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Case study 32 - minor injury

Overview

This case study aims to confirm if injuries to the neck, left shoulder, and an exacerbation to the lumbar spine injury are minor injuries, pre-existing or non-minor injuries.

Introduction

The claimant reported being struck by another car on the driver’s side of their motor vehicle. Emergency services did not attend the accident however the claimant reported the accident to police. The claimant attended their GP the same day as the accident. The GP identified injuries to the left shoulder, cervical spine, and bruised left ribs, with pre-existing cervical spondylosis. The claimant was not referred to any medical specialists by their GP.

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 reviewed 7 months post motor vehicle accident (MVA).

Low back/lumbar spine

  • Has had back pain since 2001 due to an unrelated injury
  • Reported pain to the left buttock, posterolateral thigh, leg and numbness in the left foot
  • The claimant identified walking assists in reducing symptoms
  • Mild tenderness over the midline from L3-S3
  • No muscle guarding, weakness, nor spasm
  • Reported pain on flexion, observed extension limited to one third of normal range of motion (this is noted to be consistent with the report from a specialist from 2 years prior to the MVA)
  • No signs of radiculopathy

Neck/cervical spine

  • Reported constant pain specifically to the left side of the neck
  • Observed forward protrusion of the head and neck “poke neck”
  • Left trapezius noted to be tense and tender, right side had no abnormalities
  • Active flexion was 2/3 of normal and extension ½ normal range of motion
  • Rotation of the cervical spine was symmetrical
  • Muscle guarding was present and a degree of dysmetria was noted
  • No signs of cervical radiculopathy noted

Upper extremities

  • No muscle wastage in either limb, normal reflexes and symmetrical
  • Power and sensation were normal in both limbs
  • Impingement signs were positive in the left shoulder but not in the right shoulder
  • Range of motion was reduced in the left shoulder. Specifically, less 40° in flexion and 50° in abduction

Review of Documentation

A specialist report from two years prior to the MVA confirmed degenerative changes and a loss of range of movement due to a workplace injury approximately 16 years prior.

An Allied Health Recovery Request in the months following to the MVA noted central cervical  and lumbar spine pain in addition to possible frozen shoulder due to lack of progress or clinical change over 3 months treatment. Similarly, pre-existing notes reporting low back pain being present prior to the MVA and a CT Scan identifying degenerative changes in the lumbar spine were noted.

Diagnosis

  • Cervical spine – soft tissue injury (whiplash associated disorder grade II)
  • Lumbar Spine – soft tissue injury (including an aggravation of longstanding and symptomatic degenerative change)
  • Left shoulder - 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 following injury is a minor injury

  • Cervical spine – soft tissue injury
  • Lumbar spine – soft tissue injury
  • Left shoulder - soft tissue injury