Hussain v Poultry Enterprises NSW Pty Limited

CERTIFICATE OF DETERMINATION OF MEMBER
CITATION:	Hussain v Poultry Enterprises NSW Pty Limited [2022] NSWPIC 107
APPLICANT:	Sadiq Hussain
RESPONDENT:	Poultry Enterprises NSW Pty Limited
SENIOR MEMBER:	Kerry Haddock
DATE OF DECISION:	16 March 2022
CATCHWORDS:	WORKERS COMPENSATION - Claim for cost of proposed right L3/4 microdiscectomy and L4/5 microdiscectomy; accepted injury to L3/4 disc, which was the site of previous surgery; dispute as to whether the applicant sustained injury to L3/4 disc as a result of nature and conditions rather than frank incident; whether the applicant sustained injury to L4/5 disc due to disease; whether the proposed surgery is reasonably necessary as a result of injury; Held- applicant sustained injury to L3/4 and L4/5 discs on 7 September 2019; consideration of Diab v NRMA Ltd; respondent to pay cost of proposed right L3/4 and L4/5 microdiscectomy.
DETERMINATIONS MADE:	That the respondent is to pay, pursuant to section 60(5) of the Workers Compensation Act 1987, the cost of right L3/4 microdiscectomy and L4/5 microdiscectomy.

STATEMENT OF REASONS

BACKGROUND

The applicant, Sadiq Hussain (Mr Hussain) was employed by the respondent, Poultry Enterprises NSW Pty Limited (Poultry Enterprises) as a labourer/factory hand.
Mr Hussain claims to have sustained injury to his lumbar spine as a result of the nature and conditions of his employment from 26 July 2017 to 30 September 2019; and a frank injury on 7 September 2019. He claims the cost of proposed surgery, that is right L3/4 microdiscectomy and L4/5 microdiscectomy.
On 18 August 2020, the respondent’s workers compensation insurer, Insurance & Care NSW (iCare) issued the applicant with a notice pursuant to section 78 of the Workplace Injury Management and Workers Compensation Act 1998 (the 1998 Act).
ICare disputed that the medical expenses claimed by the applicant were reasonably necessary as a result of an injury, as required by section 60 of the Workers Compensation Act 1987 (the 1987 Act). The date of injury was stated to be 6 September 2019.
By letter dated 13 January 2021, the applicant’s solicitors made on his behalf a claim for entitlements “arising from his workplace injury on 7 September 2019”. The only claim made was for the cost of future surgery. The applicant’s solicitors noted that there was no dispute with respect to his claim for weekly benefits; and he did not seek to make a claim for lump sum compensation at that time.
There is no evidence of any response to the applicant’s solicitors’ letter, but iCare had already issued a dispute notice.
The applicant lodged an Application to Resolve a Dispute (the Application) on 29 October 2021. The dates of injury were pleaded as 1 July 2017 to 30 September 2019; and 1 July 2019.
The Application claims that from 26 July 2017, the applicant was required to rapidly and repetitively bend down to the ground and lift, catch and pick up live chickens to stack them into crates at varying heights, including above shoulder height, on a large trolley. The applicant claims that as a result of his duties on 7 September 2019, he sustained disc prolapse to L3/4 and L4/5 and aggravated, accelerated, exacerbated or deteriorated the pre-existing multi-level degenerative disease in his lumbar spine, from L1 to L5.
The Application also claims a disease injury, with a deemed date of injury between July 2019 and 30 September 2019. The applicant claims that the nature and conditions of employment, involving rapid repetitive bending, lifting, reaching, stacking at variable heights, twisting and sudden back movements while in a flexed position caused, aggravated, accelerated or deteriorated the disc protrusions at L3/4 and L4/5, and multi-level degenerative disease in his lumbar spine from L1 to L5.
The applicant claims the cost of right L3/4 microdiscectomy and L4/5 microdiscectomy, in the amount of $12,384.
The respondent lodged its Reply on 22 November 2021.

ISSUES FOR DETERMINATION

The respondent accepts that the applicant sustained injury to his L3/4 disc on 7 September 2019, not on the basis of a frank incident, but on the basis of the nature and conditions of his employment on that date. It disputes that the applicant has sustained injury to his L4/5 disc, due to disease or the aggravation, acceleration, exacerbation or deterioration of a disease, pursuant to section 4(b)(i) or section 4(b)(ii) of the !987 Act. It also disputes that the proposed surgery is reasonably necessary as a result of the accepted injury on 7 September 2019.

PROCEDURE BEFORE THE COMMISSION

The matter was listed for telephone conference on 29 November 2021. The Application was amended to delete reference to the date of injury as 1 July 2017; and insert 26 July 2017. The respondent was granted leave to rely on sections 4(b)(i), 4(b)(ii), 15 and 16 of the 1987 Act.
The matter was listed for conciliation/arbitration hearing by telephone on 21 February 2022. Mr Daley of counsel, instructed by Mr Bakic, appeared for the applicant; and Mr Adhikary of counsel, instructed by Ms Israil, appeared for the respondent. Mr Hussain was present. He was assisted by Mr Ahmadzay, interpreter in the Pashto language. Ms Patterson and Ms Sparkes of EML also attended.
The applicant objected to the admission of reports of Dr Vidyasagar Casikar, dated 14 August 2020 and 11 September 2021, on the basis that the evidence was not probative. The reports were admitted, for reasons provided at the hearing, and which were recorded.

EVIDENCE

Documentary evidence

The following documents were in evidence before the Personal Injury Commission (Commission) and considered in making this determination:
(a) the Application and attached documents, and
(b) Reply and attached documents;

Oral evidence

There was no application to call oral evidence or cross-examine any witness.

FINDINGS AND REASONS

Evidence of the applicant, Sadiq Hussain

The applicant’s statement is dated 8 March 2021.
Mr Hussain commenced employment with the respondent/Multiqube in about August 2017, through an employment agency. He worked five days per week, and on occasion worked six days per week, especially around Christmas and Easter. About one to two months before “the incident”, he was made a full time employee.
The applicant’s hours varied according to the number of orders. He started at times ranging from 2.30pm to 6.00pm. He had a 15 minute break and a 30 minute lunch. He was required to work at a swift pace. He usually worked about eight hours per shift, but at times worked 6, 10 or 15 hour shifts.
The applicant was required to load crates of live chickens. They would be unloaded from trucks into pens. He and his colleagues would bend to the ground, pick them up, and stack them in crates on a large trolley. The trolleys were approximately 1.2 to 6 feet high. Once they were loaded, they would be moved to a different area for processing. The applicant was required to bend frequently to pick up the chickens, which weighed approximately 4kg. He did this all day, every day.
The applicant was working on a Thursday evening, from approximately 6.00pm to 2-3.00am. Approximately six trucks had arrived. As he was completing his shift, he experienced pain in his lower back, which radiated down to his right leg. He continued to work with the pain, but got to a point where he could not bear it any more and had difficulty standing. He completed his shift.
The applicant drove home in pain, had a shower and, as it was early in the morning, went to bed. He was not rostered to work the following day. He awoke in severe pain and attended his GP, Dr Hussain. He advised the applicant to get an X-ray and report the incident to his supervisor. He communicated his injuries to “Robert” at Multiqube after the consultation.
The applicant’s pain continued to become severe, and he had difficulty standing, walking and lying down. He had no respite from the pain, even with strong medication. He mobilised with crutches for about two weeks. He was prescribed medication such as Lyrica, Naprosyn and Targin. He attended physiotherapy and hydrotherapy, and had acupuncture, all of which provided no relief.
Dr Prashanth Rao had advised Mr Hussain that it was unlikely he would get better with conservative management, and he believed surgical decompression was the most suitable option. The applicant underwent CT guided nerve root block injections at L2 and L4 in October 2019, without relief of his symptoms.
The applicant was referred to Dr Shanu Gambhir, who performed an L3/4 microdiscectomy and decompression in or about November 2020. The pain was still prevalent after surgery, and Mr Hussain was still severely disabled and limited in his ability to perform any daily activities. He continued to have pain while standing, walking and lying down. He continued to experience severe pain in his lumbar spine and weakness in his left leg. Dr Gambhir had recommended that he have further surgery.
The surgery recommended by Dr Gambhir had been rejected by the insurer. The applicant wished to undergo it urgently, as he continued to be in pain all day, every day.
The applicant stated that he had not experienced any previous injuries to his lumbar spine.

Medical evidence

iFamily Medical Centre – Rooty Hill

The applicant became a patient of the practice in August 2017, consulting Dr Syed Zia Hussain.
On 16 January 2018, the applicant presented with symptoms of frequency of urination, and Dr Hussain recorded “also has pain in the lower back which is persistent”. Dr Hussain noted that the applicant’s back movements and straight leg raising (SLR) were restricted because of pain. He was prescribed indometacin for lower back pain.
The applicant again presented with pain in the mid and upper back on 20 January 2018. It was not improving, even with indometacin. The reason for contact was “severe disabling pain”. Dr Hussain prescribed Endone.
On 22 January 2018, Dr Hussain recorded that the applicant’s back pain was not improving, even with Endone. He referred the applicant for CT scan of his thoracolumbar spine. This was recorded on 23 January 2018 as showing no significant finding.
The applicant continued to regularly consult Dr Hussain, complaining of lower back pain, as well as for unrelated issues.
On 10 February 2019, the applicant presented with lower back pain, for the last few days, “worsening now”. There was also mild midline pain, occasional pins and needles and pain radiating to the right leg. The applicant’s risk factors were recorded as being a chicken factory worker, lifting usually 5-10 (assumed to be kgs) and “bending frequent”.
Dr Hussain recorded that the applicant’s back pain would usually settle on its own. He advised care at work, referring to lifting, bending and carrying weight. A CT of the lumbar spine was arranged.
On 24 June 2019, Dr Hussain recorded pain in the left shoulder and upper back. The applicant “does chicken catching”.
On 8 July 2019, the applicant complained of pain in the mid upper and lower back.
On 7 September 2019, Dr Hussain recorded that the applicant had been experiencing lower back pain that was ongoing. It was not responding to regular pain medications. The applicant’s back movements were restricted by pain. His SLR was slightly restricted due to pain. His reflexes were normal. He was prescribed Endone.
On 22 September 2019, the applicant complained of ongoing severe pain in the lower back, “now radiating to the right leg.” He had been to another GP, who prescribed Panadeine Forte, which did not help. He was again prescribed Endone.
Dr Hussain recorded on 23 September 2019 that CT scan showed a large disc herniation, pressing on the L3/4 nerve. It was a work-related injury, as the applicant worked in a chicken factory catching chickens. A previous CT scan was normal, “which proves this is a recent injury”. An MRI was suggested. Dr Hussain had discussed the case with a neurosurgeon, who suggested surgery may be required.
On 25 September 2019, the applicant was in severe incapacitating pain that was not responding to regular medications. Endone was changed to Targin and a CT guided cortisone injection was suggested.
The applicant again presented with severe lower back pain, not improving with medications, on 30 September 2019. He was commenced on Lyrica.
On 22 October 2019, Dr Hussain recorded that the applicant’s back pain reduced from 10/10 to 9/10 after injection.
On 30 October 2019, Dr Hussain recorded that the applicant was still in considerable pain. He did not remember having a CT scan of his back in 2018. Dr Hussain told him it was for work-related injury and did not show any significant finding. The applicant was confused when the independent surgeon asked this of him, as he did not remember being investigated for lower back pain last year. Dr Hussain showed him his record and confirmed he had been investigated.
Dr Hussain recorded on 6 November 2019 that the applicant had ongoing pain in the lower back. Surgery had not been approved.
On 25 November 2019, Dr Hussain recorded that the applicant had had back surgery. He was still in severe pain in the back and leg.
Dr Qureshi recorded on 6 January 2020 that the applicant’s post-operative pain was still an issue. He was not doing as well.
Dr Hussain recorded on 13 January 2020 that the applicant had fear and anxiety when he slept or was about to sleep. He showed symptoms of depression and anxiety on detailed questioning. Duloxetine was commenced. His dosage of Lyrica was increased due to pain that was not settling.
The applicant presented on 20 January 2020 with severe pain on the left side of the lower back with flare ups.
Dr Hussain recorded on 3 February 2020 that the applicant had pain and burning in his lower back and severe pain in his right thigh and leg. On 20 February 2020, he had ongoing pain on the right side and increasing pain on the left side.
On 5 March 2020, the applicant had ongoing pain in the lower back and pain in both legs. He was undergoing physiotherapy once a week. On 21 March 2020, Dr Hussain recorded that he had ongoing severe pain in the lower back, with pain and weakness in the left leg, particularly lower down.
Dr Hussain recorded on 31 March 2020 that the applicant was seeing the physiotherapist “Aditi” [Badhe] weekly. He discussed the applicant with the physiotherapist. The applicant had constant burning pain, predominantly in the left leg, of 9/10 intensity. He had very good functional improvement, but ongoing severe and burning left leg pain. They discussed whether he required another surgery after MRI scan, or whether he required a pain specialist referral.
Dr Hussain continued to record lower back pain and symptoms in both legs. He recorded on 17 June 2020 that the applicant had pain in the lower back --- >right leg pain worsening. There was burning pain in the lower back that was getting worse. One level below the surgery burned and hurt a lot.
On 9 July 2020, Dr Hussain recorded that the applicant had worsening pain on the left side, worse when he lay in bed and with movements. He had work-related chronic back pain following surgery. He also had pain in both legs, which was gradually getting worse. A referral to a pain specialist had been provided.
On 10 August 2020, Dr Hussain again consulted with the applicant’s physiotherapist. His function had not improved. Ms Badhe asked about a maintenance physiotherapy program, with which Dr Hussain agreed. The applicant was to continue physiotherapy fortnightly.
Dr Hussain took part in a case conference on 17 August 2020. He noted that the applicant had been reviewed by an independent neurosurgeon, who stated surgery was not going to be helpful and may be harmful. Dr Gambhir had mentioned surgery will help, so there were contrasting opinions, which was why the insurer had rejected surgery as an option. It had approved pain management and cortisone injections, Dr Hussain provided referrals to an exercise physiologist and pain psychologist.
The applicant continued to consult Dr Hussain, who recorded ongoing pain in his lower back, with minimal to no improvement. There were complaints on 12 October 2020 of ongoing burning and pain in the lower [back], with pain in the legs, particularly the left calf. The applicant was seeking another independent opinion from a neurosurgeon, so that lumbar fusion via anterior approach may be approved.
The last entry is dated 27 October 2020, when the applicant had ongoing, constant pain in his lower back. It was not improving. Another surgery had been recommended “but he only wants to go ahead with it when his surgery has been approved with surgery” [sic].

Madan Medical Co Pty Ltd t/a Westmead Medical Centre

The applicant was treated by Ms Badhe, who recorded on 18 December 2019, his first visit, a history of back pain for one month. He was chicken catching at work, lifting 10 to 15kg. There was a previous history of an L3/4 discectomy by Dr Gambhir. The applicant complained of right lateral ankle and low back pain. He had last worked on 22 September 2019.
On 28 December 2019, Ms Badhe recorded that the applicant complained of severe low back and radiating pain in the right leg after standing for five minutes. He was advised to use a TENS.
Ms Badhe continued to treat the applicant throughout 2020, with little improvement recorded. The applicant complained of severe constant back and leg pain. He sometimes rated his pain as 10/10. It was sometimes as low as 8/10. On 21 April 2020, Ms Badhe called Dr Gambhir to report neuropathic pain and slow recovery progress.
Ms Badhe’s final entry is dated 28 July 2020. The applicant rated his pain as 9-10/10. There was bilateral lower limb weakness and neuropathic pain, with allodynia in the sacrum. The applicant had discussed with Dr Gambhir and his case manager a second surgery at L5. He had a pain specialist appointment on 17 September.

Dr Prashanth Rao – Neurosurgeon and Spine Surgeon

Dr Rao reported to Dr Hussain on 8 October 2019.
Dr Rao recorded a history that three weeks ago the applicant had severe back pain when trying to stand at work. It had gradually progressed, and he had right sided sciatica in the L4 distribution. He had been on crutches for two weeks but had no bowel or bladder issues. He rated his pain as 10/10, worse on standing and lying. He had trialled pool therapy and acupuncture with no improvement.
Dr Rao reported that CT showed a large L3/4 right sided paracentral disc prolapse and nerve root compression. MRI confirmed the L3/4 large prolapse, with extension superiorly and causing severe L4 nerve root compression. Dr Rao had discussed the MRI findings with Mr Hussain, and he was keen to proceed to L2/3 and L3/4 decompression and discectomy.
Dr Rao’s impression was that the applicant had right L3/4 radiculopathy with severe weakness. He opined that Mr Hussain was unlikely to get better with conservative management, as he had severe pain, disability and weakness. They had discussed the options. Dr Rao believed surgical decompression was the most suitable. They discussed minimally invasive lumbar decompression and discectomy; the risks, expectations and procedure were discussed in detail; and the applicant’s consent was obtained.

Dr Shanu Gambhir – Neurosurgeon and Spine Surgeon

Dr Gambhir reported to Dr Hussain on 18 November 2019. He recorded a history that the applicant had developed severe right leg pain, secondary to L3/4 disc protrusion. “This started at work”.
The applicant was awaiting insurance company approval, but as his pain was quite severe, and the protrusion was large and unlikely to settle with conservative management, Dr Gambhir was admitting him to the public hospital for L3/4 discectomy and decompression.
On 27 July 2020, Dr Gambhir noted that the applicant was nine months post L3/4 microdiscectomy and decompression. The plan was to re-do the right L3/4 and perform L4/5 microdiscectomy.
Dr Gambhir provided a report dated 10 August 2021.

Dr Gambhir reported that the applicant presented in November 2019 with severe leg radicular symptoms, mainly on the right. His MRI revealed a large L3/4 protrusion and a L4/5 protrusion that was not large. They decided to operate on the worst level, hoping that by opening up at L3/4 Mr Hussain would have significant recovery and they might be able to manage the L4/5 protrusion conservatively.
The applicant had improvement in his right leg pain post-operatively, but his recovery was not complete, and he started experiencing bilateral leg symptoms. The MRI scan revealed good decompression at L3/4, but there was a small recurrence. This, combined with disc protrusion at L4/5, was the likely cause of the applicant’s ongoing symptoms.
Dr Gambhir tried to manage the applicant conservatively. He was referred to a pain specialist for injections and further pain management. He also had frequent physiotherapy. After he failed conservative therapy for nine months, Dr Gambhir recommended re-do decompression at L3/4 and L4/5, by performing microdiscectomy and decompression. It was reasonable to go ahead with decompression to improve the applicant’s leg symptoms.
Dr Gambhir considered the applicant’s work history of repetitive bending, lifting and picking things up. In a young man, he opined that work would be the main cause of his lumbar spine injury. His lumbar spine pathology would consequently be related to his WorkCover injury. “Of course,” the disc protrusion was very large at L3/4, for which a discectomy was performed. They intended to manage the L4/5 protrusion conservatively, but as the applicant was not getting better with conservative therapy, he would require re-do L3/4 microdiscectomy, as well as decompression, and L4/5 microdiscectomy.
Dr Gambhir reported that the applicant had bilateral leg radicular symptoms. The L3/4 protrusion was more towards the right and was compressing the right sided nerves. The L4/5 protrusion was more towards the left and was indenting the left L5 nerve in the lateral recess. As Mr Hussain clinically had bilateral leg radicular symptoms, he would benefit from discectomy and decompression at both L3/4 and L4/5.
Dr Gambhir disagreed with a diagnosis of “failed back syndrome”. It should only be applied if there was no anatomical cause of the pain found on MRI scan. The applicant’s post-operative MRI of the lumbar spine showed recurrence of L3/4 disc protrusion, as well as L4/5 disc protrusion that was causing impingement in the nerves of the lateral recess. This would cause leg radicular symptoms, and unless they were treated by microdiscectomy or decompression, a diagnosis of lower back syndrome should not be made. Mr Hussain was otherwise young and healthy. Overall, he would benefit from re-do L3/4 as well as L4/5 microdiscectomy.
On 13 August 2021, Dr Gambhir provided a further report.
Dr Gambhir reported that the applicant never had any significant back pain or leg radiculopathy before his work injury. His back injury happened at work. “As you know”, he had a large disc herniation at L3/4, for which he had surgery. The L4/5 [protrusion] was not large and therefore was managed conservatively. It is likely that the work related incident either caused or aggravated his injury at L4/5, as he was never symptomatic prior to the incident.
The applicant’s last MRI showed recurrence of right sided L3/4 disc protrusion and left L4/5 [protrusion]. As the applicant clinically had symptoms of radicular pain in both legs, both levels were symptomatic. Overall, the symptoms started from L3/4 and L4/5 post work-related injury and therefore, work would be substantial/main contributing factor for both L3/4 and L4/5 disc protrusions.

Dr Vidyasagar Casikar – Neurosurgeon

Dr Casikar was qualified by the respondent and reported first on 6 November 2019.
Dr Casikar noted that the applicant was a chicken catcher for 2 ½ years. He had not been working since the injury.
The history recorded by Dr Casikar was that on 6 September 2019, the applicant developed acute back pain when trying to catch chickens. He had severe pain, which he tried to manage for about seven days. As he did not get better, he consulted Dr Hussain. He had a CT scan and was advised to consult Dr Rao. Dr Rao arranged an MRI and the applicant’s next appointment was due.
Dr Casikar referred to investigations of the applicant’s lumbar spine. He diagnosed L3/4 disc prolapse. He noted a CT scan on 23 January 2018 showed a central disc prolapse at L3/4 at that time. The applicant denied any injury at that time and indicated he had a CT scan as he was generally checking up on his back. Dr Casikar found this difficult to accept.
Dr Casikar opined that the injury on 6 September 2019 was an aggravation of a previously injured disc at L3/4. The description of the injury, clinical findings and radiological appearances were consistent with this diagnosis. Employment was a substantial contributing factor to the ongoing symptoms. Both the pre-existing condition, that is L3/4 disc prolapse, and the aggravation on 6 September 2019 were related to employment. The disc protrusion was very large and unlikely to get better. A microdiscectomy was necessary, and Dr Casikar agreed with Dr Rao.
Dr Casikar was unsure if the L4/5 disc protrusion required surgery. It was not related to the workplace injury. “As far as the compensable injury is concerned”, the disc protrusion was compensable at the L3/4 segment.
Dr Casikar opined that a microdiscectomy would relieve the applicant’s sciatic symptoms. With rehabilitation, he should be able to return to normal hours of suitable duties. An upgrade to his pre-injury duties would take about three months.
On 14 August 2020, Dr Casikar reported that the applicant had attended without an official interpreter, but with a friend, Mr Sayed Hussain (to whom I will refer as Sayed, to avoid confusion, while meaning no disrespect), who volunteered to interpret.
Dr Casikar reported that Sayed was extremely abusive and indicated it was Dr Casikar’s responsibility to provide an interpreter. During the entire examination he was telling the applicant what responses he should provide. Dr Casikar believed the examination was flawed because the insurer did not provide a proper interpreter.
Dr Casikar noted that Dr Gambhir performed a microdiscectomy at L3/4 in October 2019. The outcome was poor. The applicant had persistent back pain and pain down both legs. Dr Gambhir wanted to operate on him again.
MRI dated 23 July 2020 showed post-operative changes at L2/3. Dr Casikar opined that there was perhaps a small disc protrusion at the segment. It did not appear to be compressing the nerve root. There was a background of multisegment degenerative disease.
Dr Casikar diagnosed failed back syndrome. The applicant appeared to have had a workplace aggravation on a pre-existing degenerative disease. Dr Casikar had initially indicated that the surgery suggested by Dr Rao, that is microdiscectomy, was appropriate. The applicant had the surgery by Dr Gambhir, following which his symptoms had not improved. Dr Gambhir wished to re-operate.
Dr Casikar reported that clinical examination suggested significant non-organic factors. He could not accept that bilateral hypoesthesia from the groin downwards would explain problems at L3/4 or L4/5. He believed the applicant should have input from pain management and perhaps a psychologist. Perhaps he should also have a cortisone injection at L3/4, to determine if that was the point of origin of his complaint. Any further surgery was likely to have a very poor outcome.
Dr Casikar opined that the outcome of the surgery was reasonable, but the applicant’s post-operative symptoms suggested significant emotional problems. This was the main reason he was unable to go back to his pre-injury duties.
Dr Casikar further opined that the applicant’s previous radiology reports suggested there was a disc protrusion in the lumbar segments. The present MRI showed mainly normal age-related degenerative changes. The applicant’s symptoms could not be explained on the basis of the clinical examination and radiological findings.
Dr Casikar was “a little concerned” about further surgery to the applicant’s back. He believed a more detailed evaluation of the applicant’s back pain and emotional problems needed to be undertaken. The re-exploration surgery was unlikely to relieve his symptoms but was likely to make them more severe. Dr Casikar opined that Mr Hussain would continue to complain of pain even after surgery.
Dr Casikar again reported on 11 November 2021, in response to a request from the respondent’s solicitors.
Dr Casikar did not accept that repetitive movements between July 2019 and September 2019 was the main contributing factor for the applicant’s current lumbar spine pathology. He has degenerative disease of the lumbar spine. It is a genetically determined problem, unrelated to the nature of his employment.
Dr Casikar opined that the applicant’s lumbar spinal pathology is a disease, and mainly degenerative. It is possible that he had an aggravation of a pre-existing disease. Employment was “perhaps” a contributing factor to the aggravation. He did not think it was the main contributing factor, because the applicant had significant pre-existing degenerative disease.
As regards whether the surgery was reasonably necessary, Dr Casikar opined that the applicant had already had surgery that failed to improve his symptoms. He had failed back syndrome, which does not need more surgery. Further surgery of any type was likely to fail. One would have to analyse the reason for a failed back surgery where emotional issues are the main reasons for failure to improve in a workers compensation background.
Dr Casikar opined that “at this stage” the employment injury did not materially contribute to the need for further microdiscectomy. It had failed once. Further surgery was likely to fail again. Non-surgical management of the applicant’s back pain, particularly from a psychologist, was necessary.

Dr Peter Bentivoglio – Neurosurgeon and Spinal Surgeon

Dr Bentivoglio was qualified by the applicant and reported first on 24 November 2020.
Dr Bentivoglio recorded a history that on 7 September 2019, the applicant had a work injury that was secondary to repetitive bending and lifting and packing chickens. He had not had any prior back issues. He developed low back and right leg pain. He stopped work and saw his local doctor, complaining of low back pain, going to the right leg, with some weakness of the leg, but no numbness. He had not worked since 7 September 2019.
Dr Bentivoglio then referred to the applicant’s subsequent treatment, including right L3/4 microdiscectomy on 22 November 2019. This did not result in significant benefit. The applicant still had persistent low back pain, now going into both legs, greater on the right.
The applicant had had multiple postoperative investigations. He was followed up on numerous occasions by Dr Gambhir, who last saw him on 27 July 2020 and stopped the physiotherapy he had been having after the surgery. He referred the applicant to pain specialist Dr Deshpande, who wanted a new bone scan, even though the previous one did not show any evidence of facet joint arthropathy. The new bone scan had not been done, and no cortisone injections had been done.
Dr Gambhir had recommended a re-decompression of the right L3/4 disc to decompress the right L4 nerve root again, and a microdiscectomy at L4/5 for the left L5 nerve root impingement.
The applicant rated his low back pain at 8-9/10, right leg pain as 9/10, and left leg pain as 8/10. He walked with a stick and could only walk for five minutes. He was sitting for 15 minutes and could not drive. He could not do domestic duties. There was no bladder or bowel dysfunction, but he could not maintain or sustain an erection. The power in his leg in the right side was weak. He had been seeing a psychologist for the last two months, with no great benefit to his chronic pain symptoms.
Dr Bentivoglio’s working diagnosis was mechanical axial back pain, secondary to degenerative disc disease at L3/4 and L4/5, with bilateral neuropathic pain. He was not convinced he could find evidence of radiculopathy.
Dr Bentivoglio opined that the nature and extent of the applicant’s injury was initially a significant L3/4 disc prolapse with L4 nerve root compression on the right side. This initially needed the microdiscectomy because he had evidence of a right L4 radiculopathy. This had not significantly helped his symptoms, and he now had not only right leg pain, but left leg pain secondary to disc changes at the level below, which was degenerative in nature at the L4/5 level.
The applicant’s treatment had been extensive physiotherapy and microdiscectomy with no great improvement. He had post-operative physiotherapy which had ceased and was on pain medication. He had been referred to a pain specialist who had not afforded him any cortisone injections.
Dr Bentivoglio opined that, as a consequence of repetitive bending and lifting on 7 September 2019, the applicant had sustained an acute L3/4 disc prolapse. He had a significant L4 radiculopathy, which needed operative intervention. There was associated degenerative disease at L4/5 and L5/S1. A more recent MRI showed a small persistent or recurrent prolapse at L3/4 on the right, and at L4/5 there was some lateral recess narrowing compression of the L5 nerve root from a disc bulge on the left side.
Dr Bentivoglio did not believe conservative measures would help the applicant. He opined that Dr Gambhir’s approach was reasonable, and the whole idea was to help the leg pain. It would do nothing to help the back pain and Dr Gambhir had said the applicant may well need further surgery in the form of a fusion.
Dr Bentivoglio provided a supplementary report dated 15 June 2021. He had reviewed his earlier report and had noted that the applicant’s back pain started on 7 September 2019, secondary to repetitive bending and lifting, and packing chickens.
While the applicant had maintained he had no prior back issues, Dr Bentivoglio noted his solicitors had stated he had back pain on and off before that time, so his history had been unreliable. The MRI showed a significant disc protrusion [at] the L3/4 level, which had required an acute microdiscectomy on the right, but it also showed multilevel degenerative disc disease at L4/5 and L5/S1. This was directly related to the sort of work he had done, which had been heavy lifting and repetitive bending and twisting; and “would go nicely with someone who has been getting repetitive low back pain”.
Dr Bentivoglio therefore opined that the exacerbation or worsening of the applicant’s condition in September 2019 was secondary to an acute disc prolapse at L3/4, which required urgent surgery, but that was also in association with significant degenerative disease at L4/5 and L5/S1, with lateral recess compression of the L5 nerve roots. The L3/4 disc was obviously the primary concern.
Dr Bentivoglio believed the significant disc degeneration at L4/5 and L5/S1 was related to the applicant’s workplace and the sort of work he was doing but had nothing to do with the acute disc prolapse at L3/4 which was initially operated on.
Dr Bentivoglio recorded that, after the surgery, the applicant’s symptoms did not improve, and he not only had right and left leg pain but follow up MRI showed lateral recess narrowing of L4/5, with impingement on the left L5 nerve root. The work he had done had resulted in multilevel degenerative disease in his lumbar spine, and acute L3/4 disc prolapse, which required initial surgery. The fact that the degenerative disease at L4/5 was now causing problems with left sided sciatica was why he needed surgery at that level.
Asked why he believed it was reasonably necessary for the applicant to undergo further surgery at both levels, Dr Bentivoglio responded that it was reasonably necessary to help the symptoms in his left and right legs, because he had a recurrent disc prolapse at L3/4 and at L4/5 he had left lateral recess disease. Both would explain the symptoms in his legs, which was why Dr Gambhir recommended the re-decompression.
Dr Bentivoglio opined that “just because” the applicant did not have radiculopathy, that does mean he does not have nerve root irritation. He could easily have nerve root irritation without evidence of nerve root dysfunction, so Dr Bentivoglio believed it was reasonably necessary for the applicant to have the re-do operation for the recurrent disc prolapse at L3/4 on the right; and on the left at L4/5 to decompress the L5 nerve root in its lateral recess, in the hope this would help both the right and left leg pain. This was because of nerve root irritation but no dysfunction of the nerves.
Dr Bentivoglio opined that the applicant did not have failed back syndrome. He had had one operation, and there was a recurrent disc prolapse, which explained his right L4 leg pain. He also had evidence of problems with L4/5, which had not had surgery. This was why Dr Gambhir was recommending it. Dr Gambhir had also stated that the applicant would probably need further surgery in future, because of multilevel degenerative disease at L4/5 and L5/S1, as well as at L3/4. Dr Bentivoglio believed it was reasonable to try and re-decompress the right L4 nerve root and decompress the left L5 nerve root for the first time.
Dr Bentivoglio again reported on 1 July 2021. He was asked what had changed to cause a degenerative disc at L4/5 that apparently did not require surgery in 2019 to a condition that now required surgery?
He responded that Mr Hussain had a recurrent L3/4 disc prolapse that was causing right leg pain, but then developed left leg pain. That left leg pain was caused by the lateral recess compression of the left L5 nerve root in the L4/5 lateral recess. This was just progression of the degenerative disc disease that was present on the initial MRI. It did not require surgery in 2019, and unfortunately was now causing compression and sciatic symptoms in the left leg. The lateral recess compression at L4/5 was present in 2019. It had obviously progressed and was now causing right leg pain.
Dr Bentivoglio explained that degenerative disease in someone’s lumbar spine is not a static condition. It is a slowly progressive condition. The applicant was getting symptoms caused by the lateral recess disease at L4/5 because of the progressive nature of the disease.

SUBMISSIONS

The submissions have been recorded, and I will therefore refer to them only briefly.

Applicant

The applicant submitted that Dr Gambhir was “on board” with further conservative treatment until he saw the applicant’s scans, when he determined that any such treatment was a waste of time.
The applicant referred to his evidence regarding the nature of his work as a chicken catcher. He submitted that he had back problems as far back as January 2018, but they appear to have been self-limiting. It is accepted that an event took place on 7 September 2019. Dr Gambhir could not wait for insurer approval, and the applicant had surgery in a public hospital.
The applicant submitted that his L4/5 disc was clearly a potential issue in November 2019 before the surgery. Dr Gambhir was always of the view that it was a problem. He submitted that he had moderate relief from surgery, but deteriorated very quickly, to the point where his symptoms recurred as early as February 2020, and he had symptoms in his left leg as well. In a relatively short period, he was in a lot of trouble. He relied on his GP’s clinical records and Dr Gambhir’s serial reports. Dr Gambhir had dealt with the diagnosis of failed back syndrome. His position was largely supported by Dr Bentivoglio.
The applicant submitted that the only evidence against his position is that of Dr Casikar, and that on the balance of probabilities, I would prefer the evidence of his treating doctors and Dr Bentivoglio. His treating neurosurgeon had had intimate contact with him over a period of time and assessed him on a number of occasions. Dr Casikar had not really explained the ongoing symptoms documented since the surgery.

The applicant submitted that conservative treatment had been tried and failed. Nearly 18 months of such treatment had not helped. Dr Casikar’s examination was flawed. His opinion was very much dependent on what he was told and his findings on examination. He had an inappropriate understanding of what was going on.
The applicant referred to my decision in Ruaporo v Programmed Integrated WorkforceLimited [2021] NSWPIC 12, adopting what I had said about Diab v NRMA Ltd [2014] NSWWCCPD 72 (Diab) and the cases discussed therein. He submitted that Diab was applied in Summers v Sydney International Container Terminals Pty Limited t/as Hutchison Ports [2021] NSWPICPD 35. He submitted that if I accept the evidence of Drs Gambhir and Bentivoglio, I would be satisfied that the test of “reasonably necessary” was satisfied.
The applicant submitted that he had been significantly disabled since the original injury and surgery. The aim of the proposed surgery is to relieve his leg pain and provide him with greater mobility. He submitted that if I find his L4/5 disc was injured at the time of the accepted injury on 7 September 2019 to his L3/4 disc, everything largely follows. He submitted I would find that was the case, because he had symptoms in his left leg before the surgery. It is more probable than not that the events that caused the protrusion at L3/4 also caused damage to the disc below.
The applicant submitted that, if I was against him in respect of his previous submission, then I would find that his degenerative condition was caused or aggravated by his work, and that employment was a substantial contributing factor and the main contributing factor. No other factor had been identified. He referred to the decisions in Murray v Shillingsworth [2006] NSWCA 367; and State Transit Authority of New South Wales v El-Achi [2015] NSWWCCPD 71.
In reply to the respondent, the applicant submitted that, apart from in January 2018, when he was sent for CT scan, there was no other complaint of leg symptoms until 22 September 2019. For the entire period, he continued to work, which was to his credit. This was no longer possible in September 2019, when he suffered a huge prolapse. The type of work he did was exactly the type of work in which this would occur.
The applicant submitted that the injuries on 23 January 2018 and in 2019 were both work-related. He submitted I would find that his work was precisely the type of work that would cause the onset or aggravation of a disease. Employment need only be the main contributing factor to the aggravation. There is no other factor, apart from work, that has been identified as giving rise to his symptoms. Both Dr Gambhir and Dr Bentivoglio had Dr Casikar’s reports and were aware of the matters the respondent raised. Dr Bentivoglio referred to the unreliable history but maintained his opinion.

Respondent

The respondent submitted that, assuming the relevant period of “nature and conditions” is from July 2017 to September 2019, I would not accept that the applicant sustained a disease injury. There is no evidence that his employment was the main contributing factor to the injury. The respondent referred to the decision in AV v AW [2020] NSWWCCPD 9, at [78]. Its focus was on section 4(b)(ii) of the 1987 Act, but it applies equally to section 4(b)(i).
The respondent referred to the applicant’s statement and submitted he did not consider he had issues with his back before September 2019. He stated he had no problems before the injury. While the GP’s clinical records refer to employment as a risk factor, they do not say work caused the applicant’s problems. The only reference to his employment was on 24 June 2019. The respondent submitted there is a complete lack of reference in the notes and the imaging to employment before the injury. Employment between 2017 and 2019 was not the main contributing factor to any injury.
The respondent submitted that Dr Rao did not mention the L4/5 level but noted the imaging. Dr Bentivoglio recorded a history that was consistent with the applicant’s statement, but this changed with the letter from the applicant’s solicitors. This demonstrates there was no issue with the lumbar spine before September 2019.
The respondent referred to the evidence of Drs Bentivoglio and Gambhir, which suggested the nature and conditions of his employment was the main contributing factor to the injury, including at L4/5. The respondent relied on the decision in Cruceanu v Vix Technology (Aust)Ltd [2020] NSWWCCPD 7, in which EMI (Australia) Ltd v Bes [1970] 2 NSWR 238 was discussed.
The respondent submitted that the applicant had back pain radiating to both legs before 2019, and as neither Dr Gambhir nor Dr Bentivoglio recorded this history, there was not a “fair climate” for their opinions. Dr Rao had also not considered the fact that the applicant had low back issues and radiating pain to both legs before 2019. The respondent submitted I would accept Dr Casikar’s opinion that the applicant’s condition was degenerative in nature, and I would not be satisfied that employment was the main contributing factor to any aggravation. His report should be read as a whole, predicated on the clinical picture and imaging.
The respondent submitted that, as regards the “nature and conditions” claim, I would not be satisfised that the applicant had sustained a section 4(b)(i) or section 4(b)(ii) injury. I would also not be satisfied that he had injured his L4/5 disc on 7 September 2019, which is his alternate allegation.
The respondent submitted that the proposed surgery is not reasonably necessary, relying on Dr Casikar’s evidence that the applicant has failed back syndrome. Dr Gambhir and Dr Bentivoglio disagree, but Dr Bentivoglio also found the applicant had non-organic emotional problems. He had a poor outcome from surgery and his back problems became more severe. Dr Casikar opined that employment did not materially contribute to the necessity for surgery. It was likely to fail again.
The respondent submitted that the applicant had been referred to a pain specialist and psychologist. There was no evidence that he had consulted a psychologist. No psychological evidence had been put forward. The proposed surgery was unlikely to be effective and the applicant ought to undergo further conservative measures.

SUMMARY

Injury

The applicant relied principally on the accepted injury at L3/4 on 7 September 2019 (it is also referred to as having occurred on 6 September 2019, which may be explained by the fact that he was working a night shift, but nothing turns on this), and maintained that he also sustained injury to his L4/5 disc at that time. His alternate submission was that he has a degenerative condition that was caused or aggravated by his work, to which employment was the main contributing factor.
The applicant’s evidence about the nature of his duties is that it was physical work, performed at a swift pace. There is no evidence that suggests otherwise, and I accept his evidence. He stated that on 7 September 2019, he had pain in his lower back, radiating to his right leg.
The applicant denied any previous injury to his lumbar spine. It is apparent from the medical evidence that he consulted his GP about low back pain in January 2018 and was referred for CT scan of the thoracolumbar spine, with no significant finding.
There was at that stage no history of any injury at work, but the GP has recorded that the applicant’s risk factors included his work, and he was advised to take care at work. He also told the applicant, who said in 2019 he no memory of being investigated for lower back pain in 2018, that it was for a work-related injury.
The CT scan of the applicant’s lumbar spine dated 23 September 2019 is reported as showing a large disc extrusion arising from the L3/4 disc, almost certainly compressing the descending right L3 nerve within the central canal, and also likely the exiting right L3 nerve root. There was also a prominent posterior endplate disc osteophyte complex at L4/5, which was causing moderate-grade spinal stenosis and mild foraminal narrowing bilaterally, but the exiting nerve roots appeared to exit unimpeded. The conclusion was that there was a large right paracentral disc extrusion, extending superiorly, and likely accounting for the applicant’s right side symptoms.
While the applicant initially consulted Dr Rao, he consulted Dr Gambhir shortly thereafter. It was Dr Gambhir who performed the first surgical procedure. He has reported that the applicant presented in November 2019 with severe radicular symptoms, mainly in his right leg.
The MRI of the applicant’s lumbar spine dated 5 October 2019 is reported as showing a large disc protrusion at L3/4. Relevantly, it also showed disc desiccation at L4/5, with a broad based annular bulge, containing an annular rent. There was narrowing of the lateral recesses of L5 bilaterally, and direct contact with the L5 nerves bilaterally.
Dr Gambhir has referred to the MRI in his report of 10 August 2021. He noted there were disc protrusions at both L3/4 (large) and L4/5 (not large). He hoped that by operating at L3/4, it may be possible to manage the L4/5 protrusion conservatively. He opined that the work related incident (that is, on 7 September 2019, which he referred to as the WorkCover injury) either caused or aggravated the injury at L4/5; and overall the symptoms started from L3/4 and L4/5 after the work related injury. Therefore, work would be the substantial or main contributing factor for both the disc protrusions.
Dr Bentivoglio opined that the applicant had an acute disc prolapse at L3/4 in September 2019, which required urgent surgery. That was in association with significant degenerative disease at L4/5 and also at L5/S1. The lateral recess compression at L4/5 was present in 2019 but had progressed and was causing right leg pain.
Dr Casikar accepted that the injury on 7 September 2019 aggravated a previously injured disc at L3/4. Both the pre-existing condition and the aggravation were related to employment. He noted in his first report that the applicant also had a disc protrusion at L4/5, and he was unsure if it required surgery. He opined that it was not related to the workplace injury, without providing reasons for this opinion.
In his report dated 11 November 2021 (which did not follow a further examination), Dr Casikar opined that it was possible that the applicant had an aggravation of a pre-existing disease, to which employment was perhaps a contributing factor. He did not think it was the main contributing factor, because the applicant had significant pre-existing degenerative disease. That does not mean his employment was not the main contributing factor to the aggravation, which is what he is required to establish to satisfy section 4(b)(ii) of the 1987 Act.
Dr Casikar himself described his examination of the applicant in August 2020 as “flawed”, due to the absence of an interpreter and Sayed’s behaviour. In my view, that affects the weight to be given to his report.
The applicant had degenerative disc disease, commented on by both Dr Casikar and Dr Bentivoglio. He had presented to his GP complaining of back pain in 2018 and 2019, before the injury on 7 September 2019. A CT scan in January 2018 was essentially normal. The MRI in October 2019 was not.
I am satisfied on the evidence that the applicant sustained injury to his lumbar spine, at both L3/4 and L4/5 levels, on 7 September 2019. I am persuaded particularly by the evidence of Dr Gambhir. He has treated the applicant for over two years and has performed the surgical procedure. He has explained why he decided to treat the L4/5 level conservatively. Dr Bentivoglio has explained that the lateral recess compression was present in 2019 but had progressed and was causing right leg pain. I prefer the evidence of Drs Gambhir and Bentivoglio to that of Dr Casikar.
The respondent submitted that as neither Dr Bentivoglio nor Dr Gambhir recorded a history of pain radiating to the applicant’s legs before 2019, there was not a “fair climate” for their opinions. The expression “fair climate” is a reference to the decision of the Court of Appeal in Paric v John Holland Constructions Pty Ltd [1984] 2 NSWLR 505.
The High Court in Paric v John Holland (Constructions) Pty Ltd [1985] HCA 58; 59 ALJR 84 said:
“It is trite law that for an expert medical opinion to be of any value the facts upon which it is based must be proved by admissible evidence…But that does not mean that the facts as proved must correspond with complete precision to the proposition on which the opinion is based. The passages from Wigmore on Evidence cited by Samuels J.A. in the Court of Appeal…to the effect that it is a question of fact whether the case supposed is sufficiently like the one under consideration to render the opinion of the expert of any value are in accordance with both principle and common sense.” [citations omitted].
I do not accept that there was not a fair climate for the opinions of Drs Bentivoglio and Gambhir. Dr Gambhir reported that the applicant did not have significant back pain or radiculopathy before the work injury. While Dr Hussain has recorded back and leg pain, the applicant himself apparently did not recall it, and had to be reminded of it. There is no evidence that he lost any time from work before the injury on 7 September 2019, Dr Hussain did not issue any certificates of capacity, and he made no claim for compensation. Dr Bentivoglio was made aware that the applicant had had back pain “on and off” before the injury. The fact that he has not recorded leg pain does not, in my view, mean that his opinion has not been provided in a fair climate.
As I have determined that the applicant sustained injury to his lumbar spine at both L3/4 and L4/5 levels on 7 September 2019, it is unnecessary that I determine his alternate case.

Medical treatment

The applicant relies on the principles applied by Deputy President Roche in Diab. These principles have been applied in many matters before this Commission and the former Workers Compensation Commission.
Roche DP referred to the following:
(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.
Roche DP warned that while the above matters were “useful heads for consideration”, the “essential question remains whether the treatment was reasonably necessary” (Margaroff v Cordon Bleu Cookware Pty Ltd [1997] NSWCC 13; (1997) 15 NSWCCR 204).
Both Dr Gambhir and Dr Bentivoglio support the reasonable necessity of the proposed surgery. Dr Casikar is of the opinion that the applicant has failed back syndrome.
Dr Gambhir has referred to attempts to manage the applicant’s condition conservatively. The applicant was referred to a pain specialist for injections and further pain management. He had frequent physiotherapy. He had failed conservative therapy for nine months. I note that Dr Bentivoglio reported in November 2020 that the applicant had not had cortisone injections. Dr Bentivoglio, in any event, did not believe conservative measures would help the applicant.
Dr Casikar opined that the applicant should have input from pain management and perhaps a psychologist; and a cortisone injection at L3/4.
Dr Bentivoglio recorded in November 2020 that the applicant had been seeing a psychologist for the last two months, with no great benefit. The applicant’s evidence is that in about February 2020 he attended hydrotherapy and physiotherapy. The physiotherapist has recorded that there was little improvement, and he often rated his pain as 10/10.
The applicant’s evidence is that he is in pain all day, every day, while standing, walking or lying. He is limited in his ability to perform any daily activities. Dr Gambhir reported that he walked with a stick. The overall picture is of a man with significant symptoms and disabilities.
Dr Gambhir rejected Dr Casikar’s diagnosis of failed back syndrome. Dr Gambhir opined that it should only be applied if there was no anatomical cause of the pain, referring to the findings on MRI. Dr Bentivoglio opined that the applicant did not have failed back syndrome. He had a recurrent disc prolapse at the site of the surgery and problems at L4/5.
Applying the principles of Diab, both the applicant’s treating specialist, who performed the first surgery, and Dr Bentivoglio, agree that the proposed surgery is appropriate. Dr Casikar appears to have advised against the surgery mainly on the basis that the applicant had significant emotional problems. That expression of opinion followed an examination he accepted was flawed, and with Sayed suggesting to the applicant the responses he was to give.
Both Dr Gambhir and Dr Bentivoglio have rejected alternative treatment. Dr Casikar has recommended alternative treatment, particularly from a psychologist. I have referred to the treatment undergone by the applicant above. There is no evidence that it has been effective, and the evidence suggests the contrary.
The cost of the treatment is claimed as $12,384, and there would obviously also be associated expenses and post-operative rehabilitation. It has not been submitted by the respondent that the cost of the treatment is excessive or has been a factor in liability being disputed.
Both Dr Gambhir and Dr Bentivoglio opined that the surgery has the potential to alleviate the applicant’s leg symptoms. Dr Casikar opined that re-exploration surgery was unlikely to relieve the applicant’s symptoms but was likely to make them more severe. Once again, his opinion appears to be based on his evaluation of the applicant’s emotional problems.
As for acceptance by medical experts of the appropriateness and effectiveness of the treatment, Drs Gambhir and Bentivoglio accept that the proposed surgery is appropriate and has the potential to be effective. I do not understand Dr Casikar’s opinion to be that the surgery itself is not an appropriate form of treatment, but rather that it is contraindicated for the applicant.
Applying the principles in Diab and the cases discussed therein, I am satisfied that the surgery proposed by Dr Gambhir is reasonably necessary medical treatment.
I determine that the applicant sustained injury to his lumbar spine, at both L3/4 and L4/5 levels, on 7 September 2019; and that the proposed medical treatment, that is right L3/4 and L4/5 microdiscectomy, is reasonably necessary as a result of the injury.
The order is set out in the Certificate of Determination.

[2022] NSWPIC 107

16 March 2022