Ishac v Byblos Promotions Pty Ltd
[2024] NSWPICMP 668
•19 September 2024
| DETERMINATION OF APPEAL PANEL | |
| CITATION: | Ishac v Byblos Promotions Pty Ltd [2024] NSWPICMP 668 |
| APPELLANT: | Jean Ishac |
| RESPONDENT: | Byblos Promotions Pty Limited |
| APPEAL PANEL | |
| MEMBER: | Catherine McDonald |
| MEDICAL ASSESSOR: | Mohammed Assem |
| MEDICAL ASSESSOR: | Drew Dixon |
| DATE OF DECISION: | 19 September 2024 |
CATCHWORDS: | WORKERS COMPENSATION - Workplace Injury Management and Workers Compensation Act 1998; Medical Assessor made a section 323 deduction of 100% for pre-existing cervical spine condition; Cole v Wenaline Pty Limited, and Southwell v Qantas Airways Limited considered; Held – Medical Assessment Certificate confirmed. |
BACKGROUND TO THE APPLICATION TO APPEAL
On 28 June 2024 Jean Ishac lodged an Application to Appeal Against the Decision of a Medical Assessor. The medical dispute was assessed by Medical Assessor Todd Gothelf, who issued a Medical Assessment Certificate (MAC) on 4 June 2024.
Mr Ishac relies on the ground of appeal in s 327(3)(d) of the Workplace Injury Management and Workers Compensation Act 1998 (the 1998 Act) – that the MAC contains a demonstrable error.
The President’s delegate was satisfied that, on the face of the application, the ground of appeal was made out. We conducted a review of the original medical assessment, limited to the grounds of appeal on which the appeal is made.
Rule 128 of the Personal Injury Commission Rules 2021 (the PIC Rules) and Procedural Direction PIC7 – Appeals, reviews, reconsiderations and correction of obvious errors in medical disputes set out the practice and procedure in relation to the medical appeal process under s 328 of the 1998 Act. An Appeal Panel determines its own procedures in accordance with r 128(1) of the PIC Rules.
The assessment of permanent impairment is conducted in accordance with the SIRA NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment, 4th ed 1 March 2021 (the Guidelines) and the American Medical Association Guides to the Evaluation of Permanent Impairment, 5th ed (AMA 5).
RELEVANT FACTUAL BACKGROUND
Mr Ishac is a working director of Byblos Promotions Pty Limited (Byblos) who claimed permanent impairment compensation as a result of injuries to his lumbar spine, cervical spine and right shoulder on 15 February 2021 when he was lifting a server and placing it on a rack. He had suffered previous injuries to his cervical spine in 2007 and 2019.
The Medical Assessor assessed 13% whole person impairment (WPI) comprised of 0% in the cervical spine, 7% in the lumbar spine and 6% for the right upper extremity. In respect of Mr Ishac’s cervical spine, the Medical Assessor assessed 5% WPI, placing him in Diagnosis Related Estimate (DRE) cervical category II. He deducted 100% under s 323 of the 1998 Act because Mr Ishac had been assessed in DRE category II in respect of an earlier injury.
The appeal concerns only the s 323 deduction in respect of Mr Ishac’s cervical spine.
PRELIMINARY REVIEW
We conducted a preliminary review of the original medical assessment in the absence of the parties and in accordance with the Procedural Direction PIC7.
As a result of that preliminary review, we determined that it was not necessary for Mr Ishac to undergo a further medical examination because there is sufficient medical information in the file to determine the appeal.
EVIDENCE
We have all the documents that were sent to the Medical Assessor for the original medical assessment and have taken them into account in making this determination.
Byblos’ insurer disputed that Mr Ishac suffered an injury to his cervical spine and right shoulder on 15 February 2021 based on the reports of Dr Wallace and the issue was determined by a Member of the Personal Injury Commission in a decision dated 18 March 2024.[1] The Member was satisfied that Mr Ishac suffered an injury to his cervical spine which was the aggravation of a disease and to which employment was the main contributing factor.
[1] Ishac v Byblos Promotions Pty Limited [2024] NSWPIC 130.
The matter was remitted to the President for referral to a Medical Assessor. The Member recognised in the last paragraph of his decision that “the task of assessing the degree of any permanent impairment resulting from the injury and making deductions for previous injuries, pre-existing conditions or abnormalities pursuant to s 323 of the 1998 Act falls to the Medical Assessor.”
The MAC
The Medical Assessor commenced the MAC by summarising the evidence of independent medical examiners in respect of the 2007, 2019 and 2021 injuries. He summarised the history Mr Ishac provided, including that he felt severe pain in his low back at the time of the injury “as if someone had shot a bullet into his back”. The Medical Assessor said:
“Mr Ishac was asked about the cervical spine and Mr Ishac stated he injured the neck from the ‘first’ injury in 2007. He described an injury in 2019 that affected his neck and shoulder again. Mr Ishac explained that he had neck and shoulder pain from prior injuries which did not change substantially from the subject injury.”
Summarising Mr Ishac’s present symptoms, the Medical Assessor said;
“Mr Ishac rated the cervical spine pain as a five on a scale of zero (no pain) to ten (the worst pain imaginable) when staying still and when moving the neck the pain goes to a ten. The pain has remained relatively constant since 2019. The pain is in the neck at the base.”
The Medical Assessor obtained a history of an injury to Mr Ishac’s cervical spine and right shoulder on 17 January 2007 and an injury to his left shoulder on 11 September 2009. He suffered an injury to his back in a motor vehicle accident on 17 May 2010, and resumed pre-injury duties by about 2013, though he still has restrictions in his right and left shoulders and in his neck. The Medical Assessor recorded:
“On 6 July 2019 the network server was down so Mr Ishac needed to replace it with a new one. He took the network server out of the racks which weighed about 7 kilos and placed it on the top of the rack. Mr Ishac then went to put the new network server in place and as he was doing this the old network server fell onto his head from about 2 m high. Mr Ishac was taken to Westmead Hospital and stayed overnight until they did their checks on me. He had to wear a brace around his neck for 3 months.
Mr Ishac had to take 3 months off work following this incident. He didn’t report it at that time to the insurer as he thought he would eventually get better and be able to return to work which he did. Eventually he was able to get back to work, and continued to have right shoulder and neck pain.”
The Medical Assessor set out his examination findings in respect of Mr Ishac’s cervical spine:
“The cervical posture was normal. There was positive reported tenderness to palpation of the neck left and right paraspinal muscles. There was no visible or palpable deformity in the neck region. There was no observed muscle spasm but there was positive guarding. Cervical movement was a fraction of the normal range of motion of . ¼ full cervical extension, ½ full flexion, ½ full right rotation, ¼ full left rotation, ½ full right lateral flexion, and ¼ full left lateral flexion. There was positive cervical asymmetrical loss of motion.”
The Medical Assessor reviewed radiological reports dating back to 2007:
“19 January 2007 – Xray Lumbar spine & X-ray and CT Cervical Spine
…
Cervical spine: There is visible fracture and no subluxation or dislocation of the cervical spine. There is moderate bony foraminal narrowing and lateral recess narrowing on the left at C6/7 and mild foraminal narrowing on the right at C6/7 and bilaterally at C3/4.
…
17 October 2007 – MRI Cervical Spine
The most clinically significant level is at C6/7 where there is a left paracentral disc protrusion which indents the ventral aspect of the thecal sac which also compresses the left C7 nerve within the exit foramen. There is also some foraminal encroachment on the right, with potential mass effect on the exiting right C7 nerve, this acute protrusion is seen on more chronic background changes of mild spondylotic disease.
…
25 January 2010 – CT Scan of Cervical Spine
There is degenerative spondylosis at C6/7. At this level there is disc space narrowing and a left paracentral disc protrusion. There is also associated foraminal narrowing bilaterally due to uncovertebral joint arthrosis.
…
6 July 2019 – CT Cervical Spine
No acute intracranial pathology. No acute cervical spine fracture or dislocation. Ligamentous injury is not excluded.
…
25 March 2021 – MRI of the Spine
Cervical spine: C6/7 shows severe left foraminal narrowing.
…”
The Medical Assessor diagnosed a cervical spine strain as a result of the 2021 injury. Setting out his calculations, he said:
“Cervical Spine
Table 15-5 p 392 AMA5 is used. A DRE II applies as there was positive guarding and positive asymmetrical loss of motion. Thus a 5% WPI applies.
Deductions
There was evidence of a pre-existing cervical spine condition with permanent impairment. A Medical Assessment Certificate in 2011 indicated the presence of a DRE II classification of the cervical spine. The evidence noted the presence of neck pain prior to the work place injury. As the classification of the cervical spine has not changed, I consider a 100% deduction is reasonable for the pre-existing condition.
The Final cervical spine impairment is 0% WPI.”
He agreed with Dr Bodel’s assessment in DRE cervical category II.
SUBMISSIONS
Both parties made written submissions. They are not repeated in full, but we have considered them.
In summary, Mr Ishac submitted that the Medical Assessor failed to apply s 323 correctly when he made a 100% deduction. He said that DRE classifications are made on the basis of symptoms. In this case, the Medical Assessor assessed Mr Ishac in DRE cervical category II because of asymmetrical loss of motion but that category is also appropriate for other symptoms. Mr Ishac referred to Cole v Wenaline Pty Ltd[2] (Cole) to argue that the Medical Assessor was required to determine the WPI for the subject injury, then determine what part the pre-existing condition played “in the final calculation of WPI”. He said that the Medical Assessor must make a clinical finding
“…as to how the symptoms that existed before the injury have contributed to the WPI found. It is not good enough to rely on a prior DRE finding because this does not indicate the severity of pre-existing symptoms or even what symptoms or clinical findings actually gave rise to the DRE 2 finding in the 2011 MAC.”
[2] [2010] NSWSC 78 at [32]-[38].
Mr Ishac submitted that the radiology showed a deterioration in the C6/7 disc over time, which would suggest that his symptoms after the injury are more severe. He said that the s 323 deduction should be one-tenth because “it is incorrect to assume all symptom complexes that attract a DRE 2 classification are the same.”
In reply, Byblos submitted that Medical Assessor had correctly considered Mr Ishac’s permanent impairment, and identified the prior injury from the medical evidence and the history obtained. Byblos said that the assessments made with manifestly correct.
FINDINGS AND REASONS
The procedures on appeal are contained in s 328 of the 1998 Act. The appeal is by way of review of the original medical assessment but the review is limited to the grounds of appeal on which the appeal is made.
In Campbelltown City Council v Vegan[3] the Court of Appeal held that an Appeal Panel is obliged to give reasons. Where there are disputes of fact it may be necessary to refer to evidence or other material on which findings are based, but the extent to which this is necessary will vary from case to case. Where more than one conclusion is open, it will be necessary to explain why one conclusion is preferred. On the other hand, the reasons need not be extensive or provide a detailed explanation of the criteria applied by the medical professionals in reaching a professional judgement.
[3] [2006] NSWCA 284.
In Queanbeyan Racing Club Ltd v Burton[4] the Court of Appeal held that an Appeal Panel is not limited to the ground held to have been made out by the delegate but may consider all grounds of appeal raised in the application. However, the panel is not permitted to look for errors which are not part of the grounds of appeal on which the appeal is made. We have only considered those grounds specifically raised by the appeal.
[4] [2021] NSWCA 304 at [26].
Medical evidence in the Application to Resolve a Dispute (ARD)
Mr Ishac said in his statement that in 2007, he suffered an injury to his neck and right shoulder and returned to work on selected duties after the injury on a part-time basis. He reduced his hours again after an injury to his left shoulder in 2009. In 2010, he suffered an injury to his back in a motor vehicle accident. After gradually increasing his workload, he returned to pre-injury duties by about 2013, though he still had restrictions in his shoulders and neck. He suffered an injury in 2019 and wore a neck brace for three months, during which time he was not working. Mr Ishac said that he ceased work following the injury in 2021 and that the pain in his back was different to what he had experienced before, in that he was suffering pain down his legs. He did not say anything in his statement about an injury to his neck in 2021.
Apart from some Certificates of Capacity dated between 2009 and 2017, there is little medical evidence in the ARD which predates the 2021 injury.
Dr Chwah, general practitioner, reported on 12 July 2023. Dr Chwah described the 2021 injury as a lumbar spine injury though the cervical and right shoulder pain were “still there”. He said:
“Mr Ishac had previous neck and shoulders injuries that had been stable and had settled with a residue of pain, which has no direct effect on his lower back recent injury in February 2021.”
Shortly after that report was written, Mr Ishac began to consult a new general practitioner, Dr Lim, who obtained a history of a previous C6/7 disc protrusion in 2007 but also that he suffered a neck injury on 15 February 2021. Dr Lim said that the injury related disability was to Mr Ishac’s back but he had also suffered a “cervical spine aggravation.”
Dr Lim referred Mr Ishac to Dr Singh, neurosurgeon. There is no formal report from Dr Singh but notes of his consultation on 27 April 2021 appear in Dr Lim’s notes. He recorded that Mr Ishac had a lumbar spine injury and a previous neck injury. He said that the neck and arm pain of which Mr Ishac complained was related to a previous injury when a heavy object fell on his head. He noted disc bulging and foraminal stenosis on the left side at C6/7. He recommended conservative treatment and a further consultation. Though Mr Ishac told other practitioners that Dr Singh recommended surgery, there is no record of a further consultation.
Mr Ishac’s solicitors retained Dr Bodel, orthopaedic surgeon, who reported on 6 March 2023. He recorded that Mr Ishaq suffered back, neck and shoulder pain. He identified at previous claim as a result of a motor vehicle accident where Mr Ishac injured his lower back. He was not shown any scans which pre-dated March 2021.
Dr Bodel noted that he assessed Mr Ishac for the Workers Compensation Commission in 2011 at which time he assessed 19% WPI, in respect of Mr Ishaq’s back, neck and right and left shoulders. He said that on the day of his examination, the WPI was now 17% WPI, and that there had been a slight improvement in the range of movement in Mr Ishac’s neck. Dr Bodel assessed Mr Ishac’s cervical spine in DRE category II and allowed 2% for the impact on the activities of daily living.
Byblos’ evidence
Byblos relied on reports from Dr Wallace dated 24 May 2021 and 27 April 2023. Dr Wallace did not consider that Mr Ishac suffered an injury to his neck in 2021, noting in his second report that Mr Ishac had not mentioned any such injury at the time of his first examination only months after the injury.
Radiology
A cervical spine X-ray dated 19 January 2007 was reported as showing early spondylosis at C5, C6 and C7 and that the C6/7 disk space was narrowed. A CT scan on the same day showed mild foraminal narrowing bilaterally at C3/4 and on the right at C6/7, and moderate anterior foraminal narrowing on the left at C6/7. Narrowing of the left C6/7 foramen was said to be due to body hypertrophy of the uncovertebral joint and was associated with mild lateral recess narrowing. There was a small focal disc bulge laterally on the left at C6/7, forming an osteophytic ridge and disc complex.
An MRI scan of Mr Ishac’s cervical spine on 17 October 2007 showed:
“The most clinically significant level is at C6/7 where there is a left paracentral disc protrusion on which indents the ventral aspect of the thecal sac, which also compresses the C7 nerve within the exit foramen. There is some foraminal encroachment on the right with potential mass effect on the exiting right C7 nerve.
This acute protrusion is seen on more chronic background changes of mild spondylitic disease.”
A CT scan on 22 January 2010 was reported as showing degenerative spondylosis at C6/7, at which level there was also a disc space narrowing on the left paracentral disc protrusion. There was associated foraminal narrowing bilaterally due to uncovertebral joint arthrosis. Small insignificant disc bulges were noted between C2 and C6.
Mr Ishac went to Westmead Hospital on 6 July 2019, the date of the 2019 injury. A CT scan of his cervical spine showed:
“…no prevertebral, soft tissue, swelling or epidural haematoma. No acute cervical spine fracture or dislocation is identified. Cervical vertebral alignment is within normal limits. There is a congenital fusion of the C1 vertebra with the occipital condyle. A congenital midline fusion defect of C1 is also present. Mild degenerative changes noted at C6/7.”
The most recent relevant imaging is an MRI scan dated 25 March 2021. It relevantly showed:
“C5/C6: Bilateral uncovertebral osteophyte formation is noted and it causes mild bilateral foraminal narrowing. The facet joints are within normal limits.
C6/C7: There is a prominent left lateral recess/foraminal disc osteophytic complex which causes severe left foraminal narrowing. The facet joints are within normal limits.
C7/T1: Left sided uncovertebral osteophyte formation is noted which causes moderate left foraminal compromise. The facet joints are within normal limits.
Moderate degenerative changes are noted in the facet joints at T1 /T2.
The visualised posterior fossa structures and visualised portion of the spinal cord show normal signal. The neck soft tissues are within normal limits. The flow voids within the neck are preserved.
Conclusion: C6/C7 shows severe left foraminal narrowing.”
Medical evidence – previous claims
In addition to the radiological evidence summarised above, the Reply contains reports from doctors who have examined Mr Ishac for the purpose of previous proceedings. We are not required to choose between the opinions of independent medical examiners,[5] but the reports are relevant for the history Mr Ishac gave at various times.
[5] State of New South Wales (NSW Department of Education) v Kaur [2016] NSWSC 346 at [25]-[26].
Dr Matalani assessed Mr Ishac in respect of the 2007 injury as an injury management consultant and reported to Byblos’ insurer on 30 April 2007. He said that the fall in 2007 caused a whiplash associated disorder and he observed significant restriction of the normal range of motion of Mr Ishac’s neck.
Dr Chwah referred Mr Ishac to Dr Kwok, neurosurgeon, who reported on 21 September 2007. He observed neck stiffness disproportionate to the CT scan appearance and ordered the 2007 MRI scan. It does not appear that Mr Ishac saw Dr Kwok again.
On 13 February 2010 Dr Guirgis assessed Mr Ishac for his former solicitors in respect of the 2007 injury, diagnosing post-traumatic mechanical derangement of the cervical spine and placing him in DRE cervical category II.
Dr Bodel prepared two previous MACs. The first is not in the file. The Certificate of Determination dated 11 August 2010 shows that Dr Bodel was, relevantly, asked to examine Mr Ishac in respect of the 2007 injury, assessing his neck and shoulders. In the first, he determined that Mr Ishac’s injuries had not reached maximum medical improvement. The MAC does not appear in the file but a Certificate of Determination to that effect does. The MAC dated 31 August 2011 which appears in the Reply along with other medical evidence in respect of the previous injuries. Dr Bodel assessed Mr Ishac in DRE cervical category II as a result of the 2007 injury, allowing 2% for the impact on activities of daily living and deducting one-tenth under s 323 because of degenerative change contributing to the impairment.
Consideration
Section 323 provides that there is to be a deduction from an assessment of impairment for any proportion of the impairment that is due to any previous injury, or is due to any pre-existing condition or abnormality.
In Cole v Wenaline Pty Ltd (Cole) Schmidt J considered whether there should be a deduction in respect of the back impairment of a worker who had undergone surgical treatment for a previous, well-documented injury. Her Honour said:[6]
“The section is directed to a situation where there is a pre-existing injury, or pre-existing condition or abnormality. For a reduction to be made from what has been assessed to have been the level of impairment which resulted from the later injury in question, a conclusion is required, on the evidence, that the pre-existing injury, pre-existing condition or abnormality caused or contributed to that impairment.
Section 323 does not permit that assessment to be made on the basis of an assumption or hypothesis, that once a particular injury has occurred, It will always, ‘irrespective of outcome', contribute to the impairment flowing from any subsequent injuries. The assessment must have regard to the evidence as to the actual consequence of the earlier injury, pre-existing condition or abnormality. The extent that the later injury was due to the earlier injury, pre-existing condition or abnormality must be determined. The only exception is that provided for in section 323(2), where the required deduction 'will be difficult or costly to determine'.
…
What s 323 required, however, was that the evidence be considered, so that it could be determined, firstly, what the level of impairment after the second injury was. Secondly, whether a proportion of that impairment was due to the first injury. Thirdly, what that proportion was. Undoubtedly in undertaking this exercise, the medical members of an Appeal Panel must utilise their medical judgement, knowledge and experience…”
[6] [2010] NSWSC 78 at [29]-[30] and [38].
In Southwell v Qantas Airways Pty Limited[7] Wright J said:
“… the text of s 323(1) and its context, as well as the legislative history referred to below and the scope and purpose of the 1998 Act, indicate that the word ‘proportion’ should be construed as referring to a ‘portion’ or ‘part’, when considered in relation to the whole, of the degree or level of impairment. In addition, the words ‘due to’ in relation to any previous injury, or pre-existing condition or abnormality, should be construed as meaning due to those previous or pre-existing matters and not due to the workplace injury under consideration. Otherwise, there would be no satisfactory logical basis for the deduction mandated under the section. The authorities which have considered this section, some of which are referred to in more detail in the paragraphs which follow, are consistent with this construction of s 323(1).
Thus, s 323(1) requires the assessment to focus upon whether there is any portion or part of the impairment suffered which is due to any pre-existing condition but which is not attributable to the workplace injury. If that is so, there is to be a deduction of the proportion of the whole represented by that part or portion. At that point, s 323(2) may have a role to play. …
On its terms, however, s 323(2) does not apply if it has not been determined that a deduction is to be made under subs (1) because a part or portion of the level of impairment suffered was due to the pre-existing condition. Subsection (2) relates only to ‘the extent of a deduction under this section’ not to whether such a deduction is required. As Schmidt J held, in effect, in Cole v Wenaline Pty Ltd [2010] NSWSC 78 (Cole) at [30] and [31], s 323(1) does not permit the assessment of whether a deduction is required to be made on the basis of an assumption or hypothesis, that once there is found to be a particular pre-existing condition, it will always, ‘irrespective of outcome’, contribute to the impairment flowing from any subsequent injury. Rather, the assessment of whether a deduction is required must have regard to the evidence as to the actual consequences of the pre-existing condition and whether any proportion of the permanent impairment present after the workplace injury was due to the pre-existing condition.”
[7] [2024] NSWSC 497 at [47]-[49].
The fact that a Member determined that Mr Ishac suffered an injury on 15 February 2021 does not necessarily mean that permanent impairment compensation will be awarded. The Medical Assessor determined that the level of impairment after the 2021 injury was DRE cervical category II, resulting in 5% WPI.
The Medical Assessor was then required to determine if a proportion of the impairment was due to an earlier injury. The methodology he adopted was to say that Mr Ishac had previously been assessed in DRE cervical category II in 2011 and that his classification had not changed, so that the deduction was 100%. We do not agree that focussing on the previous assessment was the correct application of the test in Cole and the subsequent cases but we consider that he reached the correct result.
When regard is had to the “actual consequences” of the pre-existing condition, set out in the pre-injury medical evidence, it is clear that all of the impairment now suffered by Mr Ishac related to the earlier injuries and, in particular that in 2007. The most useful evidence is the radiological reports which allows us to compare the 2010 MRI scan report with that prepared in 2021. The passage of time and Mr Ishac’s age account for any progression of the appearances.
Our conclusion is reinforced by the histories Mr Ishac provided immediately after the injury which did not refer to neck pain. The Medical Assessor specifically explored the impact of the 2021 injury and Mr Ishac told him that he injured his neck in 2007 and the pain did not substantially change after the 2021 injury.
Dr Bodel, who saw Mr Ishac after both injuries, said there was a slight improvement in the range of motion of his cervical spine. He specifically said that there had been no deterioration since the assessment 11 years before. The WPI assessment Dr Bodel made on 6 March 2023 was in respect of the impairment measured on the day of the examination. He was not only measuring the impairment resulting from the 2021 injury.
We agree that the proportion of the impairment which relates to the pre-existing condition is the whole of the impairment of his cervical spine.
Mr Ishac argued that the deduction should be one-tenth. His submissions focused on “symptoms”, suggesting they were different as a result of the 2021 injury. The history set out above does not support that submission.
The subjective symptoms that Mr Ishac reported are relevant but not determinative of the assessment. The Medical Assessor set out the basis for his assessment in the description of his examination of Mr Ishac’s cervical spine. Paragraph 4.18 of the Guidelines explains the Medical Assessor’s task and highlights the difference between subjective symptoms and clinical signs:
“DRE II is a clinical diagnosis based upon the features of the history of the injury and clinical features. Clinical features which are consistent with DRE II and which are present at the time of assessment include radicular symptoms in the absence of clinical signs (that is, non-verifiable radicular complaints), muscle guarding or spasm, or asymmetric loss of range of movement. Localised (not generalised) tenderness may be present. In the lumbar spine, additional features include a reversal of the lumbosacral rhythm when straightening from the flexed position and compensatory movement for an immobile spine, such as flexion from the hips. In assigning category DRE II, the assessor must provide detailed reasons why the category was chosen.”
There is no basis to make a deduction of one-tenth in a case where there is so much evidence regarding the pre-injury condition of Mr Ishac’s cervical spine. To do so would be at odds with the available evidence.
For these reasons, we have determined that the MAC issued on 4 June 2024 should be confirmed.
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