Morgan v Insurance Australia Limited t/as NRMA Insurance
[2024] NSWPICMP 340
•27 May 2024
| DETERMINATION OF REVIEW PANEL | |
| CITATION: | Morgan v Insurance Australia Limited t/as NRMA Insurance [2024] NSWPICMP 340 |
| CLAIMANT: | Abanoub Morgan |
| INSURER: | NRMA |
| REVIEW PANEL | |
| MEMBER: | Gary Victor Patterson |
| MEDICAL ASSESSOR: | Geoffrey Stubbs |
| MEDICAL ASSESSOR: | Shane Moloney |
| DATE OF DECISION: | 27 May 2024 |
| CATCHWORDS: | MOTOR ACCIDENTS – The claimant was the seat-belted driver of a Nissan Navara utility vehicle on 22 February 2022 north-bound on King Georges Road, Beverly Hills; the vehicle in front of him suddenly stopped; claimant was rear-ended by a truck in the rain; neither ambulance nor Police Officers attended; the claimant consulted his general practitioner, three weeks later, for treatment of neck pain, lumbar back pain and bilateral wrist pain; the insurer admitted liability for the claim on the basis that the claimant was not at-fault and his injuries were not minor (now threshold) injuries for the purposes of the Motor Accident Injuries Act 2017; medical disputes as to treatment and care; causation regarding proposed L5/S1 nucleoplasty; MRI scan of left shoulder and left shoulder subacromial bursa ultrasound-guided injection; request for nucleoplasty withdrawn; Review Panel certifies none of the proposed treatments relate to motor accident; Held – certificate of Medical Assessor Woo otherwise confirmed |
| DETERMINATIONS MADE: | CERTIFICATE 1. The Review Panel revokes the certificate dated 5 May 2023 and issues a new certificate determining that: The following treatment and care: (a) L5/S1 nucleoplasty; (b) MRI scan of the left shoulder, and (c) left shoulder subacromial bursa ultrasound-guided injection DOES NOT RELATE TO THE INJURY caused by the motor accident. CERTIFICATE 2. The Review Panel confirms the certificate dated 5 May 2023 issued by Medical Assessor Alexander Woo. CERTIFICATE 3. The Review Panel confirms the certificate issued on 5 May 2023 by Medical Assessor Alexander Woo. |
STATEMENT OF REASONS
INTRODUCTION
Abanoub Morgan (the claimant) was the seat-belted driver of a Nissan Navara utility vehicle on 22 February 2022 north bound on King Georges Road, Beverley Hills. The vehicle in front of him suddenly stopped. The claimant applied his brakes and managed to avoid a collision but was rear-ended by a truck in the rain. Neither ambulance nor police officers attended. He was shocked but managed to drive home. The next day, he experienced significant bilateral lower back pain. The claimant consulted his general practitioner, three weeks later, for treatment of neck pain, lumbar back pain and bilateral wrist pain. He has a pre-accident history of recurrent left shoulder dislocations. He is a right-handed trainee builder.
NRMA (the insurer) indemnified the owner and/or the driver of the insured vehicle for liability to pay to the claimant damages and statutory compensation benefits under the Motor Accident Injuries Act 2017 (the Act). The insurer admitted liability for the claim on the basis that the claimant was not at-fault and his injuries were not minor (now threshold) injuries for the purposes of the Act.
The issue presently in dispute is whether various treatments relate to the injury caused by the motor accident, are reasonable and necessary in the circumstances and will improve the recovery of the injured person.
ASSESSMENT UNDER REVIEW
Those medical disputes were referred to Medical Assessor Alexander Woo for determination of whether the following treatment and care:
(a) L5/S1 nucleoplasty;
(b) MRI scan of the left shoulder, and
(c) left shoulder subacromial bursa ultrasound-guided injection;
relate to the injury caused by the motor accident, are reasonable and necessary in the circumstances and will improve the recovery of the injured person.
Medical Assessor Woo certified on 9 May 2023 as follows:
The following treatment and care:
RELATES TO THE INJURY caused by the motor accident.
- L5/S1 nucleoplasty
The following treatment and care:
DOES NOT RELATE TO THE INJURY caused by the motor accident.
- MRI scan of the left shoulder
- Left shoulder subacromial bursa ultrasound-guided injection
The following treatment and care:
IS NOT REASONABLE AND NECESSARY in the circumstances.
- L5/S1 nucleoplasty
- MRI scan of the left shoulder
- Left shoulder subacromial bursa ultrasound-guided injection
The following treatment and care:
WILL NOT IMPROVE the recovery of the injured person.
- L5/S1 nucleoplasty
- MRI scan of the left shoulder
- Left shoulder subacromial bursa ultrasound-guided injection
STATUTORY PROVISIONS
A medical assessment matter is determined in accordance with Division 7.5 of the Act. The matter is determined at first instance by a Medical Assessor pursuant to s 7.20 of the Act and, on review, pursuant to s 7.26 of the Act, by a Review Panel consisting of two Medical Assessors and a Member assigned to the Motor Accidents Division of the Personal Injury Commission (Commission).
Part 5 of the Personal Injury Commission Act 2020 (the PIC Act) enables the Commission to make rules with respect to the practice and procedure before the Commission, including proceedings before a Panel, reviewing a decision of a Medical Assessor.[1]
[1] Section 41(2) of the PIC Act.
Rules 127 to 130 of the Personal Injury Commission Rules 2021 (the PIC Rules) are made pursuant to Part 5 of the PIC Act. A Review Panel determines how it conducts and determines the proceedings and may determine the proceedings solely based on the written Application.[2]
[2] Rule 128 of the PIC Rules.
The review of the medical assessment is by way of new assessment of all the matters with which the medical assessment is concerned, unless the parties otherwise agree, or the Review Panel otherwise decides.[3]
[3] Section 7.26(6) of the MAI Act.
All members of the Review Panel had no previous involvement with the claimant or with this matter.
CAUSATION
Sections 5D and 5E of the Civil Liability Act2002 apply to the Act.[4] Section 5D deals with the general principles of causation and s 5E prescribes the balance of probabilities as the onus of proof which the claimant always bears in relation to any fact relevant to the issue of causation.
[4] Section 3(B)(2) of the Civil Liability Act 2002.
In Briggs v IAG Limited t/a NRMA Insurance[5] his Honour Justice Wright stated at [35]:
[5] [2022] NSWSC 372.
“…the question of causation of injuries was not dealt with in Part 5 of the Guidelines but causation was addressed in Part 6, which related to assessment of permanent impairment. There is no reason to think that different principles were intended to be applied when a medical assessment was being made in relation to causation of minor injuries. Clauses 6.5 to 6.7 provided:
Causation of injury
6.5An assessment of the degree of permanent impairment is a medical assessment matter under cl 2(a) of Schedule 2 of the Act. The assessment must determine the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident. A determination as to whether the injured person’s impairment is related to the accident in question is therefore implied in all such assessments. Medical assessors must be aware of the relevant provisions of the AMA 4 Guides, as well as the common law principles that would be applied by a Court (or claims assessor) in considering such issues.
6.6Causation is defined in the Glossary at page 316 of the AMA 4 Guides as follows:
‘Causation means that a physical, chemical or biological factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following:
1.The alleged factor could have caused or contributed to worsening of the impairment which is a medical determination.
2.The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination’.
This, therefore, involves a medical decision and a non-medical informed judgment.
6.7There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause, as long as it is a contributing cause, which is more than negligible. Considering the question ‘Would this injury (or impairment) have occurred if not for the accident?’ may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes.”
THE REVIEW
The claimant sought a review of all four certificates issued by Medical Assessor Woo pursuant to s 7.26 of the Act. The claimant brought the application within the time prescribed by s 7.26(10) of the Act and cl 34 of Procedural Procedure PIC 7 (28 days). The claimant submitted there is a reasonable cause to suspect that the assessments are incorrect in a material respect.
The claimant subsequently discontinued his application in respect of the L5/S1 nucleoplasty by submissions dated 7 June 2023 which the President’s delegate admitted as a late document. The claimant maintains his application regarding Medical Assessor Woo’s findings relating to treatment of the left shoulder.
In relation to the MRI scan of the left shoulder and subacromial bursa ultrasound-guided injection of the left shoulder, the claimant submitted that Assessor Woo’s statement that the claimant did not present with left shoulder pain, until six months after the motor accident, is erroneous. The claimant refers to a clinical note of Dr George Hanna made on 27 April 2022 as being the first mention of bilateral shoulder pain. The claimant submits that, in accordance with the records of Dr Hanna, complaints of left shoulder pain began some two months after the subject accident.
The claimant’s application for review was opposed by the insurer. It was submitted for the insurer that Medical Assessor Woo correctly determined that requests for the MRI and ultrasound-guided injection to the left shoulder was not an injury from the effects of the motor accident, and not reasonable and necessary, in the circumstances, for the purposes of the Act.
President’s delegate Jeremy Lum issued a Determination of an Application for Review of a Medical Assessment on 1 August 2023 which stated the satisfaction of the President’s delegate that there is a reasonable cause to suspect that the medical assessment was incorrect in a material respect. The President’s delegate accepted the claimant’s submission there is reasonable cause to suspect that the Medical Assessor’s finding, “It was not until six months after the accident that the claimant reported left shoulder pain”, is incorrect in a material respect.
Accordingly, the application was accepted and was referred to the Review Panel, which is to assess all of the treatments that were referred to Medical Assessor Woo for assessment, that remain in dispute.
MATERIAL BEFORE THE REVIEW PANEL
The claimant relied upon the following material in relation to the matters that remain in dispute:
(a) claimant’s submissions in support of review application dated 2 and 7 June 2023 (previously summarised).
(b) Decision of President’s delegate dated 22 June 2023 (previously summarised).
(c) Claimant submissions in support of application to the Commission.
The claimant acknowledges that he suffered a left shoulder dislocation for the first time in January 2015 while surfing. This injury led to his suffering a further four dislocations in the next three years. That condition was being managed by the claimant’s treatment providers at the time of the subject accident. He commenced chiropractic treatment with Dr George Hanna shortly thereafter which continues. The claimant submits that Dr Hanna and the treating general practitioner (GP), Dr Marcus, opined that the claimant was experiencing in left shoulder pain as a consequence of the subject accident. A left shoulder ultrasound was performed on 1 August 2022 at the request of Dr Marcus which indicated that the claimant was suffering form subacromial bursitis. The claimant submits that Dr Marcus opined that the subacromial bursitis resulted from the subject accident.
The claimant was referred to Dr Moopanar, orthopaedic surgeon, in relation to his left shoulder pain. Dr Moopanar requested an ultrasound-guided cortisone injection into the claimant’s subacromial bursitis, as well as for the claimant to undergo a left shoulder MRI, in order to exclude any rotator cuff pathology not shown on the ultrasound. The insurer refused the claimant’s request to fund those treatments on the basis that there was a lack of evidence from the claimant’s treatment providers to suggest that the requested treatment was reasonable and necessary. The claimant submits that the insurer’s position is contrary to the combined opinions provided by Dr Hanna, Dr Marcus and Dr Moopanar.Reports by treatment providers
(d) Report dated 6 October 2022 by Dr George Hanna.
Dr Hanna confirms that the first mention of bilateral shoulder pain is an entry on 27 April 2022 in his clinical notes. Dr Hanna says that the claimant was required to overly rely on his shoulders to compensate for the reduction in strength, movement and functional capacity of his wrists/hands and neck, which were injured in the subject accident. Dr Hanna made a diagnosis of left shoulder posterior and anterior labral tear, subacromial bursitis and glenohumeral joint instability. His other diagnoses are not relevant for the Review Panel’s consideration. Dr Hanna opined that the recommended treatment is related to the subject accident and will improve the claimant’s recovery.
(e) Report dated 8 October 2022 by Dr Bishoy Marcus.
Dr Marcus reports that the claimant did have some paraspinal stiffness and a globally reduced range of motion in his cervical spine when first seen after the subject accident. Dr Marcus thought that the claimant had suffered a whiplash injury. A MRI scan of the cervical spine performed on 6 March 2022 demonstrated shallow disc bulging from C2/C3 to C6/C7. When seen on 1 August 2022, the claimant stated his neck pain was persistent and that he had pain going into his left shoulder, which felt very tight and restricted. Dr Marcus said that an ultrasound of his left shoulder confirmed that the claimant had subacromial bursitis. Dr Marcus notes that the claimant suffered an aggravation of his back pain on 12 August 2022 when he was lifting a box. He was then not fit for work. Dr Marcus thought that the claimant had a very good prognosis in relation to his left shoulder and expected a full recovery. He recommended MRI of the left shoulder to exclude any rotator cuff pathology not seen on ultrasound and said that his request for an ultrasound-guided cortisone injection into the subacromial bursa was standard practice for bursitis. Dr Marcus thought that the treatment was reasonable and necessary and would help resolve the claimant’s injury arising from the motor accident. It would alleviate the restricted range of motion in his left shoulder.
(f) Report dated 14 September 2022 by Dr Terence Moopanar, orthopaedic surgeon.
Dr Moopanar says that an injury to the claimant’s ankle in the subject accident “has required both upper limbs in order to rehabilitate and he now suffers severe pain and apprehension in his left shoulder”. Dr Moopanar says that MRI:
“…clearly shows a chondrolabral junction tear which remains undisplaced but is highly symptomatic. It is my opinion that rehabilitation of this injury has now caused an aggravation of a previous problem. He tells me that he has had this shoulder dislocated but prior to the accident was non-symptomatic. He is now quite symptomatic from the perspective of the left shoulder and my plan is to offer him an arthroscopy with stabilisation of the shoulder”.
The Review Panel notes that the suggested arthroscopy does not form part of the referred medical dispute.
(g) St George Hospital discharge referrals dated 7 January 2015 and 17 October 2017.
These detail previous left shoulder dislocations.
(h) Report of operation performed on 20 December 2022 by Associate Professor Nicholas Smith.
This relates to a right wrist arthroscopy and possible TFCC repair due to ulnar and dorsal wrist pain and possible scapulae instability.
(i) Supplementary report dated 22 June 2023 by Dr George Hanna.
Dr Hanna made the following diagnosis:
(i)cervical spine C5/C6 disc annular tear causing cervicogenic headaches;
(ii)cervical spine left C7 nerve root thickening and inflammation;
(iii)left shoulder anterior inferior labral tear;
(iv)left shoulder posterior chondral labral injury with glenohumeral instability, and
(v)left shoulder rotator cuff tendinopathy and subacromial bursitis.
Dr Hanna opines that injuries to the left shoulder are a direct cause of the subject accident. Dr Hanna confirms that the claimant complained to him of left shoulder pain less than four months after the subject accident, contrary to the history recorded by Medical Assessor Woo, with whom he disagrees. Dr Hanna repeats his previous statements that the proposed treatment arises from the subject accident, is necessary/reasonable and will improve the chances of recovery.
(j) Report dated 3 July 2023 by Dr Moopanar which essentially repeats what is stated in his earlier report. It is not clear if Dr Moopanar re-examined the claimant before preparing his supplementary report.
(k) Operation report by Dr Moopanar concerning arthroscopic fixation of left cuff biceps tendonitis procedure performed on 9 August 2023.
Diagnostic investigations
(l) MRI cervical spine reported by Dr Andrew Law on 6 April 2022.
Comment: Shallow disc bulging from C2/C3 to C6/C7 without a disc herniation, spinal canal stenosis, foraminal stenosis or neural impingement. No obvious ligamentous injury. The facet joints are normal in appearance and alignment.
(m) Ultrasound both wrists reported by Dr Caitlin Kapoor on 13 April 2022.
Findings: On the right, there is no joint effusion or synovitis and there is no abnormality of the extensor or flexor compartments. On the left, features of joint space synovitis are noted in relation to the TFC recess. No ganglion cyst. No tendon tear.
(n) Ultrasound left shoulder reported by Dr Shane Connolly on 12 August 2022.
Findings: The supraspinatus, subscapularis, infraspinatus and long head of biceps are intact. There is bursal thickening on abduction with punching at 45°. Abduction is unlimited. AC joint is normal.
Conclusion: subacromial bursitis.(o) MRI left shoulder reported by Dr Jaspal Hunjan on 23 August 2022.
Findings: Anteriorly at the equator, under surface glenoid labral tear seen. This manifests as chondrolabral dehiscence and adjacent thickened scapula periosteum. No medialised labral tissue, no other variant labral lesion here. At the same level but posteriorly, subtle high signal undermines more meniscoid looking posterior labrum at the equator. The high signal favouring a partially healed under surface labral tear, most likely from direct impaction. These changes may suggest traumatic injury GH joint. The patient exhibits an inherently flat and shallow glenoid to accommodate an oblong shaped humeral head. No capsular tears (HAGL or GAGL). No GH capsular redundancy, although scribbled up capsular can hide any potential capsular redundancy. Allowing for magic angle artefact, transition zone LHB, as well as anchor level normal. Extra-articular LHB normal. Trace of SA bursal effusion, with low grade distal supraspinatus (SST) tendinopathy, muscle bulk normal, no fatty replacement. ACJ normal.
Comment: The main finding is related to an acute under surface tear of anterior glenoid at 6 o’clock, disc tear extends to adjacent articular cartilage, scapular periosteum slightly scarred, but keeps the labral tear in check (no medialised labral tissue, no unstable labral lesion therefore). Low grade injury posterior labrum at the equator, no variant lesion such as Kim or POLPSA. No unstable chondroplasty at GHJ.(p) MRI bilateral shoulders reported on 21 March 2023 by Dr Jaspal Hunjan.
(q) Left subacromial bursa injection reported on 5 September 2022 by Dr Caitlin Kapoor.
(r) MRI left shoulder reported on 24 March 2023 by Dr Jaspal Hunjan.
Comment: Since the previous study of 2022, there has been minor further progression of antero-inferior labral tear….. possibility of ongoing GHJ instability. No SLAP lesion visible on disc non-orthographic study. Low grade postero superior cuff tendinopathy, with trace of subacromial bursal effusion may or may not correlate with bursitis clinically.
The insurer relied upon the following material in relation to the matters remaining in dispute:
(i) insurer’s submissions to the President’s delegate dated 8 June 2023 (previously summarised), and
(ii) insurer’s submissions for the Commission’s assessment.
None of the insurer’s submissions, nor summation of the evidence, addressed injury to and treatment of the left shoulder.
Certificate of determination – internal review dated 20 July 2022.
Liability for benefits beyond the 26 weeks from the date of the accident was declined on the basis that the claimant sustained minor injuries in the motor vehicle accident as defined in the Act.
Clinical records of Dr Marcus.
RE-EXAMINATION
The assessment report from Medical Assessor Shane Moloney is as follows:
“Mr Abanoub Morgan
MVA 22/02/2022
Mr Morgan attended the medical suites at PIC on 28 February 2024. He was unaccompanied.
Pre-accident history
Mr Morgan stated that he was working full-time as a carpenter for the past 10 years prior to the accident. He was a regular attender at the gym including weightlifting and played touch football.
He recalls that he has had several dislocations of the left shoulder. The first was in 2014 when he attended St George Hospital. Another dislocation was documented in 2016 which was reduced at Canterbury Hospital. Another reference was in 2017 with a repeat dislocation which was relocated at St George Hospital. An x-ray at that time reported no fractures but a Hills-Sachs deformity. He stated that prior to the accident his shoulders were asymptomatic. He can’t recall any previous low back pain.
History of motor accident
Mr Morgan stated that he was a driver of his car when he braked when the car in front of him suddenly stopped. It was raining at the time and a truck ran into the rear of his car. He was wearing a seatbelt at the time but airbags were not deployed. He states that his car was repaired and ambulance or police officers did not attend the scene of the accident. He states at that time he had a sore neck and was able to drive home.
History of symptoms and treatment following the motor accident
Mr Morgan states that he had pain in both wrists and neck immediately after the accident but was able to return to work one week after the accident. He finally stopped employment in August 2022 due to an increase in left shoulder pain. He is unsure when the left shoulder became symptomatic but thinks it was about 2 months after the accident when it started throbbing with increased pain with movement. The wrist continued to be painful and he was referred to an orthopaedic surgeon who did an arthroscopic repair on the right wrist in December 2022. This was followed up by further surgery to the left wrist in December 2023 and he is still wearing a splint today. Due to persistent pain in the left shoulder, he was referred to another orthopaedic surgeon, Dr Moopanar, who did an arthroscopic repair of the left shoulder in August 2023 at Nepean private hospital. He stated this was self-funded and had follow-up physiotherapy.
He was also referred by his GP to a neurosurgeon, Dr Papantoniou who initially consulted him in July 2022 and diagnosed a large annular tear the L5/S1 level and recommended nucleoplasty at the L5/S1 level.
There have been no further injuries or conditions sustained since the motor accident.
Current symptoms
At present, Mr Morgan has constant low back pain which increases with bending or prolonged standing or walking for more than 30 minutes. He has developed a shooting pain down both legs in the past year which lasted less than one day and has occurred twice in the last year. He gets pain in the left ankle with increased walking and occasional swelling. There has been no change in this condition. The left shoulder has been improving after the surgery and he is still having rehab in the form of physiotherapy. He is still wearing a splint on the left wrist after surgery which is due to be removed in the following week. The right wrist it is okay but still feels a bit weak.
Mr Morgan has not returned to full-time work since August 2022. He states that he does very little house work and driving is limited due to wrist pain. He consults his GP when necessary and has a follow-up appointment with the wrist surgeon, Dr Smith.
Current and proposed treatment
Present medication is Panadeine Forte 1 to 2 per week and an occasional Valium for back pain once or twice per month. He also takes Panadol and Nurofen 3 or 4 times per week.
As a follow-up to the surgery on his shoulders he sees a physiotherapist fortnightly and weekly for the left wrist.
Clinical examination
Mr Morgan walked into the consulting rooms with a normal gait and sat comfortably during the interview. He states that he is right-handed. His height was measured at 167 cm without shoes and weight 98 kg.
Cervical spine
On inspection there was a normal contour of the cervical spine and on testing range of movement flexion/extension, side bending rotation were all 80% of expected range with no asymmetry. On palpation there was no guarding or spasm noted in the cervical musculature.
On neurological examination of the upper limbs, reflexes were normal with normal power and no sensory changes noted. No muscle wasting was apparent with the circumference of the upper arms 36 cm bilaterally (10 cm above the olecranon process) and in the upper forearms 30 cm bilaterally (5 cm below the olecranon process).
Lumbar spine
Mr Morgan walked with a normal gait and had slight difficulty walking on his heels and toes due to discomfort in the left ankle. Squatting was limited to 50% of expected range due to low back pain.
On testing range of movement flexion/extension was 70% of expected range with side bending 80% of expected range with no asymmetry. On palpation there was tenderness over the L1 – 3 spines but no guarding or spasm noted in the lumbar musculature. Straight leg raise was 70° bilaterally with negative sciatic nerve root tension signs.
On neurological examination of the lower limbs, reflexes were equal bilaterally with normal power and no sensory changes were noted. No muscle wasting was apparent with the circumference of the lower thighs 46 cm bilaterally (10 cm above the superior patella pole) and at the maximum circumference of the calves 37 cm bilaterally.
Shoulders
On inspection of the shoulders no muscle wasting was apparent and on palpation there was tenderness over the left acromioclavicular joint. With passive movement no crepitus was detected and impingement tests were mildly positive on the left shoulder. There is a new surgical scar from the arthroscopic repair and the anterior left shoulder which is 2 cm long with colour change and suture marks are visible. However, this is only 7 months after the operation and is not fully matured.
Shoulder Movements Active ROM Measured
RIGHT
Active ROM Measured
LEFTFlexion 170° 130° Extension 40° 40° Adduction 50° 50° Abduction 170° 130° Internal Rotation 90° 80° External Rotation 90° 80° Wrist
There was a normal range of movement of the right wrist but due to the recent surgical repair of the left wrist and the post-operative splint, it was impossible to measure range of movement of the left wrist.
Comments
Mr Morgan had an arthroscopic repair of the left shoulder 8 months prior to my examination and it may be said that this is not fully stabilised as he is still having rehab. The same applies to the left wrist with more recent surgery 2 months ago.
The main discussion is whether and L5/S1 nucleoplasty is reasonable and necessary although it may be related to the injury caused by the accident. The left shoulder subacromial bursa injection and MRI it is more likely related to the recurrent dislocations prior to the accident but since the last examination he has had an arthroscopic repair of the left shoulder and is still under rehab for this.
I think the only 2 areas we need to discuss are the lumbar spine and left shoulder.
Shane Moloney”
Medical Assessor Stubbs’ review of the radiological reports is as follows:
“Morgan Abanoub – Medical imaging reviewed 3 March 2024
MRI left shoulder March 21, 2023. Radiology group.com.au – T2 coronal imaging intact cuff, minimal inferior capsular recess but no free fluid in the shoulder, minor changes in the acromioclavicular joint small area of insertional high signal supraspinatus. Sagittal T1 – intact supraspinatus infraspinatus and sub scapularis muscle, no fatty atrophy – oblique sagittal T1 – intact rotator cuff, modest joint fluid thickened inferior capsular recess. Coronal T2 as above. Axial fat suppression, joint fluid separating superior labrum from about 10 o’clock to 2 o’clock either post-traumatic or will anatomical variant, no abduction view to determining whether this is an anatomical variation or a detachment. Sagittal oblique fat suppressed. No additional findings. This MRI is done prior to the shoulder surgery.
Discussion: there is a mix of findings consistent with past trauma. Diagnosis would depend on the clinical signs particularly the apprehension tests and the past history – in this case of recurrent dislocation.
MD imaging ultrasound – various ultrasound guided injections and shoulder ankle and so forth.
Carlingford medical imaging 1800 images consisting of MRI left wrist 30 November 2022 all of which can be opened individually using DICOM viewer but not manipulated with the program. Findings consistent with the radiological reports.
MRI lumbar spine 26 October 2022 – radiology group.com.au sagittal lumbar spine sagittal T2. Bulging intervertebral discs at 3/4. 4/5 and5/ S1. S1 is more prominent than most does indent the thecal sac. It is closer to a disc protrusion; height is equal to base. Annular signal is uniformly dark throughout the lumbar spine. Sagittal T1. Good clearance in the intervertebral foramina. Axial T2 L3 to S1 capacious spinal canal normal segmentation of the nerve roots. High level of fatty atrophy in the deep musculature of the lumbar spine is moderate but not gross. At the L5 /S1 level the disc has an asymmetric bulge. Coronal T2 stir image – better nuclear signal seen in the upper lumbar discs. Nerve roots stand out in the spinal canal and seem to have an unobstructed course.
Discussion: none of the findings are post-traumatic.
Carlingford medical imaging 23 August 2022 MRI left shoulder – T2 coronal fairly normal except for remuneration inferior capture recess. Sagittal T1 – unremarkable sagittal oblique T2 minor AC joint changes. Axial T2. High signal under the anterior labrum superiorly and inferiorly biceps normal rotator cuff normal
Medical imaging reports:
Carlingford medical imaging MRI lumbar spine 30 March 2022 – sagittal T1 – findings the same as seen in October. Coronal T2 stir – same axial T2 L3-S1 – same period sagittal T2 same as in October. Axial T2 from T12 to L3 – same period. No indications of acute trauma
MRI lumbar spine 30 March 2022 Dr Ryan, basically degenerative changes as noted above. MRI cervical spine 6 April 2022 – report only not included in the imaging. Report of widespread degenerative changes without other features. The facet joints are noted to be normal, there is no spinal canal stenosis or disk herniation. These findings would be consistent with the findings and the lumbar spine, both the lower cervical and lumbar spines tend to follow the same degenerative trajectory, no report of trauma.
Ultrasound of both wrists 13 April 2022. Left-sided triangular fibrocartilage recess synovitis. This imaging is an assessable on the disc. Triangular fibrocartilage involvement is common r. MRI right wrist 10 May 2022 this imaging is unavailable. The findings are of some tendinopathy of the extensor carpi ulnaris tendon along with other findings noting the patient is currently asymptomatic. The radiologist suggests clinically testing for instability in the extensor carpi old Mahrous tendon – the trace of recess stenosis but other features of the triangular fibrocartilage in the distal radio ulnar joint and associated ligaments are normal.
MRI of the left wrist one July. This is more expensive report from a different radiologist to that that mentioned above. The findings are that the wrist ligaments were stable, there is no generalised wrist synovitis. Abnormal signal in association with the volar wrist ligaments in particular the ulnar attachment of the triangular fibrocartilage. There is otherwise no change may be due to a cluster of ganglion, change but otherwise no synovitis. Median and ulnar nerves are normal.
MRI right wrist 26 August 2022 reporting disorder degenerative not traumatic changes and again commenting on the extensor carpi old Mahrous tendon. The carpal is normal and the pathology in the extensor carpi old Mahrous tendon is a longitudinal split of 2 cm in the distal tendon. There is mild previous dialysis recess synovitis, also found in the left wrist but otherwise normal appearance of the TFC.
X-ray the right wrist performed at the same time he reported both same radiographer are of functional studies in maximum ulnar and radial deviation. The Scaife oh lunate joint does not show signs of instability. There are no abnormal findings.
MRI left ankle 21 July 2022 – reporting that the principal ankle ligaments are intact. There is no altered signal consistent with geode formation and otherwise normal signal from bones tendons and joints.
MRI cervical spine reported 15 August 2022 – a subtle 5/C6 paracentral annular tear seen reported to be a possible cause of attrition to the exiting left C6 nerve. Foraminal injection suggested. See above.
MRI of the lumbar spine reported 8 October 2022 seen above concentrates on an annular tear at L5 S1 and suggest possible to strew protrusion at L5 S1. Small annular tear is noted that the L5 S1 disc between the outer third analyst and in two thirds but it is well confined.
MRI of the left ankle reported 6 January 2023 – reporting near complete resolution of the transverse fracture of the mid-navicular body but otherwise no complicating features. Notes this should be compared report July 2022. No evidence of injury the midclavicular body is noted that. Fractures are easily diagnosed an MRI. The two films cannot be compared but the appearance of this feature over the six months between the imaging is consistent with trauma. The radiologist commented that this may represent slow resolution but this assumes that the fracture is present previously.
Discussion: none of the imaging studies of either wrist suggest significant acute injury. The plain x-rays report no evidence of Scaife oh lunate damage or other instability patterns in the carpal bones. Ultrasound and MRI imaging reports essentially the same changes in both wrists. Evidence of wear and tear in the triangular fibrocartilage and associated structures like the extensor carpi ulnaris tendon. These are the sort of changes in demand during heavy manual labour which may or may not be symptomatic. No causal relationship to the motor vehicle accident in either case.
The ankle complaint is likewise not caused by the motor vehicle accident. The relevant findings on the MRI suggest that there may have been a later injury. But that is not related to the motor vehicle accident.
Conclusion: the question asked is whether the L5/S1 nuclear plasticity suggested by associate Prof Pantoniou is causally related the accident and whether it’s reasonable and necessary. It is not dictation for nucleoplasty is the same as the indication for disc excision the treatment of acute onset sciatica with radiculopathy from disc herniation. He does not have a radiculopathy annular material will only make that disc more symptomatic. The surgery will increase his low back pain, the surgery is not reasonably necessary indeed will it is harmful.”
FINDINGS
The Review Panel conducts of all the matters with which the medical assessment is concerned.[6] The Review Panel adopts the examination findings of Medical Assessor Moloney with which Medical Assessor Stubbs concurs.
[6] Section 7.26(6) of the Act.
The Review Panel is not required to choose between competing medical opinions and is required to form its own opinion.[7]
[7] Insurance Australia Group Limited v Keen [2021] NSWCA 287.
Having considered all of the evidence, particularly the delay of at least two months in reporting left shoulder pain, the Review Panel finds that the MRI scan of the left shoulder and left shoulder subacromial bursa ultrasound-guided injection do not relate to the injury caused by the motor accident, but are more likely related to the recurrent dislocations, prior to the subject accident.
CONCLUSIONS
For these reasons, the Review Panel concludes that the certificate issued on 5 May 2023 by Medical Assessor Alexander Woo, in relation to the specified treatments, should be revoked. The new certificates appear at the commencement of these reasons.
As the review application in respect of the L5/S1 nucleoplasty has been withdrawn, there is no need for the Review Panel to issue any certificate, in relation to that treatment.
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