Dewar v Allianz Australia Insurance Limited

[2024] NSWPICMP 690

DETERMINATION OF REVIEW PANEL

CITATION:

Dewar v Allianz Australia Insurance Limited [2024] NSWPICMP 690

CLAIMANT:

Donna Dewar

INSURER:

Allianz

REVIEW PANEL

MEMBER:

Hugh Macken

MEDICAL ASSESSOR:

Michael Couch

MEDICAL ASSESSOR:

Clive Kenna

DATE OF DECISION:

3 October 2024

CATCHWORDS:

MOTOR ACCIDENTS – Review of medical assessment; threshold injury; passenger in motor vehicle; adjustment disorder diagnosed; medical dispute; prior history of chronic low back pain; prior bilateral total knee replacement; left clavicle pain; questioning about neurological symptoms; analysis of range of motion; mechanics of injury to supraspinatus muscle and tendon; presence of tendinopathy; anticular surface tear not caused by motor vehicle accident; no injuries to lumbar thoracic spine; Held – threshold injury confirmed.

DETERMINATIONS MADE:  

CERTIFICATE OF DETERMINATION

Review Panel Assessment – Threshold Injury

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

The Review Panel confirms the certificate of Medical Assessor Nigel Menogue dated 5 July 2023.

STATEMENT OF REASONS

INTRODUCTION

1. Donna Dewar (the claimant) is a 62-year-old woman who was involved in a motor vehicle accident on 6 April 2021. The claimant contends that she had just sat down on a bus when the bus stopped abruptly, and she was thrown to the floor of the bus and thereby sustained injuries.

2. Following the accident the claimant lodged an application for Personal Injury Benefits with the insurer. Thereafter the claimant sought a concession from the insurer that her injuries ought to be considered non-threshold injuries. The insurer declined to make this concession and accordingly the claimant lodged an application for Assessment of Threshold injury with the Personal Injury Commission (Commission).

3. Thereafter, the claimant was examined by Medical Assessor Nigel Menogue on
   20 June 2023 who, in a certificate dated 5 July 2023 determined that the injuries in which the claimant alleges she suffered ought to be considered threshold injuries.

4. The claimant sought a review of this determination and, in a certificate dated
   18 September 2023 the President’s delegate Golnaz Mojtahedi determined that there was a reasonable cause to suspect the Medical Assessment was incorrect in a material respect and referred the matter to this Review Panel.

5. The Panel met over a number of dates between 18 December 2023 and 17 July 2024 being the date in which the claimant was finally re-examined. The delay between the matter being allocated to the Medical Review Panel and the final examination was occasioned by a need to reschedule consequent on the availability of the Medical Assessors and the relatively restrictive availability of the claimant who could only attend on a Wednesday.

6. The Panel had issued directions in respect to the provision of material to the portal including additional documents relied upon by the insurer as well as the CCTV footage of the claimant’s accident.

7. 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 the 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.

8. The new review provision provide that a review panel consists of two Medical Assessors and a Member assigned by the Motor Accidents Division of the Commission.

9. Part 5 of the PIC Act enables the Commission to make rules with respect to its practice and procedure including proceedings before a panel reviewing a decision of a Medical Assessor.

10. 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 matter solely based on the written application.

STATUTORY PROVISIONS/GUIDELINES

1. The threshold injury constitutes a medical assessment matter pursuant to Schedule 2, cl 2 of the MAI Act.

2. A medical assessment matter is determined in accordance with Division 7.5 of the MAI Act by a Medical Assessor.

BACKGROUND

1. The claimant was Injured in a motor vehicle accident on 6 April 2021. The claimant alleges that she suffered injuries to both shoulders, cervical and lumbar spine, and left knee all of which were considered to be aggravations of underlying, pre-existing changes.

HISTORY

Relevant personal details

1. The claimant confirmed the earlier details as noted, that she was born in Australia, now aged 62 and that she had not had any formal education past 14 years of age having been on a disability pension since that time and never worked.

2. She was living in a Housing Commission residence where she had been resident since 2004. She does not drive a car, nor have a licence.

3. She acknowledges she is able to shop and will also cook her own food, wash clothes etc, commenting that she still tries.

4. Discussed later in the report is the extensive medical history prior to the incident in question of 6 April 2021.

Pre-accident medical history

1. As noted in GP notes, she has a long history of left shoulder pain (which she states dates back to 2013 although it was noted that there were images dating 2011 with regards to rotator cuff disease and reduced abduction).

2. In 2018, again pre-accident, there was reference to left knee pain, associated lower back pain at the L4/5 level with notice of sciatic and osteoarthritis of the left knee.

3. In October 2020, she had a fall in the bath which resulted in an MRI of the brain reported as normal. A Fairfield Hospital discharge summary of 12 November 2020 referenced low back pain secondary to an L4/5 stenosis with right nerve root impingement.

4. Pre-accident in November 2020, she presented to Campbelltown Hospital with a suspected slipped disc. Further imaging indicated L4/5 stenosis and ongoing issues with lower back with physiotherapy noted with treatment in early 2021, with a comment that Lyrica was beneficial for her low back pain.

5. It was also noted there were comments with regards to symptomatology pertaining to the shoulders, left knee and lumbar spine, all of which were pre-existent and pre-date the date of accident in question on 6 April 2021.

History of the motor vehicle accident

1. On 6 April 2021, the claimant states that she caught a bus on her way to Campbelltown Shopping Centre to obtain some pharmacy supplies. She was travelling alone. She had just sat down on the bus and was sorting her bags and crutches, when the bus abruptly stopped, and she was thrown onto the floor.

2. She states that she was able to get off the bus at the Campbelltown Shopping Centre and attempted to shop but was in too much pain. She did go to the pharmacy to pick up her normal medications and whilst there, she was seen by a neighbour who offered her a lift home.

3. When personally asked for greater detail, she states that this event occurred during the COVID pandemic. She had a small shopping trolley, climbed onto the bus and as she got her Opal card out, she was sitting across the bus, wasn’t standing at the time, had a bag over her shoulder and was leaning sideways when the bus unexpectedly jolted. She heard a bang at the time when she fell onto her side onto the floor then subsequently managed to stand up, holding her head, and felt she had fallen onto her left hand as she felt an electric type of shock. She had still yet to tap on with her card. The bus was heading for the Campbelltown Shopping Centre at the time where she alighted, went to the chemist, felt shocked by the events, and was experiencing pain. There she was seen in distress by a neighbour who offered her a lift home. She states at that stage she was experiencing symptoms involving the left hand which she recalls, as well as the neck, lower back, head and left knee.

History of symptoms and treatment following the subject motor accident

1. The claimant rested at home for several days and then saw her GP at the Aboriginal Medical Centre, Dr Bernand, on 8 April 2021. However, she also did attend the GP on the day of the accident in the afternoon.

2. Clinical note indicated that there was a mention of low back pain, acute on chronic, slightly worse and an appointment was made then to be seen by the GP on 8 April 2021.

3. His history noted that complaint of low back pain, a feeling of knee pressure, tenderness was elicited in the lower back and a recommendation for physiotherapy to continue.

4. She was also then referred through to Dr Abraszko, a neurosurgeon, whom she saw on
   30 June 2021, i.e. after the fall. She recorded a history of two falls, one in October 2020, together with the subject accident of April 2021. Imaging studies (see later in the report) confirmed long-standing anterior listhesis with severe facet joint arthrosis. Surgery was discussed but she was uncomfortable with the idea of surgery and a second opinion was sought from neurosurgeon, Dr Lee.

5. A complaint of left knee pain was also investigated which confirmed marked medial compartment osteoarthritis and degenerative tear of the medial meniscus, but she has not undergone any surgical intervention for such.

6. Management during this time was complicated by the COVID pandemic but she did have five Medicare-sponsored physiotherapy sessions, noting that medication long-term has been one of Lyrica, Mobic, Panadol Osteo and the Medicare-sponsored physiotherapy.

CURRENT STATUS

Current Symptoms

1. Her current complaint is one of mild pain pertaining to the neck and both shoulders, lower back pain which is central, and which is more intense, and some pain involving the left knee with the right unaffected.

Current and proposed treatment

1. She is on Lyrica, Mobic, Endone as required, Panamax and Panadol Osteo.

2. She has Medicare-funded physiotherapy.

CLINICAL EXAMINATION

1. The examination was conducted by both Medical Assessor Michael Couch and Medical Assessor Clive Kenna with Assessor Couch performing the examination and Assessor Kenna recording the clinical findings-whilst her carer sat at an adjacent table.

General presentation

1. Findings on clinical examination including specific measurements of ROM (where applicable) of each of the injuries assessed. The claimant is only 144cm in height and weighs 115kg. She walked with crutches. She sat throughout the history taking. There was no brace or corset, but she was highly sensitive to examination. She essentially remained fully clothed throughout the examination due to her personal request.

Cervical spine (cervicothoracic)

1. No muscle guarding or spasm present symmetrically reduced uniform range of motion (stiffness) but no asymmetry present.

2. No neurological deficit in either upper limb.

3. Any distal symptoms did not follow the distribution of any specific nerve root and there was no indication of a non-verifiable radicular complaint.

MOVEMENTS	RANGE EXHIBITED
Flexion	10% restriction
Extension	10% restriction
Rotation to the right	10% restriction
Rotation to the left	10% restriction
Lateral bending to the right	10% restriction
Lateral bending to the left	10% restriction

NEUROLOGICAL TESTS:
REFLEXES:

REFLEX	LEFT	RIGHT
TRICEPS JERK	Normal	Normal
BICEPS JERK	Normal	Normal
BRACHIORADIALIS	Normal	Normal

SENSATION:

1. Normal. Two-point discrimination sensation was normal and a point separation of some 6mm and sensitivity to light and firmer touch was normal throughout both upper limbs.

MUSCLE WASTING

LEFT (cm)	RIGHT (cm)
UPPER ARM	34	34
FOREARM	28	28

MUSCLE POWER

LEVEL	MOTOR POWER	LEFT	RIGHT
C4	5/5	NORMAL	NORMAL
C5	5/5	NORMAL	NORMAL
C6	5/5	NORMAL	NORMAL
C7	5/5	NORMAL	NORMAL
C8	5/5	NORMAL	NORMAL
TA	5/5	NORMAL	NORMAL

5 is active movement against gravity with full resistance

4 is active movement against gravity with some resistance

3 is active movement against gravity only, without resistance

DURAL TENSION TESTS:

TEST	RIGHT	LEFT
PASSIVE NECK FLEXION	Normal	Normal
BRACHIAL PLEXUS STRETCH	Normal	Normal

Lumbar spine (lumbosacral)

1. No muscle guarding or spasm present symmetrically reduced uniform range of motion(stiffness)but no asymmetry present.

2. No neurological deficit in either lower limb.

3. Any distal symptoms did not follow the distribution of any specific nerve root and there was no indication of a non-verifiable radicular complaint.

4. Tenderness but no muscle spasm between L4 to S1.

MOVEMENTS	RANGE EXHIBITED
Flexion	10% restriction
Extension	10% restriction
Rotation to the right	10% restriction
Rotation to the left	10% restriction
Lateral bending to the right	10% restriction
Lateral bending to the left	10% restriction

NEUROLOGICAL TESTS

REFLEXES

REFLEX	LEFT	RIGHT
KNEE JERK	Normal	Normal
ANKLE JERK	Normal	Normal

DURAL TETHERING/IRRITABILITY SIGNS

LEFT	RIGHT
Sciatic nerve stretch (straight leg raise)	Negative	Negative
Femoral nerve stretch (prone knee bending)	Negative	Negative

SENSATION 

1. Normal. Two-point discrimination sensation was normal and a point separation of some 6mm and sensitivity to light and firmer touch was normal throughout both upper limbs.

MUSCLE WASTING

LEFT (cm)	RIGHT (cm)
THIGH (measured 10cm above the superior pole of the patella)	67	67
CALF	49	49

MUSCLE POWER

LEVEL	MOTOR POWER	LEFT	RIGHT
L3	5/5	NORMAL	NORMAL
L4	5/5	NORMAL	NORMAL
L5	5/5	NORMAL	NORMAL
S1	5/5	NORMAL	NORMAL

5 is active movement against gravity with full resistance

4 is active movement against gravity with some resistance

3 is active movement against gravity only, without resistance

MUSCLE ATROPHY

THIGH	LEFT = RIGHT
CALF	LEFT = RIGHT

46.  No unilateral muscle atrophy present.

DURAL TENSION TESTS

TEST	RIGHT	LEFT
PRONE KNEE BEND	Normal	Normal
STRAIGHT LEG RAISE	Normal	Normal
SLUMP	Normal	Normal

Upper extremity

47.  Uniform range of movement for both shoulders.

Right Shoulder

Measurement	Reference (4th ed.)	Normal	Upper Extremity Impairment
Flexion	150°	Figure 38 (43)	180°	0
Extension	30°	Figure 38 (43)	50°	0
Adduction	30°	Figure 41 (44)	50°	0
Abduction	140	Figure 41 (44)	180°	0
Internal Rotation	40°	Figure 44 (45)	90°	0
External Rotation	60°	Figure 44 (45)	90°	0
Total	0

Goniometer measured

Left Shoulder

Measurement	Reference (4th ed.)	Normal	Upper Extremity Impairment
Flexion	150°	Figure 38 (43)	180°	0
Extension	30°	Figure 38 (43)	50°	0
Adduction	30°	Figure 41 (44)	50°	0
Abduction	140	Figure 41 (44)	180°	0
Internal Rotation	40°	Figure 44 (45)	90°	0
External Rotation	60°	Figure 44 (45)	90°	0
Total	0

Goniometer measured

1. It was agreed by both Assessors that due to her morphology that a full range of motion was demonstrated, and any loss of end range was blocked by her obesity.

Lower extremity

KNEES

49.  Right knee

·        Not complained of being injured.

·        She used crutches for mobility.

·        57cm across both knees

·        Valgus knees.

·        5° angle for the right knee - 10° for the left knee.

·        Range of movement for the right full extension to 105° flexion. Joint is stable.

·        Range of movement for the left knee full extension to 80° flexion.

·        Generally tender on palpation but joint stable.

·        Patellofemoral joint both right and left knees are stable.

knee

Left    Right

Extension 0°

¯

Flexion 135°

0            0

¯             

80°     105

Normal motion

Scars  Nil
Quadriceps Wasting  Nil
Swelling  Nil
Collateral Ligaments  Intact
Cruciate Ligaments  Intact
McMurray’s Test  Normal
Patello-femoral joint  crepitus
Lateral patellar tilt  Nil
Lateral drift (with quadriceps contraction)     Nil
Gait  Abnormal-using crutches
Short leg       Nil

Atrophy  Negative

Weakness  Negative

Range of movement  Normal

Osteoarthritis  yes

Amputation  Nil

Neurological deficit  Nil

Reflex sympathetic dystrophy  Nil

Vascular  Normal

REVIEW OF LATE DOCUMENTS

1. It needs to be noted that there was an application to Admit Late Documents:

   - Dr Alison Thorn dated 17 June 2024

   - A letter from Moray & Agnew dated 5 July 2024.

2. With regards to the additional documents, enclosed are reports from Dr Joanna Lee, neurosurgeon, of 18 November 2021 and 7 February 2022. It was her considered view, noting Donna had been referred for an opinion regarding whether surgery was appropriate for her lumbar canal stenosis secondary to L4/5 Grade 1 spondylolisthesis which was resulting in bilateral L4 foraminal stenosis.

3. That she had been previously seen by a colleague, Dr Abraszko, who advised on surgery for lumbar spinal fusion (which the claimant was not keen on). That the history taken was that she had been well with no low back pain until two falls. The first fall was in 2020 and the second one (related to the motor vehicle accident) was in 2021. That following the first fall she had had physio, appeared to improve, but then the second fall resulted in further exacerbation with increased back and bilateral leg symptoms.

4. X-rays were ordered. MRI lumbar spine showed a Grade 1 L4/5 spondylolisthesis and bilateral L4 foraminal stenosis which was resulting in compression of bilateral L4 nerve roots.

5. Dr Lee considered that she would benefit from a trial of conservative therapy and a further range of investigations were ordered, including a bone scan.

6. Dr Lee then reviewed the claimant in February 2022. At that time, she had had the bone scan which showed widespread significantly active discovertebral arthritis and facet joint arthritis throughout the vertebral body with significant active arthritic changes in the peripheral skeleton, inflammation reaction of arthritic knees.

7. It was noted therefore she had widespread arthritis and was best to be seen by a rheumatologist. Nevertheless, she did undergo in October 2021 a CT-guided left L4/5 perineural injection. Dr Lee assured the claimant that the widespread arthritic change was not a result of the motor vehicle accident, and she was recommended for pain management.

8. It was on that basis that she was also seen at Camden and Campbelltown Hospitals by the rheumatology department. Initial documentation is dated 11 March 2022. It was noted in that documentation that she was a 60-year-old lady at the time who had left knee medial meniscal tear and also osteoarthritic changes, lower mechanical back pain with disc prolapses and right shoulder in keeping with rotation cuff injury and subacromial bursitis. That she had a very extensive background of medical issues involving widespread osteoarthritis as well as post-traumatic stress disorder and anxiety.

9. It was noted that she had initially had an injury in October 2020 when she fell in the bathroom sustaining a left-hand injury. She recovered with conservative management and then had a further injury on the bus in April 2021 and that her complaints since then was one of left leg pain (which the registrar, Dr Yoon, considered was likely related to a left medial meniscal tear, as well as mechanical low back pain). He noted that she had also been having right shoulder pain for a number of years and she was seeing a physiotherapist.

10. In summary, he considered that she had non-inflammatory arthritis with a right shoulder subacromial bursitis, osteoarthritis involving her left knee, and the plan was for a trial of anti-inflammatories, simple analgesics and an attempted at weight loss.

11. She was then reviewed again on 10 May 2024 by the rheumatology department, noting that she remained mobile only with crutches. That the main complaint pertained to her back and that subsequently there was a request for investigation involving the lumbar spine.

1. Noting she had previously had a whole-body bone scan which indicated widespread arthralgia. Summary of the radiological investigations are referred to above.

2. I note the submission of 20 July 2023 by the claimant’s solicitor noting some dispute with regards to the incident in question and a history taken by Dr Herald

3. Dr Herald in his assessment of 31 August 2022 obtained a history that the bus started off before she had sat down and fell to the floor. He stated this history was clearly inaccurate when one views the CCTV footage. That the CCTV footage demonstrated that Ms Dewar had seated herself and was settled in the seat for a period of time before the image demonstrates that she fell to her left side onto the floor of the bus. The question is to what role the bus played in causing that fall. Dr Herald stated there was no evidence there was a problem with her seat or the way in which Ms Dewar was seated which may have placed her at risk of a fall. He considered that there was no evidence to support a causal relationship between her being seated on the bus and the subsequent fall. When challenged on such, he states that she actually fell when the bus had already moved off.

4. In a letter from Moray & Agnew (insurer’s solicitors) of 10 August 2023, they noted with regards to her multitude of physical complaints post fall, that she had a long history of pre-existent conditions and symptomatology, in particular in relation to both left shoulder pain (November 2018, dating back to even 2011), left knee pain (dating back to 2018), a history of lower back pain in a similar timeframe.

5. The claimant fell in the bath in October 2020 in which she injured three discs in the lumbar spine.  There was note of a discharge summary of 12 November 2020 with low back pain and a diagnosis of L4/5 stenosis with right nerve root impingement. In January 2021, there was ongoing lower back pain with the requirement of the use of crutches and needing physiotherapy.

6. That she was on Lyrica even pre fall of 6 April 2021, i.e. prior to that fall, and there was pre-existing pathology or symptomatology in relation to both shoulders, left knee and lumbar spine and she was already under medication.

7. That she had been seen also by Dr Abraszko with letters of 30 June 2021, 28 July 2021 in which radiological investigations confirmed advanced degenerative change of the lumbar spine. L4/5 severe facet joint arthrosis causing a 5mm anterior listhesis with severe right foraminal narrowing and compression of the right L4 nerve root.

8. That MRI of the lumbar spine in a letter of 28 July 2021 subsequently confirmed the L4/5 anterior listhesis and foraminal narrowing and subsequent to that it was determined that the best approach was conservative.

9. The Panel was able to confirm that any injury from the fall would constitute a “threshold injury” in the absence of radiculopathy or tears involving soft tissue or cartilaginous structures excluding therefore the presence of any injury which would constitute a non-threshold injury. There are threshold injuries in relation to the right shoulder, left shoulder, cervical spine, lumbar spine and left knee.

10. There is no history of radiculopathy as confirmed on clinical examination and there is the presence of long-standing and pre-existent arthritic change. That any initial symptomatology resulted in temporary aggravation has since ceased and her current clinical presentation is largely consistent with the pre-fall overall clinical presentation.

11. That being the case, with her stated level of incapacity and symptomatology, the fall is no longer a contributory factor as her current clinical presentation is due to her widespread pre-existent arthritic change. That there may have been some temporary aggravation of underlying and constitutional conditions as confirmed radiologically, but her current clinical presentation is due to the underlying and pre-existing conditions. That any initial symptomatology due to aggravation of the pre-existing conditions have since ceased and is no longer a contributory factor.

12. There is no evidence in the fall that she sustained any injury which would constitute a non-threshold injury, as there has been no evidence documented of radiculopathy, fractures or soft tissue tears, cartilaginous tears that would have been caused by the incident as noted.

RELEVANT IMAGING

1. Bone scan of 30 November 2021 - The delayed study demonstrates greatly avid arthritic changes in the medial compartments of both knees and moderately active arthritic changes involving the lateral compartments of the left knee, as well as both patellofemoral femoral compartments. As noted above, this is associated with an inflammatory action. There are also moderately active arthritic changes in the acromioclavicular joints bilaterally and moderately active arthritic changes are noted in both shoulders.

2. Cervical spine – Reported greatly active discovertebral arthritis involving the C4/5, C5/6 and C6/7 levels.

3. Thoracic spine – There was widespread very greatly active discovertebral arthritis and facet joint arthritis, most marked at T2/3 to T6/7.

4. Lumbar spine – Greatly active arthritic changes involving sacroiliac joints. L3/4 to L5/S1 greatly active discovertebral arthritic changes with greatly active facet joint arthritic bilaterally.

5. Conclusion: Very significant active discovertebral arthritis and facet joint arthritis throughout the vertebral column as outlined. Very significantly active arthritic changes in the peripheral skeleton as outlined. There is inflammatory action associated with arthritic changes in both knees.

6. Further bone scan was then taken on 23 May 2024. The conclusion was pertaining to the spine there was low-grade discovertebral degenerative changes in the mid-cervical spine as well as mid to lower thoracic spine on the right and the lumbar spine involving the mid-levels with moderate facet joint arthritis at L4/5 bilaterally and L5/S1 on the left. That there was severe inflammatory osteoarthritis in the medial compartments of the knees, moderate osteoarthritis of the right AC joint and to a lesser degree involving the left AC joint.

7. 12/3/2022 – X-ray left shoulder – The glenohumeral joint spaces maintained. There are small osteophytes forming along the inferior margin of the humeral head in keeping with developing osteoarthritic changes. There are minor osteoarthritic changes at the acromioclavicular joint with bony hypertrophy. There are small bony spurs along the lateral margin of the acromion.

8. Ultrasound left shoulder – Long head of the biceps is intact. There is a complete full-thickness tear of the supraspinatus tendon with the torn edge retracted beneath the acromion. There are features of adjacent bursitis with mild fluid distension and thickening of the bursa noted. The remaining cuff appears intact.

9. Ultrasound right shoulder – The long head of the biceps tendon is thinned and at least partially disrupted. The subscapularis appears mildly tendinotic. Supraspinatus also shows tenderness and there is moderate sized tear of the insertion measuring approximately 10mm in width and probably partly achieving full thickness. There is adjacent bursitis. The remaining cuff appears intact.

10. 9/8/2022 - CT lumbar spine – L4/5 retrolisthesis with marked bilateral facet arthropathy. Moderate to marked canal narrowing with marked narrowing of the lateral recess. Possibly causing irritation of multiple ascending nerves of the cauda equina particularly the L5 nerves. Marked right mild to moderate left foraminal narrowing possibly causing irritation of both exiting L4 nerves. L5/S1 mild broad-based posterior disc osteophytic complex. Moderate to marked bilateral facet arthropathy. Mild canal narrowing including mild narrowing of the left lateral recess. Mild bilateral foraminal narrowing.

11. 29/4/2021 - MRI cervical spine – Impression: Cervical spondylitic changes are noted. There is loss of the normal cervical lordosis angle which is most likely due to muscle spasm. Broad-based disc bulges are demonstrated at the L4/5, C5/6, C6/7 and C7/T1. In particular, there is disc osteophytic encroachment at all of the above levels stated with bilateral facet joint arthropathy.

12. 30/6/2021 – X-ray lumbar spine – Narrowing of the L4/5-disc space consistent with disc degenerative changes. Osteophytic changes in the apophyseal joints of the lower lumbar spine. There is degenerative spondylolisthesis of L4 on L5. There is stability between flexion extension. There is retrolisthesis of L3 on L4. Spondylitic changes noted in the lower thoracic spine.

13. 25/9/2021 - MRI left knee – Comment: Advanced medial compartment osteoarthritis with degenerate/ torn medial meniscus. Mild chondral wear along the patella. Joint effusion.

14. MRI thoracic and lumbar spine – Impression: At T7/T8 disc bulging is described. Lumbar spondylitic changes are described. Anterior listhesis of L4 on L5. Spinal canal stenosis is noted.

IMPRESSION FOLLOWING RE-EXAMINATION

1. In relation to assessment of threshold injury, there is no indication of radiculopathy or indeed fractures or soft tissue tears caused specifically by the fall per se on 6 April 2021.

CLINICAL COMMENTS

1. Donna Dewar is a 62-year-old individual who was involved in a bus travel incident on
   6 April 2021 when she stated that the bus abruptly stopped and she fell to the floor, as she only just also been sitting there at the time and had yet to touch off her Opal card.

2. The GP notes from the clinical some two days later commented that she got on a bus three days ago, it stopped quickly, and she flew off the seat and landed on the floor, hit her head and got tingles in the back and down both legs and feet numb with throbbing pressure in the knees. Clinical examination indicated a very tender low back, and sacroiliac joints and knees are tender medially. She was prescribed anti-inflammatories and analgesics.

3. Subsequent x-rays indicated there was no fracture of the hand.

4. MRIs of the lumbar spine confirmed long-standing severe facet joint arthritic change, and she was advised to take a conservative approach, although she was referred to a number of specialists as noted.

5. Whilst she states that she initially appeared to injure both shoulders, she states the right shoulder she felt a tearing or stretching at the time but subsequently as well as injury to the left shoulder, she states the left shoulder got better and that the right shoulder continued to be symptomatic in part.

6. In the background to this, she has a very extensive history of pre-existing anxiety, depression and PTSD and has had counselling for years. She has been on a disability pension long-term, for some 40 years prior to the bus injury.

7. The medical assessors were able to confirm that any injury from the fall would constitute a “threshold injury” in the absence of radiculopathy or tears involving soft tissue or cartilaginous structures excluding therefore the presence of any injury which would constitute a non-threshold injury. These are threshold injuries in relation to the right shoulder, left shoulder, cervical spine, lumbar spine and left knee.

8. There is no history of radiculopathy as confirmed on clinical examination and there is the presence of long-standing and pre-existent arthritic change. That any initial symptomatology resulted in temporary aggravation has since ceased and her current clinical presentation is largely consistent with the pre-fall overall clinical presentation.

9. That being the case, with her stated level of incapacity and symptomatology, the fall is no longer a contributory factor as her current clinical presentation is due to her widespread pre-existent arthritic change. That there may have been some temporary aggravation of underlying and constitutional conditions as confirmed radiologically, but her current clinical presentation is due to the underlying and pre-existing conditions. That any initial symptomatology due to aggravation of the pre-existing conditions have since ceased and is no longer a contributory factor.

CONCLUSION

1. There is no evidence in the fall that she sustained any injury which would constitute a non-threshold injury, as there has been no evidence documented of radiculopathy, fractures or soft tissue tears, cartilaginous tears that would have been caused by the incident as noted.