing factor to the need for surgery[29].
[29] See Murphy v Allity Management Services Pty Ltd [2015] NSWWCCPD 49 at [57]-[58].
In my view there is ample evidence to support a finding that the aggravation of the pre-existing degenerative condition in the applicant’s spine which occurred on 27 December 2019 has not ceased, whether or not it was a minor incident as claimed by Dr Powell. This comes from the applicant himself when he says that as he bent down to pick up an item off the floor he “…felt a sudden rip, crack, tear kind of sensation” in his lower back followed by excruciating pain to the point where he almost passed out. Dr Rao regards the single event on 27 December 2019 as a substantial contributing factor to the lower back injury, although he does refer to the recurrent lifting, bending and twisting involved in the applicant’s work. He notes that the applicant was minimally symptomatic before the injury. Dr Darwish takes a history of Mr De Bruin bending over to pick up some coke bottles which had rolled out of a box, feeling a pop in his back and developing severe pain. Dr Singh on the other hand records a history of the applicant picking up a heavy object, feeling a pop in his back and experiencing acute back and leg pain. The respondent does not put in issue that the applicant continues to suffer from severe pain and significant restrictions as a result of the condition in his lumbar spine.
I accept that the applicant continues to suffer from the effects of the injury on 27 December 2019.
Whilst I acknowledge Dr Powell’s reservations as to the appropriateness of the surgery, they are addressed by Dr Rao, who agrees that surgery is not the first option in a young patient, but does not agree that further conservative treatment, which has been unsuccessful to date, is advisable. In November 2021 Dr Rao changed his advice as to the type of surgery to be performed from a fusion at L3/4 and L4/5 of the spine, to a fusion at L4/5 and TDR at L3/4. The two procedures are to be performed during the one admission to hospital. This will according to Dr Rao limit the chances of Adjacent Segment Degeneration, one of the concerns expressed by Dr Powell.
Dr Rao also notes that the applicant has had extensive pain management treatment under Dr Deshpande, and that he is motivated to prepare himself for surgery by losing weight and attempting to lessen or give up his smoking habit. In addressing Dr Powell’s concerns over the surgery, Dr Rao notes the multidisciplinary team with a pain physician, psychiatrist, peri-operative physicians and allied health [sic, providers?] both for inpatient and outpatient utilised by him for his patients, particularly those such as Mr De Bruin, who suffers from anxiety and chronic pain with opioid addiction. The sooner the applicant undergoes the surgery the better the outcome that can be expected.
The applicant has discharged the onus on him to demonstrate that the surgery proposed by Dr Rao is reasonably necessary as a result of injury to the lumbar spine on 27 December 2019. The surgery is appropriate treatment, notwithstanding the comorbidities from which Mr De Bruin suffers. Extensive alternative treatment has been tried with limited effect. The cost of the treatment is not raised as an issue. The actual or potential effectiveness of the treatment has been commented upon by Dr Rao and Dr Darwish, and a guarded prognosis given. Dr Darwish in his report dated 10 March 2021, when commenting upon the original surgery proposal of Dr Rao and expressing his belief that the two stage procedure is not needed, says that the operation has a 60% chance of significantly improving back pain and 80% chance of improving leg symptoms. Dr Singh regards the treatment as appropriate.
Finally, Dr Powell in his last report dated 22 September 2021 when advocating his preference for the applicant to pursue a coordinated rehabilitation programme which he says is well supported in the recent literature, says that there is no right or wrong approach to the issue, and that medical opinions will often differ. Robust discussion of alternative positions is a healthy situation, although on this occasion Dr Powell notes his disagreement with the surgical treatment options proposed by Dr Rao.

SUMMARY

The surgery proposed by Dr Rao, L3/4 TDR and L4/5 anterior lumbar interbody fusion, is reasonably necessary as a result of the injury to the lumbar spine sustained by the applicant on 27 December 2019.
The respondent is to pay the applicant’s costs and expenses pursuant to s 60 of the 1987 Act as a result of injury to the lumbar spine on 27 December 2019, including the costs of and incidental to such surgery.

[2022] NSWPIC 444

8 August 2022