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Case study 25 - injury to cervical and lumbar spine

Overview

This case study explores a dispute about whether an injury (to the cervical and lumbar spine) is a minor injury under Schedule 2 section 2(e) of Motor Accident Injuries Act 2017. The Assessor found the claimant’s injury to satisfy the definition of a Minor Injury.

Introduction

The claimant was a driver whose vehicle was rear ended by another vehicle. They experienced lower back pain immediately and attended their treating doctor who recommended physiotherapy treatment.

There was no history of any other accidents or injuries.

The claimant was not working at the time of the accident.

The assessment

There is a dispute about whether the injury is a minor injury under Schedule 2 section 2(e) of the Motor Accident Injuries Act 2017 (the Act).

Clinical Examination

The claimant was assessed approximately 8 months post motor vehicle accident (MVA). The claimant noted pain in the lower back, also for a period felt pain in one buttock, however this had now resolved. Currently not receiving any treatment and reports the neck problems have resolved.

Cervical Spine (Cervicothoracic)

  • Full pain free range of movement of the cervical spine
  • No muscle spasm, guarding or radicular symptoms
  • No neurological abnormalities detected in upper extremities

Lumbar Spine

  • No muscle spasm or guarding
  • No radicular symptoms
  • Full range of motion in lower extremities
  • No neurological abnormalities detected

Summary of Documentation

Clinical notes from the treating doctor one month post MVA noted persistent neck and lower pain with radiculopathy and recommended physiotherapy.

Diagnosis

There was no evidence the claimant has radiculopathy of the lumbar spine or the cervical spine based on the current assessment. The neck symptoms have resolved and the current symptoms relate to the lower back are consistent with a soft tissue injury to the lumbar spine.

Diagnosis

  • Cervical Spine – soft tissue injury (resolved)
  • Lumbar Spine – soft tissue injury

Minor injury

Section 1.6(2) of the Act

A soft tissue injury is (subject to this section) an injury to tissue that connects, supports or surrounds, other structures or organs of the body (such as muscles, tendons, ligaments, menisci, cartilage, fascia fibrous tissues, fat, blood vessels and synovial membranes), but not an injury to nerves or a complete or partial rupture of tendons, ligaments, menisci or cartilage.

Schedule 1 [2] clause 4 of the Motor Accident Injuries Regulation 2017:

  1. An injury to a spinal nerve root that manifests in neurological signs (other than radiculopathy) is included as a soft tissue injury for the purposes of the Act.

The soft tissue injury to the cervical and lumbar spine are minor injuries because they fit the definition of a soft tissue injury as set out in Section 1.6(2) of the Act. There is no evidence based on the written information, imaging studies or the clinical assessment that establishes otherwise.

The following is a minor injury

  • Cervical Spine - soft tissue injury
  • Lumbar Spine – soft issue injury