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Case study no. 48 - Review Panel decision

Overview

The following case study examines why the medical assessment subject to a Panel Review was incorrect in a material respect. The medical assessment resulted in the finding that the injuries to the cervical spine, thoracic spine, lumbar spine and right shoulder met the definition of a minor injury in accordance with the Motor Accident Injuries Act 2017 (the Act).

The Review Panel determined that the claimant had suffered a L4-5 disc lesion consisting of partial rupture of fibrocartilage. As a complete or partial rupture of cartilage is not considered a minor injury, the original medical certificate was revoked and a new certificate issued by the Review Panel.

Introduction

The claimant was involved in a head on collision, their motor vehicle was also hit from behind. They were taken to hospital in an ambulance and discharged the following day.

A few days later the claimant consulted with a general practitioner (‘GP’). They complained of neck and right trapezial pain. There was also low back pain into the right thigh to knee level. They were referred to a cardiologist and gastroenterologist. They also received psychological and physiotherapy treatment.

Injuries to the neck, back of the head, right shoulder, right shoulder blade, middle back, lower back, right leg, and right knee were referred to a Medical Assessor (the ‘Assessor’) to determine whether they meet the definition of a minor injury.

The Assessor considered CT scans of the cervical spine and lumbar spine, which in their opinion showed degenerative changes. The Assessor noted that degenerative changes were common on radiological investigations in asymptomatic people, and considered there was insufficient information to conclude that additional imaging “abnormalities” could be  attributable to the subject motor accident. The Assessor found there had not been specific intervertebral disc injuries caused by the motor accident.

The Assessor found there had been soft tissue injuries to the cervical spine, thoracic spine, lumbar spine and right shoulder. The claimant did not sustain direct injuries to the head, right shoulder blade, right leg and right knee. There was sclerotomal pain in the right leg, not radicular symptoms.

The Assessor concluded that soft tissue injuries to the cervical spine, thoracic spine, lumbar spine and right shoulder were minor injuries.

The assessment was referred to a Review Panel (the ‘Panel’) for determination under section 7.26 of the Act.

Review Panel Deliberations

The Panel decided that the available information suggested the reported focal disc lesion at L4-5 with potential impingement of right L5 nerve root was not acute.

The Panel accepted that the reported focal disc prolapse was consistent with a partial rupture of cartilage.

The Panel needed to consider the likely age of the L4-5 prolapse and whether it was caused by the subject motor accident. Furthermore, the Panel needed to consider if the claimant’s symptoms corresponded clinically with the specific disc protrusion at L4-5.

The Panel noted that the CT scan of the lumbar spine was undertaken a few days after the motor accident. The Panel also noted from the available information that the claimant’s lower limb complaints did not meet a definition of radiculopathy.

The Panel considered that a re-examination of the claimant was required to reach a decision because it was necessary to determine the claimant’s present symptomatic complaints and ascertain whether there are clinical signs of lower limb radiculopathy.

The claimant was asked to bring radiology of the lumbar spine and right shoulder to the appointment.

The Panel requested GP records from one year prior to the motor accident to the present date, to ascertain the trajectory of the claimant’s symptomatic complaints after the motor accident.

Review Panel Re-Examination

The claimant brought various investigations of the cervical and lumbar spine to the examination. No investigations of the right shoulder or right knee were provided.

The Panel viewed the CT scan of the lumbar spine, noting degenerative change with disc space narrowing and osteophytes predominately at the L4-5 level.

The Panel also viewed the CT scan of the cervical spine and agreed with the report citing degenerative changes at C5-6 and C6-7, similar to the findings of a previous scan taken prior to the motor accident.

The Panel noted references to “radiculopathy confirmed” in the formal radiology reports of the cervical spine and lumbar spine, however the Panel further noted that radiculopathy is a clinical diagnosis, rather than one made based on imaging. Imaging demonstrating nerve root compression adds diagnostic information but in isolation is not sufficient to diagnose the presence of radiculopathy.

Review Panel Deliberations

Having reviewed the GP records and examined the claimant, the Panel discussed causation of the referred injuries: cervical spine, thoracic spine, lumbar spine and right shoulder.

The Panel found that the GP records supported injuries to the cervical spine and lumbar spine. The Panel found no contemporaneous evidence of injury to the thoracic spine. Since the motor accident, the available information confirms that the symptomatic areas are the cervical spine and lumbar spine, not the thoracic spine.

At Panel examination, the claimant did not complain of any symptomology at the right shoulder joint, rather, they described ongoing symptoms localised to the right scapula. This location is not consistent with a shoulder joint injury, with symptoms most likely referred from the neck in a sclerotomal pattern.

The Panel accepted that the claimant experienced symptoms at the right shoulder girdle since the motor accident, although found no evidence either within the documents or at examination of a discrete right shoulder injury. In summary, the Panel found no right shoulder joint injury from the motor accident as no evidence had been presented of a tear or rupture of cartilage, ligaments, muscles, or tendons at the right shoulder.

The Panel confirmed that the clinical findings at examination of both the upper and lower limbs did not confirm the presence of either cervical or lumbar radiculopathy. The Panel noted the reference in the formal reports of the CT scans of the cervical spine and lumbar spine to “radiculopathy confirmed” though, as noted above, radiculopathy is not a radiological diagnosis, it is a clinical diagnosis with specific defined criteria in the Motor Accident Guidelines .

The Panel referred the CT scan of the lumbar spine to a Medical Assessor specialising in diagnostic radiology to clarify whether the L4-5 disc herniation meant that the claimant had incurred a “cartilage rupture” from the motor accident.

The radiologist noted a narrow disc consistent with chronic disc degeneration at L4-5.

The radiologist advised that it was not possible to determine the age of the right L4-5 protrusion, whether it was acute or chronic.

The radiologist concluded that there had been a partial rupture of fibrocartilage.

Diagnosis

The Panel determined the presence of a cervical spine soft tissue injury caused by the motor accident, supported by contemporaneous GP records. There is no evidence of cervical radiculopathy. The criteria for minor injury are met for the cervical spine.

The Panel did not find a thoracic spine soft tissue injury. The claimant did not complain of symptoms in this location and there have not been any investigations of the thoracic spine.

The Panel accepted that the claimant experienced right shoulder girdle symptoms from the time of the accident, however the distribution of these is not consistent with shoulder joint pathology. There are no clinical or radiological findings to suggest abnormality of the right shoulder joint.

The Panel considered the timing of onset of symptoms post-accident – the claimant complained of right lower limb symptoms within a few days of the motor accident. The Panel decided that the claimant’s injury was non-minor based on the partial rupture of cartilage with documented symptom onset within a few days of the motor accident. There were no clinical signs to support radiculopathy.

The Review Panel found that the accident WAS a cause of the following injuries:

  • Cervical Spine – soft tissue injury with symptom radiation to right scapula
  • Lumbar Spine – L4-5 disc lesion consisting of partial rupture of fibrocartilage

The Review Panel found that the accident was NOT a cause of the following injuries:

  • Right Shoulder – soft tissue injury
  • Thoracic Spine – soft tissue injury

The following injury caused by the motor accident is NOT a minor injury for the purposes of the Act:

  • Lumbar Spine – L4-5 disc lesion consisting of partial rupture of fibrocartilage